Every finding on record at Harborview Post Acute

Based on facility policy review, medical record review, observation, and interview, the facility failed to assess and monitor surgical incision sites for 1 of 1 (Resident #102) sampled residents with a surgical wound. The findings include: 1. Review of the facility's policy titled, admission Assessment and Follow Up., dated 9/2012, revealed .The purpose of this procedure is to gather information about the resident's physical.condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments.Conduct a physical assessment, including the following systems.Skin.Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, revealed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 2. Review of the medical record revealed Resident #102 was admitted to the facility on [DATE], with diagnoses including Displaced Bimalleolar Fracture (a break in the inner and outer portion of the ankle) of right lower leg, Bilateral (right and left) Open Reduction Internal Fixation (surgical procedure to repair a break in the bone), Anxiety, Neuropathy, and Hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #102 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. Review of the Care Plan dated 5/29/2026, revealed .surgical incision to right and left ankle . Monitor and assess site for any s/sx [signs and symptoms] of infection, changes in appearance, treatment effectiveness and notify MD [Medical Director] PRN [as needed] .Treatment as ordered . Review of the Skin assessment dated [DATE], revealed surgical incision to the right outer ankle measured (length x width x depth) 0 centimeters (cm) by (x) 0 cm x 0 cm. Left ankle (outer) measurements length 0 cm x width 0 cm x depth 0 cm. Bilateral boot immobilizers noted to bilateral feet for off loading of pressure due to resident's non-weight bearing status.Rt [Right] ankle wound bed: unable to assess wound margins, unable to assess surrounding tissue, unable to assess periwound [area of skin around wound], unable to assess drainage.Lt [Left] ankle wound bed: unable to assess wound margins, unable to assess surrounding tissue, unable to assess periwound, unable to assess drainage. The facility failed to assess Resident #102''s surgical incisions on 5/29/2026. Review of the Skin assessment dated [DATE], revealed surgical incision to the right outer ankle measured (length x width x depth) 0 centimeters (cm) by (x) 0 cm x 0 cm. Left ankle (outer) measurements length 0 cm x width 0 cm x depth 0 cm. Bilateral boot immobilizers noted to bilateral feet for off loading of pressure due to resident's non-weight bearing status.Rt [Right] ankle wound bed: unable to assess wound margins, unable to assess surrounding tissue, unable to assess periwound, unable to assess drainage.Lt [Left] ankle wound bed: unable to assess wound margins, unable to assess surrounding tissue, unable to assess periwound, unable to assess drainage. The facility failed to assess Resident #102's surgical incisions on 6/2/2026. Review of the Skin assessment dated [DATE], revealed Resident #102 had the following surgical wounds.Additional notes: Spoke with Ortho Clinic regarding f/u [follow up] appt [appointment] with ortho [orthopedic] clinic on Thursday 6/11/2026 at 2:00 PM. a. Left inner ankle incision measured 7.5 cm x 0 cm x 0 cm with 8 staples intact. b. Right outer ankle incision measured 10.5cm x 0 cm x 0 cm with 11 staples intact. c. Left outer ankle incision measured 10.0 cm x 0.1 cm x 0.1 cm with 11 staples intact. Observation and interview in Resident #102's room on 6/9/2026 at 8:00 AM, revealed resident was sitting up in bed eating breakfast with walking boots to bilateral feet. Resident stated, I have difficulty sleeping at night with these boots and have increased burning to my ankles likely the incisions. Resident #102 was asked if staff have removed the boots and dressings to assess her skin and incisions. Resident #102 stated, No, they have not. During an interview on 6/10/2026 at 10:17 AM, Licensed Practical Nurse (LPN) C was asked if she had assessed the resident's surgical incisions. LPN C stated, I've only assessed for circulation, and not visually seen the surgical incisions. During an interview on 6/10/2026 at 11:07 AM, LPN A Unit Manager was asked who is responsible for entering orders for new residents. LPN A stated, I put the orders into [named electronic medical record] the DON [Director of Nursing] or ADON [Assistant Director of Nursing] can enter orders for new admit residents. LPN A was asked who performs the admission skin assessments. LPN A stated, The nurse assigned to the resident performs the initial skin assessment, and wound care will perform the skin assessment the following day. LPN A was asked if the wound care nurse saw Resident #102. LPN A stated, Yes, on 5/29/2026. LPN A was asked if the surgical incisions were assessed. LPN A stated, The skin note says unable to assess. LPN A was asked the reason it was unable to be assessed. LPN A stated, I know it's wrapped. LPN A was asked when the next skin assessment was performed. LPN A stated, On 6/2/2026. LPN A was asked if the surgical incisions were assessed. LPN A stated, No, it states the same. LPN A was asked if there was an order from the hospital for a non-removable dressing. LPN A stated, Not to my knowledge. LPN A was asked if the resident was care planned for the surgical incisions. LPN A stated, Yes, the care plan was for monitoring for signs and symptoms of infection. LPN A was asked if staff should have removed the dressings and assessed the resident's incisions. LPN A stated, Yes. Observation and interview in Resident #102's room on 6/10/2026 at 10:19 AM, revealed LPN B and Regional Nurse at the resident's bedside performing wound care on the resident's surgical wounds. The Regional Nurse stated, They received clarification today and the resident will be going to ortho tomorrow. Left lower leg without dressing, left medial ankle with 11 staples, small area of redness between 5th and 6th staple. LPN B applied non-adherent dressing to surgical incision, covered with abdominal pad, wrapped with rolled gauze, wrapped with ace wrap, applied soft walking boot to left foot. Regional Nurse removed ace wrap to right lower leg, redness to surgical incision with 11 staples intact no drainage noted. LPN B stated, The following measurements: right lateral ankle incision measured: 10.5 cm x 0 cm x 0 cm, left lateral ankle had 11 staples and measured 10 cm x 0.1cm x 0.1 cm, and the left medial ankle incision had 8 staples and measured 7.5 cm x 0 cm x 0 cm. During an interview on 6/10/2026 at 11:49 AM, LPN B Treatment Nurse was asked when was she made aware of Resident #102's surgical wounds. LPN B stated, On 5/29/2026. LPN B was asked if she assessed the resident's surgical incisions on 5/29/2026. LPN B stated, No, she refused for me to remove the dressings. LPN B was asked if she documented the resident's refusal and notified the physician of the refusal. LPN B stated, No, I did not. LPN B was asked if she assessed the resident's surgical incisions prior to today. LPN B stated, No, I did not. I realized on 5/29/2026 that she did not have any follow up orders and I made a note and failed to follow up on those. LPN B was asked who is responsible for obtaining treatment orders or ensuring residents have a follow up ortho appointment. LPN B stated, It's mine, but sometimes medical records will make the appointments. During an interview on 6/10/2026 at 2:22 PM, ADON was asked who is responsible for entering the orders for new residents. The ADON stated, The Unit Managers, DON, and I will enter the orders. The ADON was asked who is responsible for obtaining treatment orders or follow up appointments for residents. The ADON stated, The admitting nurse is responsible for obtaining clarification for medications and treatments would be the treatment nurse. The ADON was asked should a complete skin assessment be performed of surgical assessments. The ADON stated, If there is not an order to leave dressing in place then yes, a complete skin assessment should be completed. The ADON was asked if staff should document and notify the physician of the resident's refusal of care. The ADON stated, Yes.

Based on the Facility Assessment review, policy review, job description review, medical record review, facility investigation review, [Named Hospital] emergency room (ER) report, and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights and physical, mental and psychosocial well-being for 1 of 3 (Resident #1) sampled residents reviewed for falls. On 3/30/2023, Resident #1 sustained an unwitnessed fall with head injuries. Staff failed to conduct assessments, recognize injuries, and delayed transfer for medical treatment for 7 hours, resulting in actual harm to Resident #1. The findings include: 1. Review of the Facility assessment dated 2024, revealed .Facility resources needed including, but not limited to, providing competent care for residents. 2. Review of the facility policy titled, Staffing, Sufficient and Competent Nursing, revised August 2022, revealed .Our facility provides.nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and facility assessment . 3. Review of the facility personnel file for Licensed Practical Nurse (LPN) A revealed, .Job Description Acknowledgement dated 2/7/2020.Perform.duties such as documenting nurses' notes, physicians' orders.Recognize and respond to changes in patients' conditions and document observations, interventions and outcomes . 4. Review of the undated Registered Nurse (RN) job description revealed .Manages area of responsibility with the goal of achieving and maintaining the highest quality of care possible.Demonstrated competence of nursing skills within the Nurse Practice Act and associated expectations for quality care delivery. 5. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Seizures, Intestinal Obstruction, and Alcohol Abuse. Review of the facility investigation revealed Resident #1 had an unwitnessed fall on 3/30/2023 at 6:00 PM, and no injuries were noted at the time of the fall. A post fall risk score was 12, which indicated Resident #1 was at moderate risk for falls. Review of the facility Clinical Note dated 3/30/2023 at 6:41 PM, revealed .Resident [#1] was assessed with no apparent injury noted. Resident had an unwitnessed fall . Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1's cognitive status was not assessed. Resident #1 was coded for falls. Review of the Care Plan dated 3/31/2025, revealed .At Risk For Falls R/T [related to] poor mobility/poor safety awareness.keep bed in lowest position .Footware [footwear] will fit properly and have non-skid soles.Keep areas free of obstruction to reduce the risk of falls or injury.Place call bell/light within easy reach . Review of the Neurological Check Flow Sheet dated 3/31/2023 at 2:15 AM, revealed LPN A documented Resident #1's pupils were equal and reactive to light. The facility was unable to provide documentation of Clinical Notes or assessments of Resident #1's head or face showing facial bruising or the lack of bruising. Review of the Family Nurse Practitioner (FNP) Clinical Note dated 3/31/2023, revealed .Patient seen and examined.I noticed patient had swelling to the left side of his eye which was swollen and shut as well as swelling to the right side of his face. I asked the patient what happened to him he immediately stated that he fell.I was unable to understand what he was stating as to the events of him falling. He just repeated I fell.I did ask the nurse [LPN A] to identify if during his assessment the patient looked the same as when he first saw him compared to when assessing him together. Nurse stated that he was unsure of what the patient looked like during his assessment as it was dark.I informed the nurse that all head injuries are to be sent out to the hospital for a CT [Computed Tomography is a medical imaging procedure] of the head witnessed or unwitnessed. The facility was unable to provide a written order to transfer Resident #1 to the ER for evaluation. Review of the facility Nurse's Event Note dated 3/31/2023, revealed .At 0800 [8:00 AM] the resident had an unwitnessed fall and was found crawling on the floor in his room. A post fall risk score was 12, which indicated Resident #1 was moderate risk for falls. Review of the Clinical Notes dated 3/31/2023 at 8:00 AM, revealed .Off-going nurse [LPN A] was given order from FNP to send to ER d/t [due to] hematomas [a collection of blood that causes a raised area to the affected injured area] identified upon her assessment . Review of the facility Nurse's Event Note dated 3/31/2023, revealed .At 0820 [8:20 AM] the resident had an unwitnessed fall in his room. Post fall risk score was 14, which indicated Resident #1 was moderate risk for falls. First aid was administered. Review of the late entry Clinical Note documented by LPN A with an effective date of 3/31/2023 at 8:30 AM, revealed .The Family Nurse Practitioner .came in to assess resident at approximately 5am [5:00 AM] .FNP gave new order to transfer to [Named] ER [Emergency Room] for evaluation. The facility was unable to provide documentation to show what time Emergency Medical Services (EMS) was notified to transport Resident #1 to the ER for evaluation. Review of the Clinical Note dated 3/31/2023 at 12:00 PM, revealed .EMTs [Emergency Medical Technicians] arrived to transfer resident [Resident #1] to [Named Hospital]. Resident #1 was not transferred to the hospital until 7 hours after the FNP assessed the resident and instructed LPN A to send the resident to the ER. Review of the (Named) ER report dated 3/31/2023 at 2:17 PM, revealed .On my examination, he [Resident #1] most likely was not AAOx4 [Awake, Alert and Oriented [symbol for times] to Date, Place, Person, and Situation] and ambulatory yesterday. He has multiple bumps and bruises on his head, most prominently over his left eye, causing eyelid swollen closed, and clear hematoma formation. He is saying nonsensical speech sometimes and has tangential [erratic] trains of thought . During an interview on 10/22/2025 at 3:29 PM, the Assistant Director of Nursing (ADON) acknowledged she was aware that the FNP had given an order to send Resident #1 to the ER for evaluation related to his fall that resulted in a hematoma but was unaware of the location of the hematoma. The ADON was asked if Resident #1 should have been transported by 911 (emergency services). The ADON stated, My nursing judgment would have been to notify the FNP to send him out 911. The ADON was asked should staff document follow up assessment in the clinical notes after a fall. The ADON stated, That would be ideally [ideal] . During a telephone interview on 10/22/2025 at 5:29 PM, LPN C revealed she distinctively remembered Resident #1 and he attempted numerous times to get out of bed unassisted. LPN C stated she was notified by the Certified Nursing Assistant (CNA) that Resident #1 had fallen but was unsure which CNA notified her. LPN C was asked what is the process and procedure when a resident has an unwitnessed fall. LPN C stated, I do a head-to-toe assessment and notify the provider. LPN C was asked what is the process when a resident falls and hits their head. LPN C stated, I will send out 911 because that is the facility protocol. During an interview on 10/23/2025 at 10:38 AM, LPN D stated he entered Resident #1's room to complete the resident admission skin assessment, when he found Resident #1 crawling on the floor. LPN D stated he noticed Resident #1 had both eyes swollen shut, and one eye swollen shut, and a knot was on the back of his head. LPN D was not aware of an order to transfer Resident #1 to the ER for evaluation. LPN D was asked from his assessment of Resident #1, should 911 had been called. LPN D stated, That depends on what the provider says. During interview on 10/23/2025 at 2:56 PM, the Quality Service Consultant (QSC) was asked should it have taken 7 hours to transport Resident #1 to the ER after the FNP gave the order. The QSC stated, No, it should not have taken 7 hours. During a telephone interview on 10/24/2025 at 12:14 PM, the FNP acknowledged it sometimes can take 3 to 4 hours for non-emergency transfers but was not aware that it had taken 7 hours for Resident #1 to be transported to the ER. The FNP was asked based on your assessment of Resident #1, should 911 been called for transport to the ER for evaluation. The FNP stated, Yes . The FNP was asked should a neurological (neuro) checks and assessments be completed in the dark. FNP stated, No, that's not a good assessment. During an interview on 10/27/2025 at 10:47 AM, LPN A acknowledged he did not recall Resident #1. LPN A was read the FNP note dated 3/31/2023, which indicated LPN A was unsure of what the patient looked like during his assessment as it was dark. LPN A stated, No, that does not make sense . During an interview on 10/27/2025 at 12:24 PM, RN E stated she would not be able to see well if she completed neuro checks/assessment in the dark. RN E was asked the protocol for a resident with head injuries from a fall. RN E stated, .notify the provider, and the provider will say whether to send the patient out . During an interview on 10/27/2025 at 12:49 PM, LPN F was asked if neuro checks/assessments should be completed in the dark. LPN F stated, No ma'am, you can't see the patient or if they are making a facial expression, not all patients can talk. LPN F was asked who determines when a patient is sent out 911 or by non-emergency services. LPN F stated The provider will tell the nurse or you may have to ask. During an interview on 10/27/2025 at 1:10 PM, when LPN G was asked should neuro checks/assessment be completed in the dark. LPN G stated, No During an interview on 10/27/2025 at 2:22 PM, the Director of Nursing (DON) was asked did the facility identify an issue with the nurse [LPN A] completing neuro checks/assessment in the dark. The DON stated, I was not aware of that until you came in on the complaint. The DON was asked is it her expectation for neuro checks/assessments not to be completed in the dark. The DON stated, I do not expect them to do that at all .it should be completed with good lighting.

Based on policy review, medical record review and interview, the facility failed to accurately assess the nutritional status and to follow the facility's policy for monitoring weights for 1 of 3 (Resident #3) sampled residents reviewed for weight gain. The facility's failure to provide and monitor the interventions resulted in Actual Harm when Resident #3 had severe weight gain of 18.8 pounds in a five (5) day period. Resident #3 was transferred to a local hospital for evaluation and treatment with admission to the Intensive Care Unit (ICU). The findings include: 1. Review of the facility's policy titled Dietary: Weight Monitoring, revised 11/9/2021 revealed, .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as unusual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise .Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss .may indicate a nutritional problem .Evaluating/analyzing the assessment information .Monitoring the effectiveness of interventions and revising them as necessary .A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight .gain or compromised nutritional status. Assessments should include the following information .Weight .Food and fluid intake .Fluid loss or retention .Information gathered for the nutritional assessment and current dietary standards of practice are used to develop and individualize care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following, to the extent possible .A weight monitoring schedule will be developed upon admission for all resident .monitor weight weekly for 4 weeks .I clinically indicated - monitor weight daily .The physician should be informed of a significant change in weight and may order nutritional interventions .The Registered Dietitian or Dietary Manager should be consulted to assist with interventions . 2. Medical record review revealed Resident #3 was admitted on [DATE] with a diagnosis of Diabetes, Peripheral Vascular Disease, Heart Failure, End Stage Renal Disease, Congestive Heart Failure, and Malignant Neoplasm of Kidney. Review of Physician's Orders dated 9/1/2022 revealed, .Lasix 80 mg tablet .Q [every] day .Intake and Output [I & O] Two Times Daily . Review of the Nursing Admission/Readmission Form dated 9/1/2022 revealed, Weight .275 .Edema Present .No .ABDOMEN .Flat . Review of SOAP [subjective, objective, assessment and plan] notes dated 9/2/2022 revealed .history of renal cell carcinoma status post left nephrectomy, congestive heart failure .left foot ulcer .osteomyelitis .Plan .admitted to skilled nursing facility .PT [Physical Therapy] and OT [Occupational Therapy] and wound care .Start fluid restrictions of 1000 fluid oz [ounce] daily .Daily weights .give 1 time dose of Lasix 80 mg IVP [Intravenous piggyback] .Patient to continue current treatment for chronic conditions .Cefazolin 1g [gram] till 9/10/22 .Co-signed by .[Named Medical Director] on .2022-9-6 .12:28 . Review of Clinical Notes Report dated 9/3/2022 revealed, .ABD [abdominal] distended intermittent SOB [short of breath] when laying down, NP [Nurse Practitioner] in to see resident this AM n/o [new orders] Lasix 80 mg [milligrams]/ml x [times] 1 dose and CMP [Comprehensive Metabolic Panel] .Continues with .Cefazolin three times daily until 9/10/2022 . Review of Physician's Orders dated 9/3/2022 revealed, .Fluid Restrictions .1000 ml fluid restriction .By Shift Starting 9/3/2022 . and .furosemide 10 mg/ml injection solution (80 mg) intramuscular every 1 day .one time . Review of the ADMISSION HISTORY AND PHYSICAL dated 9/4/2022 revealed, .he is stabilized and is now here for PT and OT and local wound care .right kidney cancer, CHF [Congestive Heart Failure], coronary disease .urinates small volumes .abdominal pain .increase swelling in legs .extremities 2+ to 3 + edema .dressings intact bilateral feet .Assessment and Plan .Obtain ultrasound and place Foley [indwelling urinary catheter] catheter for bladder outlet obstruction .Hypertension with elevated blood pressure. I believe this may be due to urinary obstruction. Place Foley and add additional medications if needed .History of CHF .may need increased diuretics. Monitor and add additional diuretics if needed . Review of Clinical Notes Report dated 9/4/2022 revealed, .Patient c/o [complain] abdomen pain to off going shift .patient is on a fluid restriction .explained that this is possible the cause of his low urine output . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 15 indicating he was cognitively intact, 294 pounds, and no weight gain (The 294 pounds is actually a 19 pound weight gain from 275). Review of SOAP notes dated 9/5/2022 revealed, .Plan .Place indwelling foley .Monitor input and output .Continue PT and OT .Start fluid restriction of 1000 fluid .daily .Daily weights .Continue furosemide . Review of email correspondence dated 9/5/2022 at 12:51 PM from the Registered Dietitian revealed, .[Name Resident #3] .fluid restriction .is on a 1000 ml fluid restriction. I would break it down to 720 ml per dietary .280 ml per [by] nursing. I updated his tray card to reflect the breakdown . Review of Clinical Notes Report dated 9/5/2022 revealed, .scheduled abdominal ultrasound in the AM .He c/o [complains of] his abdomen hurting and his abdomen is distended but he stated that he is urinating. He is aware that he is on a fluid restriction but had dranked [drunk] over 2000 [ml] of fluid today in a 24 hour period he had been informed that he should not drink more that on pitcher of water in 24 hours. His water pitcher was been removed from the room because he is NPO [nothing by mouth] after MN [midnight] and he is noncompliant to the fluid restriction. He is swollen and has started on Lasix po [by mouth] .The patient voice that he understands that he is on a fluid restriction and also that he is too have nothing to eat or drink after MN . Review of the facility's total intake for the 9/5/2022 was 500 ml, and not the 2000 ml documented in the Clinical Notes. Review of Patient Weight Report revealed the following: .9/1/2022 .275.00 .9/6/2022 .293.80 . These weights reflect Resident #3 had an 6.39 % weight gain resulting in a 18. 8 pound weight gain in 5 days. There was no documentation daily weights were performed as ordered. Review of the FULL NUTRITIONAL assessment dated [DATE] (5 days after admission) revealed .Date admitted .9/1/2022 .Diet Order .Fluid Restriction .1000 [mililiters (ml)] .Weight Gain Comments .[blank] .WEIGHT (in pounds) 293.80 .Edema .No .Resident admitted to the facility on [DATE]. Admit wt .293.8 lbs [the resident's admission weight was actually 275 lbs] .1000 ml fluid restriction ordered .Staff to monitor weekly weights x 4 and wound healing . Review of the Care Plan dated 9/6/2022 revealed, .At risk for complication related to .has a history of Cardio heart condition .CAD [Coronary Artery Disease] .Cardiomyopathy .Monitor feet and hands for edema .monitor for SOB .Notify MD [medical doctor] if edema, chest pain, elevated BP [blood pressure] or shortness of breath occurs . There was no documentation of fluid restrictions on the care plan. Review of the Treatment Administration Record (TAR) for SEPTEMBER 2022 revealed the following intakes for Resident #3: 9/1/2022 intake was 600 ml; 9/2/2022 the intake was 2000 ml; 9/3/2022 intake was 450 ml; 9/4/2022 intake was 350 ml; 9/5/2022 intake was 500 ml; 9/6/2022 intake was 500 ml; 9/7/2022 intake 1100 ml; 9/8/2022 intake was 1030 ml; 9/9/2022 intake was 700 ml; 9/10/2022 intake was 700 ml; 9/11/2022 intake was 1200 ml, and 9/12/2022 intake was 1000 ml. Review of the Treatment Administration Record date SEPTEMBER 2022 revealed the following urinary outputs for Resident #3: 9/1/2022 the output was 300 ml; 9/2/2022 the output was 402 ml; 9/3/2022 output was 650 ml; 9/4/2022 output was 154 ml; 9/5/2022 output was 303 ml; 9/6/2022 output was 500 ml; 9/7/2022 output 750 ml; 9/8/2022 output was 602 ml; 9/9/2022 output was 353 ml; 9/10/2022 intake was 300 ml; 9/11/2022 output was 8 ml, or 9/12/2022 output was 603 ml. Review of Clinical Notes Report dated 9/12/2022 revealed, .Resident family member was knocking at the door of this facility and stated that their family member was in distress, upon evaluation of resident, his vital were within normal limits, hs [his] o2 [oxygen] sat [saturation] was in the range of 93-94% [percent], The resident was placed on 2 liters of 02 [oxygen] with good results noted .the resident stated that while he was on the phone with his family member he said that he was having trouble breathing after using the rest room . Review of Clinical Notes Report dated 9/13/2022 revealed, .8:18 AM Resident family .approached nurse cart and stated 'I'm going to call 911 for [Resident # 3], because last night he said he couldn't breathe because of the fluid in his belly' .Resident assessed, vs [vital signs] 123/67 [blood pressure], 50 [heart rate], 18 [respirations], 98.9 temperature], 02 sats 99% room air .Abdomen distention noted, and family request him to go ER [emergency room ] .n/o [new order] send to ER for abd [abdominal] distention . Review of [Named Hospital] records dated 9/13/2022 revealed, .History of present illness .presents from nursing home with complaints of shortness of breath .the patient also has been reporting a 40-pound weight gain over the past 2 weeks .In the emergency department, the patient was found to be severely bradycardic with a heart rate of 27. The patient was given atropine which did improve his heart rate. The patient was then started on dopamine as his heart rate continued to decrease. It was also found on his laboratory studies that the patient had hyperkalemia .Impression .Hyperkalemia secondary to worsening chronic kidney disease .Acute respiratory failure with hypoxia .Acute on chronic congestive heart failure .Fluid overload .Foot wound .Plan .Transfer to intensive care unit level of care for now .Nephrology has arranged for dialysis .will start on continuous positive airway pressure at night and with naps .wound care and ortho have been consulted for foot wound .Weight 144.8 Kg [318.56 pounds, this is a 43.56 weight gain since 9/1/2022] .ProBNP [B-type natriuretic peptide] of 12,709 .[levels are higher when heart failure is worse] .9/13/2022 with shortness of breath and anasarca [generalized swelling throughout the body] with recent 40 pound weight gain . During a telephone interview on 2/21/2023 at 8:08 AM, the Resident's daughter was asked about Resident #3's stay in the facility. The daughter stated .my father was taken to this facility from the hospital on September 1, 2022 .he came for rehab [rehabilitation] .he had fluid buildup starting to form on the second day .it got worse on the third day .he starts developing fluid chest and stomach .they said he was to get catheter .they never did anything .we pulled him out .we called an EMS [emergency medical services] .he could not breathe .my mom went there and said call EMS .or I'm calling the cops .he had an IV [intravenous] drip of antibiotics .he was to get it 3 times a day .he was lucky he got it once a day .for infection in his foot .[Named LPN #4] .she was his nurse for that day .she called the EMS for my mom to get him out of there . The daughter was asked if she was Resident #3's responsible party and should the facility notify her of changes. The daughter stated .Yes . The daughter was asked if the facility provided any education on his fluid restriction or mention he was noncompliant. The daughter stated .No .if he was on a fluid restriction, they would bring him pitchers of water each day . The daughter was asked if they [family] brought in extra fluids for Resident #3. The daughter stated .no ma'am .the only way he had fluids .if they gave it to him . During a telephone interview on 1/3/2023 at 2:14 PM and 2/16/2023 at 12:52 PM, Nurse Practitioner (NP) #1 was asked what interventions were in place for Resident #3. NP #1 stated .Lasix .gave a dose of IV [intravenous] Lasix .monitor weight daily . The NP #1 was asked should the nursing staff have monitored his weight daily. NP #1 stated .Yes .when have CHF, fluid overload, on fluid restriction of 1000 ml a day and on I's and O's [input and output] . NP #1 was asked would you expect the nursing staff to follow physicians orders. NP#1 stated .Yes . The NP #1 was asked how the orders get to the nurse staff and put into the system. NP #1 stated .I tell them verbal or write on the lab paper .I will make my notes that what I did .when I tell them .if they don't carry out the order I'm not going to pin point .I follow up .see if done .I put on my notes .I tell them the assessment and plan .before I do that .I have told the nurse, or the nurse manager on that side, I don't document who I talked to . The NP was asked should nursing staff members follow recommendations and plan. NP #1 stated .Yes .that's what is taught in school . During an interview on 2/15/2023 at 5:17 PM, the Director of Nursing (DON) was asked if the NP ordered daily weights, how was that information relayed to the nursing staff? The DON confirmed the nursing staff did not receive the orders for daily weights. The DON was asked what should have been done when Resident #3's 18. 8 pound weight gain was discovered. The DON confirmed the facility should have gotten a re-weight and notified the NP. The DON was asked what should the staff do if the resident goes over the 1000 ml fluid restriction. The DON confirmed the resident should not go over recommended fluid restriction, but if he/she does go over restricted amount, should notify the family, notify the NP and the MD, and do education with the family and resident. During a phone interview on 2/16/2023 at 11:17 AM and on 2/21/2023 at 12:03 PM, the Registered Dietitian (RD) was asked if she goes to Resident #3's room for her initial assessment, what is the process. The RD stated .I can't remember if I went to see him or not .I can't remember .Normally I would go and say hi and see if [the resident] have any food preferences .and any updated .I go and do a beside visit or if in the dining room .I go see them to see if chewing issues .want chocolate milk with the lunch anything . RD was asked about the nutrition assessment with no mention of the resident weight gain or initial weight is that correct. The RD stated .Yes . The RD was asked if a resident have a significant weight gain in a short period of time what intervention would she put in place. The RD stated .I wound notify the NP and MD .I would think it had to be fluid .I would make them aware in this short time .I recommended he receive 720 ml from dietary and 280 ml from nursing . The RD was asked if it was realistic for nursing to be limited to 280 ml when the resident was receiving antibiotic intravenous infusion of 300 ml a day . The RD stated .No . During an interview on 2/16/2023 at 11:22 AM, the Assistant Director of Nursing (ADON) was asked should you care plan if a resident is noncompliant and educated the resident and family. The ADON stated .Yes .if identified .the nurse document .we chart education on fluid restriction . The ADON was asked was it realistic to give 720 ml for dietary and 280 ml for nursing when the resident was getting 300 ml in antibiotics. The ADON stated .No ma'am .I do not . The ADON was asked how often are the weight and wound meetings held and who attends the meetings. The ADON confirmed the weight and wound meeting are held weekly and the DON, myself, the managers, and treatment nurse attend the weekly meeting. During an interview on 2/21/2023 at 10:56 AM, MDS #1 confirmed if a resident is on a fluid restriction and diuretics, it should be captured on the care plan. The MDS #1 confirmed if there is an order, we normally do the initial care plan based on the resident's diagnosis and if there are changes, we update the care plan. During a telephone interview on 2/21/2023 at 2:55 PM, The Medical Director was asked if a resident had an 18 pound weight gain what is the expectation of the staff. The Medical Director stated .normally if that is the case .they let us know if there is a big change . The Medical Director confirmed the nursing staff should follow the orders for fluid restriction and if the resident is noncompliant would expect to see documentation in the chart. The Medical Director was asked about documentation in the history and physical of a urinary catheter. The Medical Director stated .yes, I had them do an ultrasound to see if need placement of a urinary catheter .based on the results of the ultrasound .yes . During a telephone interview on 2/21/2023 at 4:19 PM, the Ex-wife was asked to tell me about the day she came to the facility to checked out Resident #3. The ex-wife stated .the night before he called to tell me how bad he was .he was complaining .I was there the next morning at 8:00 AM .I talked to his nurse .I want him out of there .we had been telling them for days he could not breath .he was retaining fluid .they said many times was going to put catheter in him .they never did .we got tired of them not doing anything .he was there for wound care of his feet .they were going to let him die .that's my opinion .they said they tried get hold of the doctor for EMS [emergency medical services] .she [nurse] asked my relationship .told her the ex-wife, next of kin .she took care of it .he had hallucination .did not know what was going on .was starting at me .not acknowledge what I was doing . The Ex-wife was asked how often she came to visits Resident #3. The Ex-wife stated .6 times while he was there .I came on the day shift .evening and weekend . The Ex-wife was asked if she noticed any swelling. The Ex-wife stated .Yes .he could not lay in his bed .he slept in a chair in that room for days .his legs, arms, and chest you could see it .his chest was getting bigger .in his face, everywhere .my understanding was they had an order .to put one [catheter] in, it never happen .when he got to the ER they looked at me and said where did he come from .they let him get to this .he went straight to ICU [intensive care unit] and went to dialysis to get fluid off of him . Did they [facility staff] tell you he was noncompliant or educate you and him on his fluid intake. The Ex-wife stated .I never heard that .I know they kept bringing him water .after awhile he was not drinking or eating .he was so full from the fluid .he could not eat . During a phone interview on 2/22/2023 at 8:04 AM, the Restorative CNA was asked if she weighed Resident #3 on 9/1/2022 and on 9/6/2022. The Restorative CNA stated .Yes .ma'am .more than likely I was the only one doing the weights at that time . Restorative CNA was asked if she knew if Resident #3 had a 18 pound weight gain. Restorative CNA stated .No .ma'am . The Restorative CNA was asked how she tracked the weights of the residents. The Restorative CNA stated .I do not keep up with the weight gain or loss .I give them [weights] to the DON . There was no documentation Resident #3 was monitored for daily weight changes, edema, care planned for fluid restrictions or received education on fluid restriction. The failure of the long term care facility to monitor the resident's weight and edema status as well as ensure the resident was on fluid restrictions resulted in an eighteen 18.8 pound weight gain over five days. The resident was sent to the hospital on 9/13/2022 with increased shortness of breath and swelling. The resident was admitted to ICU for treatment. There was no further weight documentated prior to the transfer to the hospital. When the resident was admitted to the hospital, the weight of the resident was documented at 318.56 pounds. Resident #3 gained 43.56 pounds from 9/1/2022 to 9/13/2022 while receiving care at this long term care facility.

Based on policy review, medical record review, and interview the facility failed to notify the family of a resident's significant weight gain for 1 of 3 (Resident #3) sampled residents reviewed for change in condition and failed to notify the resident's responsible party, Nurse Practitioner and Medical Director of a fall for 1 of 3 (Resident #6) sampled residents reviewed for falls. The findings included: 1. Review of the facility's policy titled Notification of Change, revised 11/30/2017, revealed .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies the resident's representative, consistent with his or her authority when there is a change requiring notification .Circumstances requiring notification include .Accidents .resulting in injury .Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health .exacerbation of a chronic condition . 2. Medical record review revealed Resident #3 was admitted on [DATE] with a diagnosis of Diabetes, Peripheral Vascular Disease, Heart Failure, End Stage Renal Disease, Congestive Heart Failure, and Malignant Neoplasm of Kidney. Review of Patient Weight Report revealed Resident #3 weighed 275 lbs on 9/1/2022, the day of admission to the facility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 15 indicating he was cognitively intact, weighed 294 pounds (lbs), and had no weight gain. Review of Patient Weight Report revealed Resident #3 revealed on 9/6/2022 the resident weighed 293.80 lbs five (5) days after admission to the facility. Review of the FULL NUTRITIONAL ASSESSMENT, dated 9/6/2022, revealed .Date admitted .9/1/2022 .Diet Order .Fluid Restriction .1000 [mililiters (ml)] .Weight Gain Comments .[blank] .WEIGHT (in pounds) 293.80 .Edema .No .Resident admitted to the facility on [DATE]. Admit wt .293.8 lbs [the resident's admission weight was actually 275 lbs] .1000 ml fluid restriction ordered .Staff to monitor weekly weights x 4 and wound healing . Resident #3 had an 6.39 % weight gain from admission of 9/1/2022 to 9/6/2022 resulting in a 18. 8 pound weight gain in 5 days. The Nutrition assessment failed to capture Resident #3's admission weight of 275 pounds. During a telephone interview on 12/28/2022 at 8:27 AM and on 2/21/2023 at 8:08 AM, the daughter was asked if she was Resident #3's responsible party (RP) and should the facility notify her of changes. The daughter confirmed she was Resident #3's RP. Resident #3's daughter also confirmed the facility did not notify her when Resident #3 had an changes in his condition. During an interview on 2/15/2023 at 5:21 PM, the Director of Nursing confirmed the responsible party and the Medical director or Nurse Practitioner should be notified with all falls and any changes in condition. During a telephone interview on 2/21/2023 at 2:55 PM, the Medical Director was asked if a resident had an 18.8 pound weight gain what would he expect the staff to do. The Medical Director stated, .normally if that is the case .they let us know if there is a big change . The Medical Director confirmed the nursing staff should follow the orders for fluid restriction and if the resident is noncompliant, he would expect to see documentation in the chart. 3. Medical record review revealed Resident #6 was admitted on [DATE] with a diagnosis of Coronary Artery Disease, Hypertension, Lower Back Pain, Anxiety Disorder, Edema, Hemiplegia, Diabetes, and Chronic Pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) of 11 indicating the resident was moderately impaired and required physical help with transfer. Review of the Clinical Notes Report dated 1/19/2023 at 11:53 AM revealed, .Resident reported to this nurse she had a fall last week and she has been hurting on her left side since then. Resident daughter was present when resident reported this to this nurse [Licensed Practical Nurse [LPN #1]. Resident stated CNA [Certified Nursing Assistant #1] dropped her when transferring her to chair from bed. Resident also stated CNA stated she reported fall to UM [Unit Manager #1]. Resident stated UM never came. Resident also stated she reported pain to her left side and fall yesterday to therapy. Therapy informed resident pain and fall was reported to UM. Today daughter stated she was very upset she was not notified and tx [treatment] was not provided to her mother. This nurse reported concerns and complaints to DON [Director of Nursing], and NP [Nurse Practitioner]. Awaiting instructions from NP. This nurse administered scheduled PRN [as needed] medication to resident for pain. Resident stated pain is 10 out of ten to her whole left side. Resident stated upper arm does not hurt. This nurse assessed resident for bruising, and injury. None noted. No swelling noted .Xray [Radiology] of affected extremity . Review of the Clinical Notes Report dated 1/19/2023 at 2:50 PM revealed, .Therapy staff member notified this nurse that resident did not want to participate in therapy. Therapy informed this nurse that resident stated her left arm was sore because resident had a fall, last week. Therapy further stated the resident did not want to tell her who was with her when she fell . This nurse informed therapy I would speak with resident. This nurse went to resident's room to inquire about fall and when it happened. Resident stated the CNA [Certified Nursing Assistant] was helping her transfer from wheelchair to bed when her leg gave out. Resident further stated the cna [CNA]: helped her to the floor. Resident state they [she and the the CNA] were able to get her up by pushing up on bed and using the arm of wheelchair. Whem [when] this nurse inquired who was the cna, resident reluctantly stated CNA's name. This nurse Immediately spoke with ADON [Assistant Director of Nursing] for instructions. Event not [note] completed regarding resident's self-reporting and interventions . Review of the GRIEVANCE RECORD dated 1/19/2023 revealed .RP [responsible party] was informed today by resident of an assisted fall that occurred one week ago and she [the resident's responsible party] is upset that she did not receive notification from staff nor f/u [follow-up] x-ray were ordered .event was not reported until today [1/19/2023] . During a telephone interview on 2/13/2023 at 11:55 AM, Daughter #1 was asked when was she notified by the facilty of Resident #6's fall, she stated .when she [Resident #6] called me on the 18th she was in pain and let her fall she reported to therapy .they reported it to [Named unit manager #1] . During an interview on 2/13/2023 at 12:06 PM, Resident #6 was asked what happened when she fell in the facility. Resident #6 stated .the girl let me fall .that how everything got started .[Named CNA #1] .said she reported it to [Named Unit Manger #1] .it was in the day time .they were getting me ready for therapy .she was trying to get me out the bed .she told them she placed me on the floor .but she did not .she let me fall .I hurt my back .she tried to get me up herself .I was trying to help her .she put the wheelchair behind me .she had my arm pulling me up off the floor .she got me back to the wheelchair .I helped her . During an interview on 2/15/2023 at 10:54 AM, Unit Manager #1 was asked how she found out Resident #6 had fallen. Unit Manager #1 stated .therapy came to me one afternoon .I was at nursing station .[therapy] told me the patient said she had a fall the week before .she did not want to do therapy, her arm was sore .she didn't fall by herself .someone was with her .she did not want to get her in trouble .went to the patient room .asked her what happen .where .how did she fall .she stated beside her bed .did someone help you .she said [Named CNA #1] .was with me .I asked her what was going on .she said she was trying to help her with transfer .her leg gave out .I was supposed to write event note on the 18th .I just forgot to complete the note .I had a lot going .I honestly forgot to do it .the next day I put it in as a self-reported fall .resident reported to me . Unit Manager #1 was asked if she notified the responsible party. The Unit Manager stated .No .I was writing up because I did not call the daughter to notify her .not sure with the self-report I was to notify the daughter . In reviewing the event note the Unit Manager was asked how she determined the resident did not have any injuries. The Unit Manager stated .No .I Can't .

Based on policy review, medical record review and interview, the facility failed to provide treatment and care as ordered by the physician when orders for fluid restrictions, intravenous medications, and wound care treatments were not provided for 1 of 3 (Resident #3) sampled residents reviewed for fluid restriction and wound care. The findings included: 1. Review of the facility's policy titled Medication Administration revised 1/2021 revealed, .Medications will be administered by Licensed medical or nursing personnel .While administering medication the nurse will observe the 8 Rights of Medication Administration .Right Time - Check to ensure the medication is given within the time constraints of the order . Review of the facility's policy titled Physician's Verbal Orders revised 5/24/2021 revealed, Physician orders may be received by telephone, by a licensed nurse .The physician should sign the order on his/her next visit to the facility .Follow through with orders by making appropriate contact or notification .Verbal orders are those given to the nurse by the physician in person or by telephone, however, are not written by the physician in the medical records . Review of the facility's policy titled Pressure Injury Prevention and Non-Pressure Ulcer Management revised 10/15/2021 revealed, .This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. It is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure ulcers/injury present, and to promote wound healing of various types of wounds in accordance with current standard of practice and Physicians orders .Diabetic ulcer refers to ulcers caused by the neuropathic and small blood vessel complications areas of Diabetes. They typically occurs over the planter (bottom) surface of the foot on load bearing areas such as the ball of the foot .Surgical wound refers to any healing and non-healing, open or closed surgical incision .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, starting with prompt assessment and treatment, including efforts to identify risk, stabilize, reduce or remove underlying risk factor, monitor the impact of the interventions, and modify the interventions as appropriate .Evidenced-based treatment in accordance with current standards of practice will be provided for all residents who have a pressure injury, non-pressure ulcer or other skin damage .Pressure injuries will be differentiated form non-pressure ulcers/injuries, such as arterial, venous, diabetic, surgical . 2. Medical record review revealed Resident #3 was admitted on [DATE] with a diagnosis of Diabetes, Peripheral Vascular Disease, Heart Failure, End Stage Renal Disease, Congestive Heart Failure, and Malignant Neoplasm of Kidney. Review of Patient Weight Report revealed Resident #3 weighed 275 pounds (lbs) on 9/1/2022, the day of admission to the facility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 15 indicating he was cognitively intact, weighed 294 pounds, and had no weight gain. (This was a 19 lb weight gain since admission on 9/1/2022). Review of Physician's Orders dated 9/1/2022 revealed the following: .CEFAZOLIN FOR INJECTION 1 GM [gram] (1gm/NS [normal saline] 100 ml [mililiters]) .Three Times Daily for Nine Days . Intake and Output (I & O) Two Times Daily . Wound Care Consult .Wound Care .(R) [right] foot Wash with Betadine Sol [solution], & [and] rinse there after each time with NACL [sodium chloride] sol. For irrigation. Blot dry with 4 x 4 [4 inches wide and 4 inches long] gauzes, Apply a thin film of Iodosorb 0.9 % [percent] topical gel ointment to the wound. Cover with DSG [dressing] bid [twice a day] & PRN [as needed] .Two Times Daily . (L) [left] foot Wash wound with Betadine Sol, & rinse there after each time with NACL sol [solution].for irrigation Blot dry with 4x4 gauzes, Apply a thin film of Iodosorb 0.9 % topical gel ointment to the wound. Cover with DSG bid & PRN .Two Times Daily . Review of Physician's Orders dated 9/2/2022, revealed .Wound Care Every 1 Day .(L) pinky toe Wash wound with Betadine Sol, & rinse there after each time with NACL sol for irrigation. Blot dry with 4x4 gauzes, Apply a thin film of iodosorb 0.9 % topical gel ointment to the wound. Cover with DSG bid & PRN . Review of Physician's Orders dated 9/8/2022 revealed .Wound Care Every 1 Day (R) foot Wash with Betadine Sol, & rinse there after each time with NACL sol. for irrigation. Blot dry with 4x4 gauzes, Apply a thin film of iodosorb 0.9 % topical gel ointment to the wound. Cover with DSG bid & PRN .Two Times Daily . (L) foot Wash wound with Betadine Sol, & rinse there after each time with NACL sol. for irrigation. Blot dry with 4x4 gauzes, Apply a thin film of Iodosorb 0.9 % topical gel ointment to the wound. Cover with DSG bid & PRN .Two Times Daily . Review of the Treatment Administration Record (TAR) for the month of SEPTEMBER 2022 revealed the resident's fluid intakes: on 9/2/2022 the resident's intake was 2000 ml, 1000 ml above restriction; on 9/7/2022 the resident's intake was 1100 ml, 100 ml above restriction; on 9/8/2022 the resident's intake was 1030 ml, 30 ml above restriction, and on 9/11/2022 the resident's intake was 1200 ml, 200 ml above restriction. Review of the TARecord for the month of SEPTEMBER 2022 revealed the following treatments were missed on the resident's right foot: 9/2/2022 on the 7pm-7am shift; 9/3/2022 on the 7am-7pm shift; 9/4/2022 on the 7pm-7am shift; 9/5/2022 on the 7pm-7am shift; 9/6/2022 on the 7am-7pm shift, and 9/7/2022 on the 7pm-7am shift. Review of the TARecord for the month of SEPTEMBER 2022 revealed the following treatments were missed on the resident's left foot: 9/2/2022 on the 7pm-7am shift; 9/3/2022 on the 7am-7pm shift; 9/4/2022 on the 7pm-7am shift; 9/5/2022 on the 7pm-7am shift; 9/6/2022 on the 7am-7pm shift, and 9/7/2022 on the 7pm-7am shift. Review of the TARecord for the month of SEPTEMBER 2022 revealed the following treatments were missed on the resident's pinky toe: 9/2/2022; 9/3/2022; 9/4/2022; 9/5/2022; 9/6/2022, and 9/7/2022. Review of the Medication Administration Records date SEPTEMBER 2022 revealed the resident missed the following doses of Cefazolin 1 gm: 9/6/2022 at 8:00 AM, 9/6/2022 at 4:00 PM, 9/9/2022 at 12:00 AM, 9/9/2022 at 4:00 PM, and 9/10/2022 at 4:00 PM. During an interview on 2/15/2023 at 5:17 PM, the Director of Nursing (DON) was asked should the nursing staff follow doctors' orders. The DON confirmed the staff should follow the doctors' orders. During a telephone interview on 2/21/2023 at 2:55 PM, the Medical Director was asked should the nursing staff follow doctors' orders. The Medical Director confirmed the nursing staff should follow the doctors' orders.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the residents were free of accidents and ensure assistive devices were in good working order for 3 of 4 (Resident #6, 8, and 12) residents reviewed for falls. The findings included: 1. Review of the facility's policy titled Fall Risk - Fall Prevention revised 2/20/2020 revealed .To provide a coordinated system to identify Resident at risk for falls and develop an individual interdisciplinary plan of care to reduce the risk of falls and subsequently injury .The fall risk assessment will be completed by a licensed nurse . upon admission/readmission to the facility .After a fall .Maintenance Director or designee will ensure equipment used by the resident is in working order . Review of the facility's policy titled Occurrence Reporting revised 12/1/2022 revealed, .Our facility shall strive to provide a safe environment with methods to reduce accidents and methods to minimize injury form accidents .The following are examples accidents/incidents are events/occurrences that require the completion of a Nurse event note .Falls .All observed, reported, or other acquired knowledge of and occurrence shall be reported to the charge nurse or DON [Director of Nursing] by the employee who finds or witnesses the incident .The charge Nurse shall initiate the investigation by interviewing and gathering witness statements .from staff, resident .to determine the root cause . 2. Medical record review revealed Resident #6 was admitted on [DATE] with a diagnosis of Coronary Artery Disease, Hypertension, Lower Back Pain, Anxiety Disorder, Edema, Hemiplegia, Diabetes, and Chronic Pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment, and required physical help with transfer. Review of the Physician's Orders dated 12/12/2022 revealed, .Transfer .Dependent w/ use of Mechanical Hoyer lift x 2 person . Review of the Care Plan dated 12/12/2022 revealed, .At Risk For Falls R/T [related to] left side deficits .1/18/2023 fall .intervention - repair locks on wheelchair .Remind .to call for assistance before moving from bed-to-chair and from chair-to-bed . Review of Physical Therapy Notes dated 12/12/2022 revealed .Comments .Min A [minimal assist] . Review of the Occupational Therapy Note dated 1/18/2023 revealed Precautions .fall risk .left side weakness .Pt stated her left side hurts today, no weight exercised done on that side. Nursing was informed of pain . Review of the Interdisciplinary Team Occurrence Investigation Worksheet, revealed .Date of incident .1/18/2023 (reported) .if yes, what type of injury .L [left]-side pain .medical treatment .x-ray .possible contributing factors .other w/c .Physical Function problems that may have contributed to the fall .Gait disturbance .Muscle Weakness .Loss of balance .Intervention(s) put in place .replacement of defective equipment . Review of the NURSE'S EVENT NOTE dated 1/19/2023 (no time documented) revealed .Resident stated she had fallen, last week in her room. CNA [Certified Nursing Assistant] was assisting her with transfer from wheelchair to bed. Resident stated her leg gave out and CNA assisted her to sitting position on floor. Resident further stated she did not hurt herself .Observed fall .Injury No apparent injury .1/19/2023 .13:40 [1:40 PM] .Resident reported to therapy staff member that her left arm was hurting and she did not want to participate. Resident reported to therapist that she had a fall sometime last week. This nurse inquired of resident regarding fall. Resident stated she was being assisted from her wheelchair to her bed, by a CNA, when her leg gave out and she fell to floor with CNA's assistance. She further stated she and the CNA were able to get her into bed. Stated she did not have any pain at the time . Review of the Clinical Notes Report dated 1/19/2023 at 11:53 AM revealed .Resident reported to this nurse she had a fall last week and she has been hurting on her left side since then. Resident daughter was present when resident reported this to this nurse [Licensed Practical Nurse (LPN #1)]. Resident stated CNA #1 dropped her when transferring her to chair from bed. Resident also stated CNA #1 stated she reported fall to UM [Unit Manager (#1)]. Resident stated UM never came. Resident also stated she reported pain to her left side and fall yesterday to therapy. Therapy informed resident pain and fall was reported to UM. Today daughter stated she was very upset she was not notified and tx [treatment] was not provided to her mother. This nurse reported concerns and complaints to DON [Director of Nursing], and NP [Nurse Practitioner]. Awaiting instructions from NP. This nurse administered scheduled PRN [as needed] medication to resident for pain. Resident stated pain is 10 out of ten to her whole left side. Resident stated upper arm does not hurt. This nurse assessed resident for bruising, and injury. None noted. No swelling noted .Xray [Radiology] of affected extremity . Review of the Clinical Notes Report dated 1/19/2023 at 2:50 PM revealed .Therapy staff member notified this nurse that resident did not want to participate in therapy. Therapy informed this nurse that resident stated her left arm was sore because resident had a fall last week. Therapy further stated the resident did not want to tell her who was with her when she fell . This nurse informed therapy I would speak with resident. This nurse went to resident's room to inquire about fall and when it happened. Resident stated 'the CNA was helping her transfer from wheelchair to bed when her 'leg gave out.' Resident further stated 'the cna helped her to the floor.' Resident stated 'they [she and the CNA] were able to get her up by pushing up on bed and using the arm of wheelchair.' Whem [when] this nurse inquired who was the cna, resident reluctantly stated CNA's name. This nurse Immediately spoke with ADON [Assistant Director of Nursing] for instructions. Event not [note] completed regarding resident's self-reporting and interventions . Review of the Interdisciplinary Team Occurrence Investigation Worksheet revealed, .Date of incident .1/18/2023 (reported) .if yes, what type of injury .L [left]-side pain .medical treatment .x-ray .possible contributing factors .other w/c .Physical Function problems that may have contributed to the fall .Gait disturbance .Muscle Weakness .Loss of balance .Intervention(s) put in place .replacement of defective equipment . During an interview on 2/13/2023 at 12:06 PM, Resident #6 was asked what happened when she fell in the facility. Resident #6 stated .the girl let me fall .that's how everything got started .[Named CNA #1] .said she reported it to [Named Unit Manger #1] .it was in the day time . getting me ready for therapy .she was trying to get me out the bed .she told them she placed me on the floor .but she did not .she let me fall .I hurt my back .she tried to get me up herself .I was trying to help her .she put the wheelchair behind me .she had my arm pulling me up off the floor .she got me back to the wheelchair .I helped her . During an interview on 2/13/2023 at 3:47 PM, the Assistant Director of Nursing (ADON) was asked when she was notified of Resident #6's fall. The ADON stated .on the 18th [1/18/2023] from [Named Unit Manager (UM) #1] .therapy reported to her [UM #1] the resident did not want to participate due to a fall one week ago . The ADON was asked if Resident #6 was assessed, an event note completed, and the family notified. The ADON stated .No .on the 19th [Named Licensed Practical Nurse [LPN #1] .informed me [Named Complainant] .wanted to speak to management . her mom had a fall she was unaware of .went and talked to the patient .tell me about that [the fall] .what happened .one time she said she was dropped .one time she said she was assisted with the fall .assessed her pain .we did order x-ray .they were clear no fractures .told her if she was in pain, she had prn [as needed] hydrocodone .I would get it scheduled .I did .I told the charge nurse to give her a pain medication . The ADON was asked if she knew the wheelchair was malfunctioning. The ADON stated .yes .I checked it out .assessed the wheelchair .it was still not working .it would not lock on the left side the wheelchair .it still moved . The ADON was asked should the staff member do with a malfunctioning wheelchair. The ADON stated .the nurse or the aide should put it in TELS [a building management platform that replaces logbooks and helps track preventative maintenance and any issues] . The ADON was asked should CNA #1 have moved the resident during the fall. The ADON stated .the aide should not move the resident .leave them there .report it .so the nurse can come assess the resident .help get them up off the floor .complete event note .write statements . The ADON was asked should the CNA #1 have written a statement the day of the fall. The ADON confirmed the staff members should have written statements the day of the fall and given to the charge nurse. During an interview on 2/14/2023 at 9:00 AM, CNA #1 was asked if she knew the wheelchair was malfunctioning and if she reported it to anyone. CNA #1 stated .Yes .ma'am .the Assistant Maintenance man .he said you still going to use the chair .she had 2 chairs in her room .one was to tight and uncomfortable .so I used her old one that was not working good .I was trying to get her up for therapy .get her up .she is a stand pivot .she holds with one hand .the side was not locking and the chair moved back away from us .I sat her on the floor .I asked her if she was comfortable with me getting her in the chair .took her arm and pants and moved her in the chair .I had her grab the side that locked .moved her to the wheelchair . CNA #1 was asked what is the process when you witness a fall. CNA #1 stated .with the fall assist to the ground .go get help .don't get them up .get the nurse come back and assess them .we lift them off the floor .report to the nurse and write a statement . CNA #1 was asked if she wrote a statement. CNA #1 stated .No .I should have .no ma'am I did not . CNA #1 was asked if she reported the fall. CNA #1 stated .I had been saying something about her wheelchair for the longest .when I told them chair messing up .nurse was charting and did not get up . CNA #1 was asked if she knew how to put things into TELS. CNA #1 stated .No .I don't know how to use TELS . During an interview on 2/14/2023 at 3:44 PM, LPN #2 was asked if she was informed by CNA #1 Resident #6 had a fall on 1/11/2023. LPN #2 stated .the [Named CNA #1] walked up and stated that [Named Resident #6] something was wrong with her wheelchair .she got her to the floor .she assisted her in the bed without help .I did move. It was not my resident . LPN #2 was asked if LPN #1 went to check on the resident. LPN #2 stated .I don't know if she looked at her or not .she said ok .I don't feel like I should go down and check on her resident when she was sitting there with me . LPN #2 was asked what is the process when aide report a resident has fallen. LPN #2 stated .If CNA comes to me I'm going straight to the resident room and assess them . LPN #2 was asked if she worked the 500 hall. LPN #2 stated .Yes .I pick up extra I have the 500 hall . LPN #2 was asked if she remembered getting in report Resident #6 had a fall. LPN #2 stated .did not remember get in report she had a fall .no .no one mention until she came back from therapy . LPN #2 was asked if she knew Resident #6 had a fall should she have completed follow-up note. LPN #2 stated .Yes . During a telephone interview on 2/15/2023 at 8:47 AM, LPN #1 was asked to tell me about Resident #6's fall. LPN #1 stated .all I know is one day went in to give medication .the daughter was in there .she said called the state .[going to] sue this place, her mother fell in the room .complained of pain to her left side .so then I went to the resident .talked to her asked what happened .she said [Named CNA #1] dropped her trying to transfer her from the bed to the wheelchair .dropped her on the floor . LPN #1 was asked what day was this on. LPN #1 stated .the 19th [1/19/2023], she told me the day before she reported to therapy .they reported it to the unit manager .I was on the hall passing meds [medication] .when I came in the room .that is when the daughter started to tell me what was said .then I asked the resident what happen .after [resident] told what happen .I asked why didn't she report it to me .I did not report because [Named CNA #1] .said she reported .who did she report it to .the lady with short hair and glasses . LPN #1 was asked if she remembered CNA #1 coming to the nursing station and report it to you and LPN #2. LPN #1 stated .she never reported to me .I told the DON if I dropped the ball .I would be professional to admit I dropped the ball .but to my knowledge, she never told me she had a fall or was attempting to fall .DON stated that she looked at the camera and [Named CNA #1] said LPN #2 .Assistant Maintenance Director was standing there .she did see the picture on the video .she said she do believe [Named CNA #1] did tell me .she wrote me up for not properly handling the fall .I did not agree to the write up .I'm no long working there .told her if woman called state .I will tell them what occurred when they call me . During an interview on 2/15/2023 at 9:54 AM, the Therapy Director was asked if Resident #6 received therapy and what type(s) of therapy. The Therapy Director stated .Yes .OT [Occupational Therapy] .upper body strength, dressing, and grooming . The Therapy Director was asked how did Resident #6 get to the therapy gym. The Therapy Director stated .the CNAs get her ready in her wheelchair .we would bring her to the gym . The Therapy Director was asked if Resident #6 had reported a fall. The Therapy Director stated .Yes .at the end of her treatment she [Resident #6] complained her left side was hurt .she [Resident #6] could not tell the day .she [Resident #6] said a few days ago . I asked .did it happen yesterday or the day before .she [Resident #6] said I don't recall the date .it was during the transfer .It did not go well .the CNA placed her [the resident] on the floor . The Therapy Director confirmed she reported it to Unit Manager #1. Therapy Director was asked if she knew the wheelchair was malfunctioning. The Therapy Director stated .I assisted her up in her chair .yes ma'am .I know one day when she was here .her wheelchair was not locking .I switched her chair out .I moved it out of the way .I do remember doing that . The Therapy Director was asked if she should have taken it to maintenance, put it into TELS, and documented the chair was malfunctioning. The Therapy Director stated .Yes .I probably should have .I did not put it into TELS .I just got busy .I did not document the wheelchair was not working in my notes . During an interview on 2/15/2023 at 10:54 AM, the Unit Manager #1 was asked how she found out Resident #6 had fallen. The Unit Manager #1 stated .therapy came to me one after noon .I was at nursing station .told me the patient said she had a fall the week before .she did not want to do therapy, her arm was sore .she didn't fall by herself .someone was with her .she did not want to get her in trouble .went to the PT [physical therapy] room .asked her [Resident #6] what happened .where .how did she fall .she [Resident #6] stated beside her bed . [asked resident] did someone help you .she [Resident #6] said [Named CNA #1] .was with me .I [UM #1] asked her [Resident #6] what was going on .she [Resident #6] said she [CNA] was trying to help her [Resident #6] with transfer .her leg gave out .did not fall she [CNA] helped me [Resident #6] down to the floor .asked the day she [Resident #6] fell if she was hurt .she said no .when I [UM #1]talked with her .she [Resident #6] said she hurt her arm .arm was sore .she [Therapy Director] told me on the 18th [1/18/2023] .I was supposed to write event note on the 18 th .I just forgot to complete the note .I had a lot going .I honestly forgot to do it .the next day I put it in as a self-reported fall .resident reported to me . The Unit Manager #1 was asked if she notified the responsible party. The Unit Manager stated .No .I was writing up because I did not call the daughter to notify her .not sure with the self-report I was to notify the daughter . In reviewing the event note the Unit Manager was asked how she determined the resident did not have any injuries. The Unit Manager stated .No .I Can't . During a telephone interview on 2/16/2023 at 4:35 PM, the Administrator was asked what is the process for reporting a wheelchair is malfunctioning. The Administrator stated .If have equipment not working .staff should put it in the TELS system for repair .tell staff equipment not working .when identified not working .chair unstable .that is the standard . The Administrator was asked what should the therapy staff do if notice a wheelchair not working. The Administrator stated .if she [resident] was in therapy .and the chair was not working .they [therapy] should have changed out the wheelchair .there should be some note she [resident] received a different chair .they [therapy] should have all the chairs numbered to identify the wheelchairs .when last time serviced . The Administrator was asked who is responsible for updating the order when there is a change in transfer. The Administrator confirmed the lead therapist/therapy manager should have made the changes. The Administrator was asked what should happen when a nurse finds out the resident had a fall. The Administrator stated .anytime reported there is a fall .she [nurse] should have done an assessment .gathered the staff statements .anyone else involved .try to get a picture of what occurred .that is part of the event note process .notify the medical doctor [MD] .responsible party .follow up on the fall .the MD may give order, for some labs .may send them out for an evaluation . The Administrator was asked should the MD/NP [Nurse Practitioner] come assess the resident after the fall. The Administrator state .Yes .If they are notified .they look at the resident .may not do it the same day .the Nurse Practitioner here more regular .when notified .she should have some type of intervention with the resident that they were notified and followed up . 3 Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with a diagnosis of Dementia, Hypertension, Dysphagia, Anxiety Disorder, and Gastroesophageal Reflux. Review of the quarterly MDS assessment dated [DATE] revealed Resident #8 had a BIMS of 3, indicating she was had severe cognitive impairment and required physical help with activity of daily living (ADL). The MDS documented Resident #8 had no history of falls. Review of the Occurrence dated 2/2/2023 revealed, .Location of the occurrence .Residents room .How was the Resident positioned when you observed them .laying of floor beside bed laying on her left side . Review of the NURSE'S EVENT NOTE dated 2/2/2023 revealed, .Location .Patient Room .Occurrence .Unobserved Fall .Injury Swelling .Indicate area of injury large lump on left side of forehead over left eye . There was no documentation on the event note that identified the laceration/skin tear above the residents right eye. Review of Initial skin assessment dated [DATE] revealed the resident had an injury to .Head .Top of Head .Left .Front .Distal . However, there was no description of the type of injury and did not indicate the skin tear above the right eye. The facility failed to complete an accurately skin assessment for Resident #8 after her fall and on returned to the facility from the hospital. Review of the Clinical Notes Report dated 2/2/2023 at 6:56 PM revealed, .This nurse was called to resident room to find resident laying on her stomach with her face down with bed in lowest position, this nurse assessed resident and resident could not explain what happened resident was place in the bed and VS are as following BP 129/71, 73,18, 96 % [percent], 98.0, UPON ASSESSMENT resident has large knot to left side of forehead above left eye, resident has no other skin issues or areas of concern. FNP [Family Nurse Practitioner] notified with new orders to send to hospital. Resident RP [Named daughter #2] notified with request to sent [send] to [Named Hospital] . Review of the Interdisciplinary Team Occurrence Investigation Worksheet dated 2/2/2023 .was medical treatment provided .transfer to ER .the root cause of occurrence poor safety awareness .Intervention(s) put in place .apply bed bolsters to bed to define bed parameters . Review of the [Named Hospital Records] dated 2/2/2023 revealed .EMS [emergency medical services] reported that they thought she had fallen but according to the staff they think that something fell off the shelf above her head hitting her on the left side of her face .She is stating that something fell of the shelf next to her bed as well .Skin .small 1 cm [centimeter] v shape skin tear to right face .PROCEDURE .cleaned patient's right temporal skin tear and applied Dermabond for closure .visible hematoma over her left eyebrow .Diagnosis .Head injury .facial hematoma .possible neck injury given patient's age and frailty despite her denying pain on exam .IMPRESSION .Facial hematoma .Facial laceration .PATIENT EDUCATION .Hematoma .Laceration Care .Follow up with primary care provider .Within 305 days .Laceration Care .Wash area with soap and water . Review of the Clinical Notes Report dated 2/3/2023 at 1:58 AM revealed, .Resident returned back to facility via ambulance on stretcher no s/s [signs and symptoms] of distress resident a [alert]x [times]2 has large hematoma to left eye, eye lid is swollen shut. Resident vs [vital signs] wnl [within normal limits] denies pain at this time will notify np [nurse practitioner] and md [medical director] and rp [responsible party] of resident's return . Review of the NURSE'S EVENT NOTE dated 2/14/2023 (12 days after the fall incident) revealed, .Location Incident Occurred .Patient Room .Injury Skin Tear .Indicate area of injury right side of head (near right temple) .This nurse was notified of area to resident right side of head .area has adhesive glue applied at hospital at time of resident LOA [leave of absent]. Area dry with sight scab noted. Resident shows no s/s [signs and symptoms] of pain or discomfort r/t [related to] area .Treatment nurse notified .RP [responsible party] advised this nurse she was aware and it was treated at the hospital . During a telephone interview on 2/14/2023 at 12:49 PM, Daughter #2 was asked about the incident when Resident #8 had a fall. Daughter #2 stated .Incident report was not filed till the next day and it seem incomplete .she scooted to the end of the bed .fell hit her forehead .found by [Named CNA #3] told the LPN [Named Unit Manager #2] .got off floor placed in bed [Named Unit Manager #2] called at 6:30 PM on 2/2/2023 .said she had fallen out of bed . spoke to NP .transfer to ER for CT [Computerized Tomography - scan to reveal abnormalities of the head/brain] .scan, [Name Hospital] .I met her there .my sister went to the nursing home .to talk to [Named Unit Manager #2] and the CNA had left for the day .she wanted to speak to them .light in the room was out, the power was out when talked to [named Unit Manager] the day she fell the power was out, she took photos and the fall mat not in front of bed was on the side .bed was low as it could go .1 foot off the floor .she had a skin tear on the right forehead .the DON said she examine [Resident #8] that morning .she had bruise on her left arm . During an observation and interview in the resident room on 2/15/2023 at 5:21 PM the DON was asked during a fall should the staff complete a head-to-toe assessment and skin assessment. The DON stated .when I assessed her .I saw the bruise on her left arm, the bruising on her cheeks and the knot over her the left eye .because she always wears a turban or a hat .I did take the hat off .no .I did not remove the hat .I was more concern about the knot to the left side of her face .She [the nurse] documents the bruising .the knot but not the laceration on the right forehead . The DON was asked to remove the black hat off the resident head. Observation on the right side of face above the right eye was a wound with Dermabond intact. The DON confirmed the nursing staff should complete a head-to-toe skin assessment. 4. Review of the medical record revealed Resident #12 was admitted on [DATE] with a diagnosis of Hypertension, Anxiety Disorder, Dementia, Esophagitis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 had a BIMS of 13, indicating she was cognitively intact. Resident #12 required physical help with activity of daily living (ADL) and had no history of falls. Review of the Care plan dated 1/22/2023 revealed .Interventions .Keep bed in lowest position .dycem to w/c [wheelchair] .Bed alarm in place .chair alarm .Footware will fit properly .have non-skid soles . Observation in the resident's room on 2/15/2023 at 5:17 PM with the Director of Nursing (DON) revealed Resident #12 did not have a bed alarm on her bed. During an interview in the resident's room on 2/15/2023 at 5:17 PM the DON was asked if Resident #12 should have a bed alarm as documented on the care plan, the DON stated, .yes .it should have been on her bed .staff should follow the care plan .resident care need should be followed .I'm the one who update the care need .I put the interventions in place .

Based on policy review, observation, and interview, the facility failed to maintain equipment in good repair in 1 of 1 (Resident #6) sampled residents reviewed for wheelchair function. The findings included: 1. The facility's INSTRUCTIONS DIRECT SUPPLY TELS [a building management platform that replaces logbooks and helps track preventative maintenance and any issues], dated 2/25/2023 revealed, .Inspect wheelchairs for damaged or missing components .check wheelchair for proper operation .Ensure wheelchair is tagged with resident's name .Items identified as poor condition should be removed from service . 2. Medical record review revealed Resident #6 was admitted on [DATE] with a diagnosis of Coronary Artery Disease, Hypertension, Lower Back Pain, Anxiety Disorder, Edema, Hemiplegia, Diabetes, and Chronic Pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) of 11 indicating she was moderately impaired and required physical help with transfer. Review of the Work Orders dated 1/1/2022 - 2/13/2023 revealed there were no work orders documented in TELS (TELS is a building management platform that replaces logbooks and helps track repairs) for the repair of any wheelchairs in the facility. During an interview on 2/15/2023 at 11:39 AM, Certified Nursing Assistant (CNA) #1 was asked how long was Resident #6's wheelchair not working properly. CNA #1 stated .I'm going to be honest .about a week before she fell .I know it was not working . CNA #1 was asked if she ever notice her having a different wheelchair. CNA #1 stated .No .not when I got her up . During an interview on 2/15/2023 at 5:17 PM, The Director of Nursing (DON) was asked to how long was the wheelchair malfunctioning. The DON stated .I was told the wheelchair was changed out by [Named CNA #1] .I was told the chair was in disrepair the week prior to the fall .on 1/18/2023 .ADON [Assistant Director of Nursing] went to her room and found she had the same chair .it would not lock the chair continued to move . The DON confirmed the wheelchair should have been removed. During an interview on 2/21/2023 at 1:23 PM, when the Maintenance Director was asked the process when staff identify malfunctioning equipment, he stated .anytime have problem with equipment .everything has to go thorough TELS .once it's put in TELS .we get to it .fix it .I make note in TELS .I put in a comment .I have them put it in TELS so we can track it .and know if there is something else needs to be done . Observation in the Therapy Gym on 2/21/2023 at 1:45 PM, with the Maintenance Director and the Therapy Director, revealed in the right side of the gym was a oversized and a high back wheelchair that was unlabeled. During an interview on 2/21/2023 at 1:45 PM, the Therapy Director and the Maintenance Director were asked the procedure for assigning and tracking a wheelchair when issued to a resident. The Therapy Director stated .our system is when we have a patient .we find an appropriate wheelchair .we don't have a system to track the wheelchairs . The Maintenance Director was asked if he completed preventive maintenance on a wheelchair when the resident is discharged . The Maintenance Director confirmed that he would just clean the wheelchair and return them back to therapy. The facility had no system in place to track the equipment when assigned to the residents.

Based on policy review, medical record review and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided during meal services for 1 of 4 (Resident #6) sampled residents reviewed for ADL care. The findings include: 1. Review of the facility's policy titled Resident rights and Resident Responsibilities revised 10/24/2022 revealed, .The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences . Review of the facility's policy titled Activities of Daily Living (ADLs), Revised 3/9/2022 revealed, .The facility shall, based on the resident's comprehensive assessment and consisted with the resident's needs and choices, ensure a resident's abilities in activities of daily living (ADL) do not deteriorate unless .Eating include meals and snacks .A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition . 2. Medical record review revealed Resident #6 was admitted on [DATE] with a diagnosis of Coronary Artery Disease, Hypertension, Lower Back Pain, Anxiety Disorder, Edema, Hemiplegia, Diabetes, and Chronic Pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) of 11 indicating she was moderately impaired. Resident #6 required physical help with transfer. Review of the Meal Times revealed .Dinner .500-600 Hall Cart .5:10 PM . This is the hall Resident #6 resided. Review of the GRIEVANCE RECORD dated 2/1/2023 revealed .RP [responsible party] informs that resident contacted her late evening on 1/31/23 [2023] and reported that she did not receive her supper tray . During an interview on 2/13/2023 at 11:17 AM, the Director of Nursing (DON) was asked should the residents receive their meal trays timely. The DON stated .Yes . During a telephone interview on 2/13/2023 at 11:55 AM, the complainant confirmed her mother did not get her meal tray till 10:00 PM on 1/31/2023. During a telephone interview on 2/22/2023 at 7:45 AM, Certified Nursing Assistant (CNA) #2 was asked about Resident #6 missing a meal. CNA #2 stated .I did not pass her tray that day .I had a cart myself .other people were giving her tray .she got her breakfast and lunch tray .during dinner that night someone had went home .I passed the 700 and 800 Hall trays .someone passed 500 .no one came to me and told I was responsible for passing her tray .someone had done it for breakfast and lunch that day . CNA #2 was asked if she was assigned to Resident #6 that day. CNA #2 stated .Yes .they gave me her . CNA #2 was asked who had passed the breakfast and lunch tray to Resident #6. CNA #2 stated .I'm sure the .nurse .

Based on the Centers for Disease Control and Prevention (CDC) guidelines, Employee Screening Logs, Employee Schedules, and interview, the facility failed to follow CDC infection control guidelines to ensure practices to prevent the potential spread of COVID-19 when 11 of 93 staff members (Certified Nursing Assistant (CNA) #1 and #2, Licensed Practical Nurse (LPN) #1 and #2, Dietary Staff #1, #2, #3, and #4, Housekeeping Staff #1, Business Office Staff #1, and Admission Nurse #1) failed to complete screenings for the prevention and detection of COVID-19 prior to working for 3 of 4 days (4/8/2022, 4/9/2022, and 4/11/2022) reviewed and when 4 of 4 staff members (CNA #3, #4, #5, and #6) failed to perform appropriate hand hygiene and appropriate infection control practices during perineal care. The facility had a census of 89. The findings include: Review of the CDC document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022, revealed .Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Establish a process to identify anyone entering the facility, regardless of their vaccination status .options could include (but are not limited to) : individual screening on arrival at the facility . Review of the Facility's Policy and Protocol Booklet titled, Coronavirus 2019 (COVID-19) Response Plan . revised 2/3/2022, revealed .pg. 18. All staff .are required to sign in the Screening Log at the receptionist desk .They will be screened for .presence of active signs and symptoms of respiratory illness . Review of the facility's undated policy titled, PERINEAL CARE FOR A FEMALE WITH HAND WASHING REQUIRED, revealed .Perform hand hygiene .Separate labia .Clean both sides of labia from front to back .Clean the middle of the labia from front to back using a clean portion of the washcloth with each single stroke .Rinse both side of labia from front to back .Rinse middle of labia from front to back .Pat dry .Scrub/wash hands together for at least twenty (20) seconds with soap .Rinse hands thoroughly .Dry hands .turn off faucet with a clean, dry paper towel . Review of the Employees Schedules and Employee Screening Logs from 4/6/2022 - 4/11/2022, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 4/8/2022- CNA #1, #2, Dietary Staff #1, and Business Office Staff #1 b. 4/9/2022- LPN #1, Dietary Staff #2, #3, and #4. c. 4/11/2022 LPN #2, Dietary Staff #1, Housekeeping Staff #1, Business Office Staff #1, and Admission Nurse #1. During an interview on 4/21/2022 at 8:25 PM, the Director of Nursing (DON) confirmed all staff should be screened for COVID-19 upon entering the facility and prior to beginning work. Review of the medical record, revealed Resident #57 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .maintain indwelling catheter .Catheter site care . Observation in the resident's room on 4/20/2022 at 2:39 PM, revealed CNA #3 and #4 entered Resident #57's room and entered the bathroom. CNA #3 washed his hands for 8 seconds and CNA #4 washed her hands for 6 seconds. CNA #3 filled a basin with water, donned (put on) his gloves, and positioned Resident #57 on her left side. Resident #57's catheter was not secured. CNA #3 moistened the washcloth and applied soap, cleaned from back to front on each side of the labia, and cleaned from back to the front and down the middle of the labia. CNA #3 dried the area from the back to the front of the labia and failed to rinse each area. Observation in the resident's room on 4/21/2022 at 3:39 PM, CNA #5 and CNA #6 entered Resident #57's room, placed down a barrier on the over bed table, entered the bathroom and filled a basin with water. CNA #5 and #6 donned their gloves and failed to perform hand hygiene. CNA #5 applied soap to a washcloth, cleaned in a downward motion from front to back on each side of the labia and dried the area. CNA #5 failed to rinse the area. During an interview on 4/21/2022 at 4:01 PM, the DON confirmed that the catheter should be secured. The DON confirmed the staff should wash, rinse, then dry, and wipe from front to back when performing perineal care. The DON confirmed that the staff should wash their hands for 20 seconds.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by carbon build-up on the pots and pans, dirty storage racks, pink substance build-up on the water curtain of the ice machines, dirty floors, a dirty dish machine, dirty utility carts and a dirty prep (prepare and make ready) table. The facility had a census of 93 with 85 of those residents receiving a tray from the Kitchen. The findings include: Review of the CLEANING SCHEDULE, revealed .Carts - Spray and wipe down outside Friday AM [morning] Aide .Kitchen Floors - Sweep Daily AM Aide . Review of the [Named] Department of Health and Human Services/Food Inspection and Safety, dated 2005, revealed .What exactly is slime .It is a type of mold or fungus that accumulates from bacterial growth on surfaces that are constantly exposed to clinging water droplets and warm temperatures. Water residuals may be present on these surfaces due to machine construction or the presence of scouring utensils such as steel wool or scouring pads. If the residuals are left exposed and not wiped clean or the machine is not sanitized regularly, you will then see bacteria and mold growths in the moist, cool environment of your ice machine. Most times, slime will take on a pinkish tone; if left untreated, the pink will turn to red, green, brown and even black ropes of slime hanging from the freezer panels inside the machine after a while . Observation in the Kitchen on 4/18/2022 at 9:25 AM and 4/20/2022 at 8:13 AM, revealed a large pot sitting on the 6-eye burner with carbon build-up coating over half of the pot on the outside. Observation in the Kitchen on 4/18/2022 at 9:28 AM and 4/20/2022 at 8:14 AM, revealed a large storage rack with white and brown crumbs and 5 sheet pans with large amount of carbon build-up. Observation in the Kitchen on 4/18/2022 at 9:31 AM, revealed the water curtain in the ice machine with a large amount of pink substance along the bottom of the water curtain. The water curtain was dripping into the ice machine. Observation in the Kitchen on 4/18/2022 at 9:33 AM, revealed at the hand sink, the floor had a large amount of dark stains that extended under the hand sink and the 3-compartment sink. Observation in the Kitchen on 4/18/2022 at 9:34 AM and 4/20/2022 at 8:40 AM, revealed the top of the dish machine had large amount of dried food particles and dark brown stains covering the top. Observation in the Kitchen on 4/18/2022 at 9:34 AM and 4/20/2022 at 8:42 AM, revealed 10 sheet pans, 2 sauce pots and 2 large skillets with a large amount of carbon build-up on a drying rack in the dish room. Observation in the Kitchen on 4/18/2022 at 9:37 AM and 4/20/2022 at 8:32 AM, revealed 6 utility carts with a large of amount of food substance and brown stains on the outside of the utility carts in the clean area of the kitchen. Observation in the Kitchen on 4/18/2022 at 9:39 AM and 4/20/2022 at 8:31 AM, revealed a prep table with a large amount of dark dried substance and white particles on the top and the middle shelves. Observation in the Kitchen on 4/20/2022 at 8:37 AM, revealed in the dish room there was a utility cart with a large of amount of brown stains on the inside and outside of the cart, with a large amount of food particles and a used medication cup, with several clean cups, bowls, plates, and divided plates. During an interview on 4/20/2022 at 8:48 AM, the Director of Nutrition Services confirmed the ice machines should not have pink substance on the water curtain, and the Kitchen should not have carbon build-up on the pots and pans. The Director of Nutrition Services confirmed the Kitchen should not have dirty utility carts, dirty prep tables, dirty equipment, and dirty floors. Observation in the 400 Hall Nourishment Room on 4/20/2022 at 10:57 AM, revealed along the bottom of the water curtain was a thin line of pink substance and a white dried substance on the inside ledge of the ice machine. During an interview on 4/20/2022 at 11:25 AM, the Dietary Manager (DM) confirmed that the ice machines should be checked daily and completely emptied and cleaned monthly. During an interview on 4/21/2022 at 5:06 PM, the DM confirmed that he is responsible for monitoring the dietary staff and the cleaning of the Kitchen. The DM confirmed the pots and pans should not have carbon build-up, should not have pink substance build-up in the ice machines, should not have dirty utility carts, dirty prep tables, dirty equipment, and dirty floors.

Based on the policy review, medical record review, and interview, the facility failed to communicate with [CONDITION(S)] for 1 of 1 sampled residents (Resident #67) reviewed for [CONDITION(S)]. The findings include: Review of the facility's policy [CONDITION(S)], dated 10/18/2021, revealed .The facility will communicate, coordinate, and collaborate relevant information with the [CONDITION(S)] clinic to ensure safe, continuous care of the resident .communication .which is sent to [CONDITION(S)] .[CONDITION(S)] clinic will communicate .by returning the completed .form to the facility .Documentation will include assessment of the resident's condition before and after [CONDITION(S)] .pre and post [CONDITION(S)] weights .skin integrity .nutrition/hydration .evidence of infection, bleeding .complications . Review of the medical record, revealed Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[CONDITION(S)] Monday-Wednesday-Friday .[Named [CONDITION(S)] Facility] . Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #67 was assessed for receiving [CONDITION(S)] services. Review of the medical record, revealed the [CONDITION(S)] Communication Forms were completed on 3/31/2022, 4/5/2022, and 4/7/2022. Review of the medical record, revealed Resident #67 also went to the [CONDITION(S)] on 4/2/2022, 4/9/2022, 4/12/2022, 4/14/2022, 4/16/2022, and 4/19/2022. The facility was unable to provide communication sheets for each [CONDITION(S)] visit. During an interview on 4/21/2022 at 4:02 PM, the Director of Nursing (DON) confirmed the communication sheets should be completed with each [CONDITION(S)] visit.

Based on medical record review, observation, and interview, the facility failed to ensure residents were assisted with Activities of Daily Living (ADLs) for 2 of 3 sampled residents (Resident #11 and #45) reviewed for ADLs. The findings include: Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Care Plan revised 10/11/2021, revealed .Self care deficit .bathing .hygiene .Bathing - Bath/Shower .3x[times]week/prn [as needed] as tolerated alternating days with bed baths . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #11 was severely impaired cognitively, and was dependent on staff for ADL's. Review of the of the ADL Verification Worksheet dated 4/1/2022 - 4/21/202, revealed Resident #11 received no baths or showers. The facility was unable to provide documentation of Resident #11's baths or showers. Observation in the resident's room on 4/18/2022 at 10:16 AM and 4/18/22 at 5:09 PM, revealed Resident #11 had large amount of dry flaky skin on his face and forehead, and a large amount of white flakes in his hair. During an interview on 4/21/2022 at 3:29 PM, the Director of Nursing (DON) confirmed the ADL sheet should be completed daily and Resident #11 should have received a bath or shower 3 times a week. During an interview on 4/21/2022 at 7:17 PM, Certified Nursing Assistant (CNA) #3 stated .most of them [residents] are not getting shower/baths .there are some that are vocal .if they complain .they will get one [shower/bath], we have scheduled shower day .residents are not going as shower schedule .we document the showers or bath on the kiosk [computer for daily documentation of ADLs] .if not documented .they did not get it .I know the rule if not documented it was not done .we have had multiple meeting about the showers . CNA #3 confirmed Resident #11 has not had baths or showers three times a week. Review of the medical record, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 12/17/2021, revealed .Self care deficit R/T [related to] ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, and transfers .Bathing - Bath/Shower .3xweek and as needed or requested . Review of the ADL Verification Worksheet dated 2/2/2022-4/14/2022, revealed Resident #45 received a shower on 2/3/2022, and bed baths on 2/2/2022, 2/8/2022, 2/11/2022, 2/13/2022, 2/18/2022, 3/2/2022, 3/8/2022, 4/5/2022, 4/8/2022, and 4/14/2022. Review of the ADL Flow Sheets for 2/1/2022-4/19/2022, revealed Resident #45 received showers on 2/15/2022, 2/21/2022, 2/25/2022, 3/3/2022, 3/10/2022, 3/17/2022, 3/20/2022, and 4/9/2022. Review of the facility's ADL bath and shower documentation revealed the following: Resident #45 was documented as having received 2 baths or showers the weeks of 2/6/2022-2/11/2022, 2/20/2022-2/26/2022, 2/27/2022-3/5/2022, and 3/6/2022-3/12/2022. Resident #45 was documented as having received 1 bath or shower the weeks of 3/13/2022-3/19/2022, 3/20/2022-3/26/2022, and 4/10/2022-4/16/2022. Resident #45 was not documented as having received a bath or shower the week of 3/27/2022-4/2/2022. During an interview on 4/19/2022 at 6:50 PM, the Director of Nursing (DON) confirmed baths and showers should be documented on days they are given.

Based on medical record review, observation, and interview, the facility failed to provide care and services for residents with enteral feedings when residents received the incorrect enteral feeding and enteral feedings were administered at the incorrect rate for 2 of 3 sampled residents (Resident #11 and #80) reviewed with Percutaneous Endoscopic Gastrostomy (PEG) tube feedings. The findings include: Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 4/19/2022 at 11:16 AM, revealed LPN #4 administered a bolus tube feeding to Resident #11. LPN #4 donned gloves, placed an enteral feeding syringe in the feeding tube port, checked for stomach residual, and administered a bolus feeding of strawberry ensure plus through Resident #11's feeding tube. During an interview on 4/21/2022 at 11:34 AM, the Director of Nursing (DON) confirmed Resident #11 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #80 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 4/18/2022 at 11:51 AM, 2:20 PM and 3:38 PM, 4/19/2022 at 11:42 AM and 4:12 PM, and on 4/20/2022 at 8:14 AM, revealed an enteral feeding pump administering [MEDICATION(S)] 1.5 at 50 ml an hour to Resident #80. During an interview on 4/21/2022 at 10:38 AM, the DON confirmed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on medical record review, observation, and interview, the facility failed to follow professional standards of practice for a Midline Catheter for 1 of 1 sampled residents (Resident #75) reviewed for a Midline Catheter. The findings include: Review of the medical record, revealed Resident #75 was admitted to to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician Orders dated 4/15/2022, revealed .Insert Midline Catheter per MD [Medical Doctor] order . There were no orders for monitoring or care of the Midline catheter. Review of the 4/2022 Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 4/18/2022 at 9:45 AM, revealed Resident #75 was sitting in his wheelchair, with a Midline Catheter to his upper right arm with a dressing dated 4/16/2022. During an interview on 4/19/2022 at 6:20 PM, the Director of Nursing (DON) confirmed the Midline Catheter was inserted on 4/16/2022, and there were no Physician's Orders for the monitoring and care of the Midline Catheter.

Based on policy review, medical record review, observation, and interview, the facility failed to obtain orders for oxygen for 2 of 2 sampled residents (Resident #11 and Resident #95) reviewed for Respiratory Care. The findings include: Review of the facility's policy titled, Oxygen Concentrator and Oxygen Storage, with a revision date of 12/2021, revealed .Obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .nasal cannula .) . Review of the medical record, revealed Resident #11 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Treatment Administration Record dated 3/2022 and 4/2022, revealed no documentation of the oxygen therapy. The facility was unable to provide orders for oxygen therapy. Observation in the resident's room on 4/18/2022 at 10:16 AM, 4/19/2022 at 8:33 AM, 4/20/2022 at 7:59 AM, 4/20/2022 at 2:04 PM, and on 4/21/2022 at 10:40 AM, revealed Resident #11 was receiving 2 liters of oxygen binasal cannula (BNC). During an interview on 4/21/2022 at 11:34 AM, the Director of Nursing (DON) confirmed that Resident #11 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record, revealed Resident #95 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .at ( .liters/[per]minute .) . There was not a rate of administration for the oxygen. Observation in the resident's room on 4/18/2022 at 10:28 AM and 2:50 PM, 4/19/2022 at 5:33 PM, and 4/20/2022 at 8:12 AM and 5:20 PM, revealed Resident #95 was receiving oxygen at 2 liters per minute through a [CONDITION(S)] mask. During an interview on 4/21/2022 at 10:47 AM, the DON confirmed oxygen orders should include the rate of administration.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a medication administration rate of less than 5% (percent) when 2 of 4 nurses (Licensed Practical Nurse (LPN) #2 and #3) failed to properly administer medications for 2 of 5 sampled residents (Resident #80 and #95) observed during medication administration. This resulted in a medication administration error rate of 7.41%. The findings include: Review of the facility's policy titled Medication Administration, with a revision date of 2/9/2022, revealed .Medications administered via [by way of] feeding tube .Prior to administering medication, check for patency by administering a fluid flush as ordered .Each medication should be administered separately .Flush between medication . Review of the medical record, revealed Resident #95 was admitted to the facility on on 12/14/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)], [CONDITION(S)], Gastrostomy, Depression, and Pulmonary Embolism. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unable to provide an order to cocktail (mix and administer together) Resident #95's medications. Observation in the 100 Hall on 4/19/2022 at 9:47 AM, revealed LPN #2 prepared the following medications for administration to Resident #95: a. [MEDICATION(S)] 250 mg 1 tablet b. [MEDICATION(S)] 5 mg 1 tablet c. [MEDICATION(S)] (generic [MEDICATION(S)]) 200 mg 1 tablet d. [MEDICATION(S)] 0.5 mg 1 tablet e. [MEDICATION(S)] 20 mg 1 tablet f. Vitamin D3 50 mcg 1 capsule g. [MEDICATION(S)] 15 mg 1 tablet h. [MEDICATION(S)] 10 ml liquid i. [MEDICATION(S)] 15 ml liquid LPN #2 put on (donned) gloves, opened the medications, placed them in individual medication cups, and placed them on a tray. LPN #2 then placed the 5 tablets, except the Vitamin D3 and [MEDICATION(S)] into 1 medication cup, crushed the combined tablets, and placed the cup of cocktailed medications back on the tray. LPN #2 entered Resident #95's room with the medications on the tray, and placed it on the over bed table. LPN #2 entered the bathroom and obtained 200 ml of water in a plastic cup, poured 10 ml of water into each of the cups with the Vitamin D3, [MEDICATION(S)], and the cocktail medications, and placed the cup of water on the tray with the medications. LPN #2 connected the enteral feeding syringe to the enteral tube and verified placement. LPN #2 poured 15 ml of water into the syringe, poured the cocktailed medications into the syringe, administered the medication by gravity, poured 30 ml of water into the syringe, poured the remaining liquid and dissolved medications into the syringe one at a time, failed to flush between the medications, and poured the remainder of the water into the syringe. The failure to administer each medication separately to Resident #95 resulted in medication error #1. Review of the medical record, revealed Resident #80 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unable to provide an order to cocktail Resident #80's medications. Observation in the 700 Hall on 4/20/2022 at 9:11 AM, revealed LPN #3 prepared the following medications for administration to Resident #80. a. Aspirin 81 mg 1 tablet. b. Multivitamin 1 tablet c. [MEDICATION(S)] 75 mg 1 tablet d. Famotidine 40 mg 1 tablet e. Famotidine 1.25 ml liquid f. [MEDICATION(S)] 17 grams powder LPN #3 placed the tablets and liquid in individual medication cups, crushed the tablets individually, took the medication into Resident #80's room and placed them on a barrier on the over bed table. LPN #3 entered Resident #80's room, washed her hands, obtained a cup of water from the sink, diluted the medications with 15 ml of water, and placed the cup of water on the barrier with the medications. LPN #3 donned gloves, disconnected a feeding from Resident #80's feeding tube, and verified placement of the tube with an enteral feeding syringe. Then, without flushing the enteral tube, LPN #3 poured 2 cups of crushed medication, 1 at a time, into the syringe. When the medications did not flow through the tube by gravity, LPN #3 poured an unmeasured amount of water into the syringe. LPN #3 placed the plunger onto the syringe an applied light pressure, the medication did not go through the feeding tube. LPN #3 then poured the 2 medications mixed with water, from the syringe into a cup and flushed the enteral tube with 15 ml of water. LPN #3 poured the cocktailed medications into the syringe and administered them by gravity. LPN #3 poured the other cups of medications into the syringe,1 at a time, failing to flush between the medications, and flushed the enteral tube with 45 ml of water. The failure to administer each medication separately to Resident #80 resulted in medication error #2. During an interview on 4/21/2022 at 10:44 AM, the Director of Nursing (DON) confirmed medications should not be cocktailed without an order and staff should flush enteral feeding tubes prior to administering medications and between medication administration.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 2 of 10 medication storage areas (the 200 Hall Medication Cart and the Treatment Cart) were observed unlocked, unsecured, and unattended. The findings include: Review of the facility's policy titled, Medication Administration: medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy, revised 9/20/2021, revealed .all drugs and biologicals will be stored in locked compartments .( .medication carts .) . Observation on the 200 Hall on 4/19/2022 at 11:10 AM, revealed the 200 Hall Medication Cart was opened, unattended, and unlocked in the hallway in front of room Resident #11's room with the door closed. During an interview on 4/19/2022 at 11:13 AM, Licensed Practical Nurse (LPN) #3 confirmed that she should not leave the medication cart unlocked, unsecured, and unattended. Observation on the 300 Hall on 4/20/2022 at 2:20 PM, revealed the Treatment Cart was opened, unlocked, unsecured and unattended, in the hallway in front of Resident #57's room with the door closed. During an interview on 4/20/2022 at 2:22 PM, the Wound Care Nurse confirmed that he should not leave his Treatment Cart unlocked and unattended. During an interview on 4/21/2022 at 1:50 PM, the Director of Nursing (DON) confirmed that the medication and treatment carts should not be unlocked, unsecured, and unattended.

Based on medical record review, observation, and interview, the facility failed to maintain accurate medical records related to dietary intake and weights on 2 of 5 sampled residents (Resident #39 and #70) reviewed for Nutrition. The findings include: Review of the medical record, revealed Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #39 required extensive assist with eating. Review of the Activity of Daily Living (ADL) Verification Worksheet dated 4/1/2022 - 4/20/2022 revealed incomplete documentation of the dietary intake for the following days: 4/2/2022 no documentation for dinner. 4/3/2022 no documentation for lunch or dinner. 4/4/2022 no documentation for breakfast or lunch. 4/6/2022 no documentation for dinner. 4/7/2022 no documentation for lunch and dinner. 4/12/2022 no documentation for lunch and dinner. 4/17/2022 no documentation for dinner. 4/20/2022 no documentaion for dinner. No meal percentages were recorded for the entire day on 4/1/2022, 4/5/2022, 4/9/2022-4/11/2022, 4/13/2022-4/16/2022, 4/18/2022 and 4/19/2022. During an interview on 4/21/2022, the Director of Nursing (DON) confirmed the ADL Verification Worksheet were incomplete. Review of the medical record, revealed Resident #70 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ADL Verification Report dated 3/31/2022-4/16/2022 revealed Resident #70 consumed 75% of supper on 4/4/2022. No other meal percentages were recorded. Review of the Patient Vital Sign Report dated 3/28/2022-4/20/2022 revealed the following weights: a. 3/28/2022 - 222.00 pounds (lbs) b. 3/29/2022 -199.00 lbs. c. 3/30/2022 - 73.00 lbs. d. 3/31/2022 - 74.00 lbs. e. 3/31/2022 - 189.00 lbs. f. 4/1/2022 and 4/2/2022 -199.00 lbs. g. 4/3/2022 - 222.00 lbs. h. 4/4/2022 - 224.00 lbs. i. 4/5/2022 - 216.00 lbs. j. 4/6/2022 - 199.00 lbs. k. 4/7/2022 - 75.00 lbs. l. 4/8/2022 and 4/9/2022 - 222.00 lbs. m. 4/10/2022 - 220.00 lbs. n. 4/11/2022 - 221.00 lbs. o. 4/12/2022 - 201.00 lbs. p. 4/13/2022 - 217.00 lbs. q. 4/14/2022 - 216.00 lbs. r. 4/14/2022 - 246.00 lbs. s. 4/15/2022 - 245.00 lbs. t. 4/16/2022 and 4/17/2022 -199.00 lbs. u. 4/18/2022, 4/19/2022 and 4/21/2022 - 200.00 lbs. v. 4/20/2022 - 228.00 lbs. During an interview on 4/20/2022 at 2:50 PM, the Restorative Certified Nursing Assistant (CNA) confirmed she has been trained to do weights and she does the weekly and monthly weights in the facility. The Restorative CNA confirmed she was not aware Resident #70 was on daily weights and did not know who had been weighing the resident. Observation in the 100-300 Hall Common Area on 4/20/2022 at 3:02 PM, revealed the Restorative CNA zeroed the wheelchair scales and weighed Resident #70. Resident #70 weighed 271.8 lbs. The Restorative CNA deducted the weight written on the back of the wheelchair, 43.4 lbs, and confirmed Resident #70 weighed 228.4 lbs. During an interview on 4/20/2022 at 3:20 PM, the DON confirmed Resident #70's weights were not recorded accurately. During an interview on 4/21/2022 at 10:44 AM, the DON confirmed meal percentages should be recorded on the ADL Verification Record and should not have blanks.

Based on observation and interview, the facility failed to ensure that waste was properly contained and maintained in a sanitary condition to prevent the harborage and feeding of pests when 2 of 2 dumpsters (Dumpster #1 and #2) were observed open with a large amount of garbage lying in front and around the bases. The findings include: Observation of the dumpsters on 4/20/2022 at 7:15 AM, revealed the dumpsters' doors were open, with a large amount of trash and debris lying in front of the dumpster, with meal tickets, paper cups, Styrofoam boxes, and other debris. Observation of the dumpsters on 4/20/2022 at 8:17 AM, with the Director of Nutrition Services, revealed Dumpster #1 had a large amount of trash in front of the dumpster, including plastic straws, cups, Styrofoam cartons, ketchup packets, sugar packets, water bottles, salt and pepper packets, meal tickets, surgical masks, plastic wear, pudding cups, and mustard packets. Dumpster #2 had paper cups, straws, gloves, and Styrofoam cartons lying around the base of the dumpster. During an interview on 4/20/2022 at 8:17 AM, the Director of Nutrition Services confirmed the dumpster doors should stay closed and trash should not be lying on the ground around the dumpsters. During an interview on 4/20/2022 at 10:54 AM, the Dietary Manager confirmed the dumpster area should be cleaned daily.

Based on medical record review and interview, the facility failed to ensure assessments were completed to accurately reflect the residents' status for 1 or 1 sampled residents (Resident #95) reviewed for [CONDITION(S)] care. The findings include: Review of the medical record, revealed Resident #95 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)], [CONDITION(S)], Gastrostomy, Depression, and Pulmonary Embolism. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #95 was not coded as receiving [CONDITION(S)] care. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .One Time Daily Starting 1/27/2022 . During an interview on 4/21/2022 at 10:47 AM, the Director of Nursing confirmed Resident #95 should have been coded as receiving [CONDITION(S)] care on the MDS dated [DATE].

Based on policy review, facility investigation review, medical record review, and interview, the facility failed to provide adequate supervision to prevent neglect for 1 of 6 sampled residents (Resident #1) reviewed for wandering and elopement. The facility's failure resulted in Immediate Jeopardy when Resident #1, a cognitively intact resident assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 exited the facility through the front doors, walked down a heavily traveled street, and crossed more than one major intersection late in the evening. Resident #1 was found at his previous residence more than 24 hours later. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-600 on 10/1/2021 at 8:55 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 9/27/2021 through 10/2/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 10/2/2021 at 1:50 PM, and was validated onsite by the surveyor on 10/3/2021 through review of the root cause analysis, in-services, resident interviews, observations, and staff interviews and resident interviews. The findings include: Review of the facility's policy titled, Abuse Prohibition Plan, revised 6/10/2021, revealed .Purpose: The resident will not be subjected to mistreatment, neglect, exploitation, or misappropriation of property .'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Training: All employees will receive training during orientation, annually and with ongoing sessions. Training will include, but is not limited to .How to identify residents who are at risk for abuse, neglect .Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms include, but are not limited to .Wandering or elopement-type behaviors .PREVENTION .The facility has a prevention/intervention program which includes, but is not necessarily limited to, the following .Wander-guard System [a bracelet device worn by the resident that will trigger the door to alarm when the resident gets too close to the door] .Door alarms for designated exit doors .Door locks requiring security code access after hours . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Elopement Risk assessment dated [DATE], revealed .the patient is identified as being at high risk for elopement .INTERVENTIONS .Wanderguard bracelet initiated [checked which indicated it had been put on the resident at admission] Diversional Activities [checked] Care Plan initiated [checked] . Review of the Clinical Note dated 9/27/2021 at 11:30 AM, revealed .Resident [Resident #1] was noted impulsive and with exit-seeking behaviors today. Resident was seen with a bag of his personal belongings standing near the entrance of the front door, attempting to exit from locked doors. Social Services, Administrator, and this nurse were present and attempted to redirect resident. Resident was very agitated and expressed his desire to leave this facility. After speaking with SW [Social Worker], Admin [Administrator] and DON for several minutes, resident informed [staff] that he would not attempt to leave facility but would instead wait for his brother to pick him up after he has been properly discharged . Resident was also compliant with wander guard placement [not applied until 9/27/2021 as previously documented on 9/23/2021], which was completed after resident displayed exit-seeking behavior. RP [Responsible Party] was contacted, but did not answer. A voicemail was left for him, explaining the importance of a return call since resident had verbalized and attempted to execute an exit from facility . Review of the Clinical Note dated 9/28/2021 at 2:12 AM, revealed .Upon making my night time medication rounds, resident [Resident #1] was not in his room, this nurse asked the CNA [Certified Nursing Assistant] on the hall if she had seen resident, CNA said she thought she saw him go into his bathroom, other staff notified and a complete search of the building and outside property, when resident was not located, this nurse contacted ADON [Assistant Director of Nursing] [Named ADON], and called 911, officers arrived, staff again searched the building and outside property. A report was made with [Named Police Department] [Named Officer]. Several attempts were made to contact residents RP [Responsible Party] [Named RP] .no answer x [times] 3, left voicemail, RP called facility back and was notified by this nurse, of the situation, RP was asked if resident had ever had behavior like this before, he said he had not that he was aware of but that he would probably be trying to go back [to where] he had been staying at [Named Address], this nurse called 911 dispatch back and notified them of this, resident left all of his belongings except for his cell phone in his room, at facility, ADON and Administrator came to facility, DON aware as well . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Monitor .rt [right] leg .two times daily . Review of the Care Plan dated 9/28/2021, revealed Resident #1 had the interventions for wandering and exit seeking behaviors to .Ensure all doors alarms/locks are armed to reduce the risk of [Named Resident #1] leaving secure area .record behaviors on Behavior Tracking Form, and Use wander guard/location monitor daily . Review of the Elopement Risk assessment dated [DATE], revealed .patient [Resident #1] is identified as being at high risk for elopement .INTERVENTIONS .wanderguard bracelet initiated diversional activities Care Plan initiate/updated to reflect elopement risk and interventions implemented . Review of the Administrator's Timeline from the facility's investigation dated 9/28/2021, revealed .Notified by DON, resident was carrying a bag of clothing: 10:45 am-10:55 am [10:45 AM-10:55 AM on 9/27/2021] .[Named Resident #1] Sitting around the front lounge area. 11 am [11:00 AM] .Resident [Resident #1] was waiting in the area as if he was going to be picked up. 11:15 [AM]-noon .Resident [Resident #1] had bag standing around Social Service office. 12 noon .Resident [Resident #1] took bag of items back to his room. After 12 noon .DON spoke with resident [Resident #1] to get permission to place wander guard on resident. 1:45pm [PM] .Resident [Resident #1] would not cooperate, refusing wander guard. 1:49 pm-2:pm [1:45 PM-2:00 PM] .Administrator notified, the DON and Administrator spoke with resident [Resident #1] and notified resident brother via telephone of resident wanting to leave. Resident nodded to discharge with brother. 2:25pm [2:25 PM] .Resident [Resident #1], DON, Administrator, Maintenance Assistance all together while addressing resident. 2:40 pm [2:40 PM] .Resident nodded he understood. Agreed to have wander guard placed on ankle for safety to discharge before the brother arrived. 2:50 pm [2:50 PM] .Resident [Resident #1] appeared to be calm and understood the wander guard was for safety. 3:20 pm [3:20 PM] .Multiple messages left for [Named Brother], to notify discharge of [Named Resident #1]. 3:20 pm-3:25 pm [3:20 PM-3::25 PM] .Resident [Resident #1] sat down in the lounge, peaceful not exit seeking. 3:50 pm-4:00 pm [3:50 PM-4:00 PM] .Resident returned to his room. After 4 pm [4:00 PM] .Monday evening 9/27/2021 at approximately 8:45 pm [8:45 PM]. Staff (Aide) noticed resident was missing .Nurse looking for resident [Resident #1] for meds [medications]. Approximately 9:00 pm [9:00 PM] .Received a phone call from ADON: 9:18 pm-9:25 pm [9:18 PM-9:25 PM] .The staff of [Named facility] unable to locate [Named Resident #1] inside of building. 8:45-9:30 pm [8:45 PM-9:30 PM] .The team immediately begin [began] to search the interior of building then the exterior of the building. 9:00-10:20 pm [9:00 PM-10:20 PM] .All the rooms lock and unlock searched. Exterior grounds searched. 9:30-10:45 pm [9:30 PM-10:45 PM] .Upstairs area searched. 9:50 pm [9:50 PM] .ADON notified administrator, DON Regional Nurse. 9:20 pm [9:20 PM] .Police dept [department] notified, adult protection services and brother notified. 9:25 pm [9:25 PM] .Administrator attempted to notify brother voice mail kept coming up. 9:49 pm [9:49 PM] .Administrator notified Regional Director, who spoke with the brother. 10:20 pm-10:44 pm [10:20 PM-10:44 PM] .Returned to [Named facility] search the building again. Went in one side of the building and came out on the other side .Searched the dumpster area, searched each car in the parking lot with flashlight. 1:00 am [AM] .Drove north on [Named Street] for 4 miles searching for resident [Resident #1]. 1:05 am-1:20 am [1:05 AM-1:20 AM] .Came back to [Named Facility] drove down to [Named Street] and [Named Street]. 1:35 am [1:35 AM] .Notified facility resident still not found . Review of the facility investigation included the Administrator's written statement dated 9/28/2021, which revealed .Spoke with a [Named Person] [Security at Named Care Home where Resident #1 previously resided] would look in their lounge area and speak with security to see if [Named Resident #1] had been there. Mrs. [Named Person] not aware who he [Resident #1] is, but he could have come they're [there] without her knowing .Spoke with Sergeant [Named Sergeant] Police Department. 10:27 am [10:27 AM] .Interview the brother [Named Brother] .9/28/2021 received a call back from [Named Person at Named Care Home where Resident #1 previously resided] requested the release of information be resent .Wanted to see if the signature [Named Resident #1's] signature was accurate. Would not give any information if resident was safe or if resident was at the location . Review of the undated written statement by Licensed Practical Nurse (LPN) #3, revealed .On 9/27 [2021] upon making my medication rounds on 500 hall, I asked CNA assigned to resident [Resident #1] when was the last time she saw him. I had seen the resident upon first arriving on shift. She said she thought she saw him go in his bathroom, water was heard running in bathroom, ambulance was hear [here] for a lengthy amount of time to transport a resident, so alarm was sounding with ambulance personal [personnel] going out. The alarm was turned off by another staff member. I alerted staff and we begin [began] to search the building and property around facility. I got on the phone & [and] announced amber alert [code for missing resident]. I called, ADON, and 911, officers arrived .We continued to search the facility. ADON came to facility. Reports filed. RP notified. Administrator & DON notified . Review of the undated written statement by CNA #1, revealed .Around 6:30 pm, I heard the door alarm going off. At this moment I was preparing myself for the shift. I did see ambulance transporting a resident for discharge. At 8:45 pm, I was notified by nurse [Named LPN #3] that a resident was missing. I followed protocol and helped search all perimeters of the building . Review of the undated written statement by LPN #1, revealed .I arrived to work late @ [at] approximately 6:15 PM. 2 EMT's [Emergency Medical Technician] c [with] a stretcher were near the front entrance. I was let in by another employee. A few minutes later I heard the front door alarm so I looked outside and did not see anyone so I cleared the alarm & went back to my work station. While the EMTs were here between 6:15 [PM]-7 [7:00] PM the alarm was heard at least one other time by this nurse. The alarm was on for a few moments around 6:45 PM & was apparently cleared by another staff member shortly thereafter. [Named LPN #3] came to this nurse @ approximately 8:30 PM & asked me if I seen resident [Resident #1] .Shortly thereafter [Named LPN #3] announced over head that resident was missing. Everyone in the bldg. [building] stopped what they were doing & searched for resident . Review of the undated written statement by CNA #2, revealed .I was working 500 hall. I heard the commode flushing. I saw him [Resident #1] in the room about 6:30 [PM] or 7:00 [PM] and I precidy [proceeded] to work on the hall. The nurse call & ask me had I seen him [Resident #1]. She told me he was not in his room we started it was about 8:30 [PM] searching room to room . Review of the written statement dated 9/28/2021 by CNA #3, revealed .heard the alarm go off at about 6:30 PM. I noticed transport taking resident out about 7 [7:00] PM. Was notified by the nurse at about 9 [9:00] PM that the resident was missing. Staff started protocol . Review of the undated written statement by LPN #2, revealed .Was alerted that resident .was missing after 8:30 PM while doing my medication pass. Assisted CNA in looking through rooms on 300 hall for resident. At about 7:30 PM the door alarm was going off but the front doors were closed and secure . During an interview on 9/28/2021 at 5:10 PM, the Administrator stated, .the morning receptionist unlocks the front door. She gets here between 6:45 AM-7:00 AM. The front doors are on a timer and automatically sets the door and alarm and requires a code to get out. It automatically locks at 8:00 PM. You can also manually lock and unlock the front door. His window was checked, and the screen hadn't been moved. All the doors were checked, and they hadn't been tripped. The light will keep blinking and a code to be put in to reset the door .went into his [Resident #1]'s room and bathroom. He [Resident #1] still had all of his clothes here. We drove to a place on [Named Street, location where the resident previously resided] and we tried to get in. Spoke with a Ms. [Named Person] and she told us we needed a medical release of information and when she received it, she would have to speak with her supervisor. The brother thought this was one of the places he would be at .We now feel that the resident [Resident #1] left the building while the facility was transferring a resident home by an ambulance. He [Resident #1] simply waited until the EMTs had the front door alarming because they had held it open too long and proceeded to walk out. The door locked after he had left the building. He was dressed nice that day. He had on an outfit and was clean and shaven so he may have looked like a visitor or family member .According to two written statements, staff responded to the door alarm and seeing the ambulance outside the door, assumed the ambulance staff had held the door open too long causing the door to alarm and they simply reset the alarm .The resident was his own responsible party, not his brother . During an interview on 9/28/2021 at 5:30 PM, the DON stated, .staff knows who are the wanderers because they have a wanderguard and it is on their Resident Care Needs [a computer system that informs the CNAs of the residents' needs]. The nurses know who has the wanderguards because they have to document it on the MAR [Medication Administration Record] and the CNAs know because of the Resident Care Needs . During an interview on 9/29/2021 at 7:30 AM, the DON stated, .After reading some of the witness statements, I have concluded the resident left the building through the front door while there was an ambulance transferring a resident .the statements document the front alarm was alarming and staff were turning it off because they assumed it was the transportation people that had set the alarm off . During a telephone interview on 9/29/2021 at 8:50 AM, with the Administrator, DON, and the Manager of Client Services for the Care Home had Resident #1 in the room with her and she was relaying the questions the Administrator and DON were asking. Resident #1 was asked what time he left the facility or if it was dark outside at the time he left. He stated, don't know what time it was. He was asked if someone picked him up from the facility. He stated, No. He was asked if he left through the side door and he stated, No. When asked if there were trees and sidewalks at the door, he stated, Yes. He was asked if he saw an ambulance in front of the door and he stated Yes. He was asked if he still had his wander guard on and stated, Yes. During an interview on 9/29/2021 at 12:51 PM, the DON was asked if the nurse should have initiated the wander guard on admission. The DON stated, .It appears, the nurse should have put a wander guard on him [Resident #1] according to her documentation . During a telephone interview on 9/29/2021 at 1:02 PM, LPN #1 stated, .When I got to work, there were 2 EMTs at the front entrance .a resident was being transported home .They [EMT] were here when the alarm went off, so I assumed they were the cause. I didn't go outside but I peered through the front windows and didn't see anything, so I reset the alarm . During an interview on 9/30/2021 at 10:57 AM, the Medical Director was asked if he thought a resident who displayed exit seeking behaviors and had a wander guard should be monitored. The Medical Director confirmed Resident #1 was alert and oriented to person, place, and time, and was unable to speak but understood what others were saying. The Medical Director stated, .I want to know why the alarm went off .they didn't know he was leaving . During a telephone interview on 9/30/2021 at 7:03 PM, LPN #2 stated, .Around 7:30 PM, I heard the front door alarm, so I went up to the front door to turn it off. The doors were locked and there was no one around. There wasn't an ambulance or any transport vehicles at the front. I did not go outside to check why the alarms were going off because the doors were safe and secure . Interview with the Administrator on 10/2/2021 at 8:35 AM, the Administrator confirmed he had spoken with [Resident #1's Physician] and [Named Physician] had been in contact with [Named Care Home], filling his medications. The physician told the Administrator [Named Resident #1] had lived at the care home for the last couple of years and preferred to stay there rather than the facility. The surveyor verified the Removal Plan by: 1. Visual signs alerting residents, families and friends were posted at the front door and in patient rooms as a reminder to notify staff when leaving the facility and signing out at the Nurses' Station by 9/28/2021. Visual signs were posted on 9/29/2021 alerting ambulance employees, paramedics, families, and vendors to notify facility personnel immediately if anyone leaves the facility when they are entering or exiting the building. Visual signs alerting staff that door codes are not to be given out to anyone except staff were posted at the alarm panel on 10/1/2021. The surveyor made observations of the signs. 2. Cognitive/alert and oriented residents were educated by the Social Services Director or designee on proper Leave of Absence (LOA)/personal outing and were educated on the Against Medical Advice (AMA) procedure by 10/1/2021. The surveyor reviewed the education and interviewed alert residents. 3. The Nurse Managers reviewed/revised/completed 100 percent (%) of facility residents Elopement Risk Assessments by 10/1/2021. Facility residents identified as high risk for elopement plans of care were reviewed and revised as needed by 10/1/2021. The surveyor reviewed the assessments and Care Plans. 4. A letter was mailed to the Resident Representatives, educating them on the facility's process for Unplanned LOA and Personal Outing by 10/1/2021. The surveyor reviewed the letters that were sent the Resident Representatives. 5. The facility's Elopement and Wandering Patients Policy was reviewed and revised on 10/1/2021, to include . a. Employees should identify the location and respond to an alarm timely b. Upon arrival to location of alarm observe the physical environment both inside and outside for wandering or exit seeking residents. c. Complete a head count on wandering/exit seeking residents to determine location. d. If unable to locate a resident initiate the procedure for locating a missing resident . The surveyor reviewed the revised policy. 6. Review of the Abuse Prohibition Plan Policy was conducted on 10/1/2021 by the Regional Director of Operations and the Director of Clinical Education. On duty personnel were educated on the Abuse Prohibition Plan on 10/1/2021 and the off-duty personnel will be educated upon return to work. Newly hired personnel will be educated during their orientation on the Abuse Prohibition Plan. The surveyor reviewed the education and interviewed staff on all shifts. 7. A letter was faxed or mailed to Emergency Medical Services (EMS)/Transport companies to notify staff immediately if a resident leaves the facility without a staff member. The surveyor reviewed the letters sent. 8. The Hospital Transfer Form was updated in the Electronic Health Record on 10/1/2021 to include the observation of EMS staff securing patient in ambulance for transport. Education was provided to the on-duty staff 10/1/2021 and the off-duty staff will be educated upon return to work. The surveyor reviewed the form and interviewed staff on all shifts. 9. The Regional Director of Operations educated the facility Administrator and Director of Nursing on 10/1/2021 on the facility policy and procedure of Abuse Prohibition Plan, Emergency Preparedness, and Elopement and Wandering Patients. The surveyor reviewed the education and interviewed the DON. 10. On 9/29/2021, on duty personnel were educated on responding to any alarms in the building promptly and to do a visual resident observation if a resident exhibited exit seeking behavior or expresses a desire to leave LOA/AMA. On duty staff were educated that door codes were not to be given to anyone except facility staff. The off-duty personnel will be educated upon return to work. Newly hired personnel will be educated during their orientation. The surveyor reviewed the education and interviewed staff on all shifts. 11. The facility arranged to have a vendor on site 9/29/2021 to assess the video surveillance camera operation and provide a quote for replacing/repairing the system. The vendor while on site also assessed the annunciator panel operation/implementation on the south wing of the facility and provided a quote for installation. Quotes were received and approved by Corporate staff on 9/29/2021 and the repairs/installation will begin 10/4/2021. The surveyor reviewed the quotes and interviewed the Administrator. 12. An elopement drill was completed on 10/1/2021 by the Administrator and Director of Nursing. The surveyor reviewed the drills. 13. The Medical Director was notified by the Administrator to discuss the Removal Plan of the Immediate Jeopardy and the action plans to provide adequate supervision to prevent a resident, assessed for wandering, from leaving the facility without staff knowledge. 14. The Quality Assurance and Performance Improvement (QAPI) committee met on 10/1/2021 to discuss the Removal Plan of the Immediate Jeopardy to include Resident Education, Responsible Party Education, Staff Education, Emergency Personnel/Visitors/Vendors Education, and reviewed facility policies and procedures to provide adequate supervision to prevent a resident, assessed for wandering, from leaving the facility without staff knowledge. The surveyor interviewed the QAPI members. 15. The facility held a Governing Body meeting by a telephone conference on 10/1/2021 to review and approve the facility's action plan to provide adequate supervision to prevent residents assessed at high risk for elopement, from leaving the facility without staff knowledge. Members of the Governing Body were interviewed. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility investigation review, medical record review, and interview, the facility failed to provide adequate supervision to a resident assessed for wandering and having exit seeking behaviors for 1 of 6 sampled residents (Resident #1) reviewed for wandering/exit-seeking behaviors. The facility's failure resulted in Immediate Jeopardy when Resident #1, a cognitively intact resident assessed with wandering and exit seeking behaviors, eloped from the facility without staff knowledge. Resident #1 exited the facility through the front doors, walked down a heavily traveled street, and crossed more than one major intersection late in the evening. Resident #1 was located more than 24 hours later, at his previous residence. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-689 on 10/1/2021 at 8:55 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 9/27/2021 through 10/2/2021. An acceptable Removal Plan, which removed immediacy of the jeopardy, was received on 10/2/2021 at 1:50 PM, and was validated onsite by the surveyor on 10/3/2021 through review of the root cause analysis, in-services, observations, and staff and resident interviews. The findings include: Review of the facility's policy titled, Elopements and Wandering Patients, dated 11/1/2017, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .'Wandering' is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless .'Elopement' occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so .The facility is equipped with door locks/alarms to help avoid elopements .Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, [CONDITION(S)], [CONDITION(S)] Affecting the Right Side, Dysarthria (difficulty with speech due to weak speech muscles) and Anarthria (a more severe form of dysarthria), Human Immunodeficiency (a virus that attacks the body's immune system), Seizures, Depression, and Malignant Neoplasm of Lung Parts. Review of the Elopement Risk Assessment on admitted d 9/23/2021, revealed Resident #1 was identified as being at high risk for elopement and an intervention of a wander guard (a mechanical bracelet device that will cause the door to alarm when the resident gets close to the door) was to be initiated. Review of a Clinical Note dated 9/27/2021 at 11:30 AM, revealed Resident #1 was impulsive and had exit-seeking behaviors. Resident #1 was seen with a bag of his personal belongings standing near the entrance of the front door and attempting to exit through the locked doors. The Social Services, Administrator, and a nurse were present and attempted to redirect him. Resident #1 was very agitated and expressed his desire to leave the facility. After he spoke with the Social Worker, Administrator, and DON for several minutes, Resident #1 informed them that he would not attempt to leave the facility but would instead wait for his brother to pick him up after he had been properly discharged . A wander guard was placed on the resident (not applied until 9/27/2021 as previously documented on 9/23/2021). The facility attempted to contact the brother, but he did not answer the telephone. A voicemail was left for the brother, explaining the importance of a return call as the resident had verbalized the desire to leave and had tried to exit the facility. Review of the Care Plan dated 9/28/2021, revealed Resident #1 had the following interventions for wandering and exit seeking behaviors documented, .Ensure all doors alarms/locks are armed to reduce the risk of [Named Resident #1] leaving secure area .record behaviors on Behavior Tracking Form, and Use wander guard/location monitor daily . Review of a Clinical Note dated 9/28/2021 at 2:12 AM, revealed .Upon making my night time medication rounds, resident was not in his room, this nurse asked the CNA [Certified Nursing Assistant] on the hall if she had seen resident, CNA said she thought she saw him go into his bathroom, other staff notified and a complete search of the building and outside property, when resident was not located, this nurse contacted ADON [Assistant Director of Nursing] [Named ADON], and called 911, officers arrived, staff again searched the building and outside property. A report was made with [Named Police Department] [Named Officer]. Several attempts were made to contact residents [resident's] RP [Responsible Party] [Named RP] .no answer x [times] 3, left voicemail, RP called facility back and was notified by this nurse, of the situation, RP was asked if resident had ever had behavior like this before, he said he had not that he was aware of but that he would probably be trying to go back [where] he had been staying at [Named Address], this nurse called 911 dispatch back and notified them of this, resident left all of his belongings except for his cell phone in his room, at facility, ADON and Administrator came to facility, DON aware as well . Review of a Physician's Order dated 9/28/2021, revealed an order for a wander guard. Review of an Elopement Risk assessment dated [DATE], revealed Resident #1 was identified as being at high risk for elopement and a wander guard bracelet and diversional activities were initiated. The Care Plan for elopement was initiated/updated to reflect the elopement risk and interventions were implemented. Review of the Administrator's Timeline from the facility's investigation dated 9/28/2021, revealed the following: a. At 10:45 AM-10:55 AM the Administrator was notified by the DON that the resident was carrying a bag of clothing and was sitting around the front lounge area. b. At 11:00 AM, Resident #1 was in the front lounge area as if he was waiting on someone to pick him up. c. At 11:15 AM-12:00 PM, Resident #1 had a bag and was standing around the Social Service office. d. At 12:00 PM, Resident #1 took the bag of items back to his room. e. After 12:00 PM, the DON spoke with Resident #1 to get permission to place a wander guard on him. f. At 1:45 PM, Resident #1 was uncooperative and refusing the wander guard. g. At 1:49 PM-2:00 PM, the DON and Administrator spoke with Resident #1 and notified the resident's brother by telephone that Resident #1 was wanting to leave the facility. h. Resident #1 agreed to being discharged with his brother. i. At 2:25 PM, Resident #1, the DON, Administrator, and Maintenance Assistant again approached the resident to allow them to apply the wander guard bracelet. j. At 2:40 PM, Resident #1 nodded he understood and agreed to have a wander guard bracelet placed on his ankle for safety until the brother arrived. k. At 2:50 PM, Resident #1 appeared calm and indicated he understood the wander guard was for his safety. l. At 3:20 PM, multiple telephone messages were left for the brother to make him aware Resident #1 was ready for discharge. m. At 3:20 PM-3:25 PM, Resident #1 sat down in the lounge, was peaceful, and did not demonstrate any exit seeking behaviors. n. At 3:50 PM-4:00 PM, Resident #1 returned to his room. o. On 9/27/2021 at approximately 8:45 PM, a CNA noticed Resident #1 was missing. The nurse was looking for the resident to administer his medications. p. At approximately 9:00 PM, The Administrator received a telephone call from the Assistant Director of Nursing (ADON). q. At 9:18 PM-9:25 PM, the staff in the facility were unable to locate Resident #1 inside of the building. r. At 8:45 PM-9:30 PM, the team immediately began to search the interior and exterior of the building. s. At 9:00 PM-10:20 PM, all the rooms locked and unlocked were searched, and the exterior grounds were searched. t. At 9:30 PM-10:45 PM, the upstairs area was searched. u. At 9:50 PM, the ADON notified the Administrator, the DON, and the Regional Nurse. v. At 9:20 PM, the Police Department and Adult Protective Services were notified. w. At 9:25 PM, the Administrator attempted to notify the brother but was only able to get the voice mail. x. At 9:49 PM, the Administrator notified the Regional Director, who spoke with the brother. y. At 10:20 PM-10:44 PM, the entire building was once again searched, the dumpster area was searched, and each car in the parking lot was searched with a flashlight. z. At 1:00 AM, the Administrator drove 4 miles north on (Named Street), searching for the resident. aa. At 1:05 AM-1:20 AM, the Administrator drove down several streets within the area of the facility searching for the resident. bb. At 1:35 AM, the Administrator notified the facility they were unable to locate the resident. Review of a written statement from the timeline dated 9/28/2021 written by the Administrator, revealed that the Administrator spoke with a Named Person, who was Security at the Named Care Home where Resident #1 previously resided, and she stated would look in their lounge area and speak with security to see if Resident #1 had been there. The Named Person was not aware who Resident #1 was, but he could have come there without her knowing. The Administrator spoke with the Named Sergeant at the Police Department. On 9/28/2021, the Administrator received a call back from the Named Person at the Named Care Home where Resident #1 previously resided and requested the release of information to be resent. The Named Person wanted to see if the signature Resident #1's signature was accurate. The Named Person would not give any information if Resident #1 was safe or if he was at the care home. Review of the undated written statement by Licensed Practical Nurse (LPN) #3, revealed that on 9/27/2021, she was making her medication rounds on the 500 Hall and she asked the CNA assigned to Resident #1 when was the last time she saw him. LPN #3 had seen the resident upon first arriving on shift. The CNA said she thought she saw him go in his bathroom, water was heard running in the bathroom, the ambulance was at the facility for a lengthy amount of time to transport a resident, so the alarm was sounding with ambulance personnel going out of the door. The alarm was turned off by another staff member. LPN #3 alerted staff and the staff began to search the building and property around facility. LPN #3 got on the phone and announced an amber alert (code for missing resident). LPN #3 called the ADON and 911. The officers arrived and staff continued to search the facility. The ADON came to the facility, reports were filed, the RP was notified, and the Administrator and DON were notified. Review of the undated written statement by CNA #1, revealed that around 6:30 pm on 9/27/2021, the CNA heard the door alarm going off. At that time, CNA #1 was preparing for the shift. At 8:45 pm, CNA #1 was notified by LPN #3 that Resident #1 was missing. CNA #1 helped search all perimeters of the building. Review of the undated written statement by LPN #1, revealed that LPN #1 arrived to work late at approximately 6:15 PM. Two Emergency Medical Technicians (EMT)s with a stretcher were near the front entrance. LPN #1 was let in the door by another employee. A few minutes later, LPN #1 heard the front door alarm LPN #3 looked outside and did not see anyone, cleared the alarm, and went back to the workstation. While the EMTs were at the facility between 6:15-7:00 PM, the alarm was heard at least one other time by LPN #1. The alarm was on for a few moments around 6:45 PM and was apparently cleared by another staff member shortly thereafter. LPN #3 came to LPN #1 at approximately 8:30 PM and asked LPN #3 if had seen Resident #1. Shortly thereafter, LPN #3 announced over head that Resident #1 was missing. Everyone in the building stopped what they were doing and searched for the resident. Review of the undated written statement by CNA #2, revealed that CNA #2 was working on the 500 Hall. CNA #2 heard the commode flushing and saw Resident #1 in the room about 6:30 PM or 7:00 PM and proceeded to work on the hall. The nurse called and asked CNA #2 if had seen Resident #1. LPN #3 told CNA #2 that Resident #1 was not in his room and CNA #2 and LPN #3 started searching room to room around 8:30 PM. Review of the written statement dated 9/28/2021 written by CNA #3, revealed that CNA #3 heard the alarm go off at about 6:30 PM and noticed EMTs taking a resident out around 7:00 PM and was notified by the nurse at about 9:00 PM that the Resident #1 was missing. The staff started searching for Resident #1. Review of the undated written statement by LPN #2, revealed that LPN #2 was alerted that Resident #1 was missing after 8:30 PM while doing medication pass. LPN #2 assisted the CNA in looking through rooms for Resident #1. At about 7:30 PM, the door alarm was going off, but the front doors were closed and secure, LPN #2 did not go outside to search when the alarm was sounding. During an interview on 9/28/2021 at 5:10 PM, the Administrator stated, .the morning receptionist unlocks the front door. She gets here between 6:45 AM - 7:00 AM. The front doors are on a timer and automatically sets the door and alarm and requires a code to get out. It automatically locks at 8:00 PM. You can also manually lock and unlock the front door. His window was checked, and the screen hadn't been moved. All the doors were checked, and they hadn't been tripped. The light will keep blinking and a code to be put in to reset the door .went into his [Resident #1]'s room and bathroom. He [Resident #1] still had all of his clothes here. We drove to a place on [Named Street, location where the resident previously resided] and we tried to get in. Spoke with a Ms. [Named Person] and she told us we needed a medical release of information and when she received it, she would have to speak with her supervisor. The brother thought this was one of the places he would be at .We now feel that the resident [Resident #1] left the building while the facility was transferring a resident home by an ambulance. He [Resident #1] simply waited until the EMTs had the front door alarming because they had held it open too long and proceeded to walk out. The door locked after he had left the building. He was dressed nice that day. He had on an outfit and was clean and shaven so he may have looked like a visitor or family member .According to two written statements, staff responded to the door alarm and seeing the ambulance outside the door, assumed the ambulance staff had held the door open too long causing the door to alarm and they simply reset the alarm .The resident was his own responsible party, not his brother . During an interview on 9/28/2021 at 5:30 PM, the DON confirmed the staff were aware of the residents that wander because the nurses are required to document in the Medication Administration Records that they have monitored the resident for the wander guard's location, and the CNAs have the residents with wander guards listed in their Resident Care Needs (the computerized plan that documents the residents' care and needs). During an interview on 9/29/2021 at 7:30 AM, the DON confirmed after reading some of the witness statements, it was determined the resident left the building through the front door while the ambulance was transferring a resident. Two separate employees had documented in their written statements that they had heard the alarm and walked to the front to reset the alarm without searching the grounds. During a telephone interview on 9/29/2021 at 8:50 AM, with the Administrator and DON, the Manager of Client Services for the Named Care Home had Resident #1 in the room with her and she was relaying the questions the Administrator and DON were asking to the resident. He greeted with a hello. Resident #1 was asked what time he left the facility or if it was dark outside. He stated, don't know what time it was. He was asked if someone picked him up from the facility. He stated, No. He was asked what door he left through, maybe the side door. He stated, No. He was asked if there were trees and sidewalks at the door he exited. He stated, Yes. He was asked if he saw an ambulance in front of the door he exited and he stated Yes. He was asked if he still had his wander guard on and he stated, Yes. During an interview on 9/29/2021 at 12:51 PM, the DON was asked if the nurse should have initiated the wander guard on the Admission Elopement Risk Assessment. The DON confirmed the nurse should have placed the wander guard on the resident at that time because Resident #1 was assessed as a high risk for elopement at that time. During a telephone interview on 9/29/2021 at 1:02 PM, LPN #1 confirmed he had heard the front door alarm that evening when he was at work. He stated he went to the front door and reset the alarm because he assumed the ambulance staff had triggered the alarm. During a telephone interview on 9/30/2021 at 7:03 PM, LPN #2 stated, .Around 7:30 PM, I heard the front door alarm, so I went up to the front door to turn it off. The doors were locked and there was no one around .I did not go outside to check why the alarms were going off because the doors were safe and secure . During an interview on 9/30/2021 at 10:57 AM, the Medical Director was asked if he thought a resident who had a wander guard due to exhibiting exit seeking behaviors should be monitored. The Medical Director confirmed Resident #1 was alert and oriented to person, place, and time, could not talk but understood what anyone said to him. The Medical Director stated, .I want to know why the alarm went off .they didn't know he was leaving . The surveyor verified the Removal Plan by: 1. On 9/28/2021, visual signs alerting residents, families and friends were posted at the front door and in patient rooms as a reminder to notify staff when leaving the facility and signing out at the Nurses' Station. On 9/29/2021, visual signs were posted alerting ambulance employees, paramedics, families, and vendors to notify facility personnel immediately if anyone exits the facility through the front door area when they are entering or exiting the building. Visual signs alerting staff that door codes are not to be given out to anyone except staff were posted at the alarm panel on 10/1/2021. The surveyor made observations of the signs. 2. By 10/1/2021, cognitive/alert and oriented residents were educated by the Social Services Director or designee on proper Leave of Absence (LOA)/personal outing and Against Medical Advice (AMA) procedures. The surveyor reviewed the education and interviewed alert residents. 3. By 10/1/2021, Elopement Risk Assessments were reviewed/revised/completed on 100 percent (%) of the facility residents by the Nurse Managers. The plans of care for the facility's residents that were identified as high risk for elopement. The surveyor reviewed the assessments and Care Plans. 4. Resident Representatives were educated on the facility's process for Unplanned LOA and Personal Outing by a letter mailed on 10/1/2021. The surveyor reviewed the letters that were sent. 5. The facility's Elopement and Wandering Patients Policy was reviewed and revised on 10/1/2021, to include . a. Employees should identify the location and respond to an alarm timely b. Upon arrival to location of alarm observe the physical environment both inside and outside for wandering or exit seeking residents. c. Complete a head count on wandering/exit seeking residents to determine location. d. If unable to locate a resident initiate the procedure for locating a missing resident . The surveyor reviewed the revised policy. 6. A letter was faxed or mailed to Emergency Medical Services (EMS)/Transport companies to be sure to notify staff immediately if a resident leaves the facility without a staff member. The surveyor reviewed the letters sent. 7. On 10/1/2021, the Regional Director of Operations educated the facility Administrator and Director of Nursing on the Abuse Prohibition Plan, Emergency Preparedness Plan, and the Elopement and Wandering Patients Policy. The surveyor reviewed the education and interviewed the DON. 8. On duty personnel were educated on 9/29/2021 on actions to take when a resident exhibits exit seeking behavior or indications the resident wishes to leave LOA/AMA. The actions to take included responding to any alarms in the building promptly and to do a visual check of every resident bed. On duty staff were educated that door codes were not to be given to anyone except facility staff. The off-duty personnel will be educated upon return to work. Newly hired personnel will be educated during their orientation. The surveyor reviewed the education and interviewed staff on all shifts. 9. The facility arranged to have a vendor on site 9/29/2021 to assess the video surveillance camera operation and provide a quote for replacing/repairing the system. The vendor while on site also assessed the annunciator panel operation/implementation on the south wing of the facility and provide a quote for installation. Quotes were received and approved by Corporate staff on 9/29/2021 and the repairs/installation will begin 10/4/2021. The surveyor reviewed the quotes and interviewed the Administrator. 10. An elopement drill was completed on 10/1/2021 by the Administrator and Director of Nursing. The surveyor reviewed the drills. 11. The Administrator contacted the Medical Director to discuss the Removal Plan of the Immediate Jeopardy and the action plans developed to provide adequate supervision to the residents to prevent a resident that has been assessed for wandering, from leaving the facility without staff knowledge. 12. The Quality Assurance and Performance Improvement (QAPI) committee met on 10/1/2021 to discuss the Removal Plan of the Immediate Jeopardy which included Resident Education, Responsible Party Education, Staff Education, Emergency Personnel/Visitors/Vendors Education, and reviewed the facility policies and procedures to provide adequate supervision to prevent a resident, assessed for wandering, from leaving the facility without staff knowledge. The surveyor interviewed the QAPI members. 13. The facility held a Governing Body meeting by telephone conference on 10/1/2021 to review and approve the facility's action plan to provide adequate supervision to prevent residents assessed at high risk for elopement, from leaving the facility without staff knowledge.

Based on policy review, medical record review, observation, and interview, the facility failed to properly assess, identify, report, and treat wounds for 3 of 4 sampled residents (Resident #4, #5, and #6) reviewed for non-pressure related wounds. The facility's failure to identify, assess, and report Resident #4's arterial wound resulted in Immediate Jeopardy to Resident #4 when the arterial wound deteriorated and a new arterial wound was identified. The facility's failure to timely and accurately assess a macerated abdominal wound resulted in Immediate Jeopardy for Resident #5. The facility's failure to provide preventive measures and treatments resulted in actual Harm and Immediate Jeopardy for Resident #6 when the arterial wound deteriorated and developed eschar ( a dry hard scab). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, Regional Nurse Consultant, and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 9/22/2020 at 11:30 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-684. The facility was cited F-684 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective 8/2/2020 through 9/24/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/24/2020 at 4:30 PM, and was validated onsite by the surveyors on 9/25/2020 through review of assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) meeting minutes, observations, and staff interviews. The findings include: Review of the facility's policy titled, Pressure injury Prevention and Non-Pressure Ulcer Management, revised 11/2019, showed, .Arterial Ulcer .refers to ulcers caused by [MEDICAL CONDITION] .which commonly occur on the tips and tops of toes .tops of the foot .or distal to the medial malleolus .Licensed nurses will conduct a full body assessment on all residents upon admission/re-admission and weekly .findings will be documented in the medical records .Assessments of non-pressure ulcers or skin damage will be performed by a licensed nurse and documented weekly on the non-Ulcer skin Assessment form in the EHR (electronic health record) .Nursing assistants will report any skin concerns to the resident's nurse .Monitoring .The attending physician/NP (Nurse Practitioner) /PA (Physician Assistant)/CNS (Clinical Nurse Specialist) will be notified for the following .Presence of a new non-pressure ulcer or other skin damage .lack of healing .non-pressure ulcer .or other skin damage. Development of complications (infection .abscess .or development of a sinus tract .) Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #4 had a Brief Interview of Mental Status (BIMS) of 99, which indicated he was severely cognitively impaired, was at risk for developing pressure ulcers/injury, and a Stage 3 pressure ulcer was present. Review of the Care Plan dated 1/15/2020 and updated on 9/9/2020, showed, .At risk for impaired skin integrity .see doctor's orders and treatment notes for current interventions .assist .encourage/assist him to turn .reposition every 2 hours .Monitor for discoloring .Has Arterial wound to left Heel .May wear Prevalon boots to provide pressure relief on heels .feet . Review of the April through September 2020 recapitulation Physician order [REDACTED].CLEANSE (Left Heel Arterial Wound) WITH WOUND CLEANSER, PAT DRY, APPLY COLLAGEN POWDER AND CALCIUM ALGINATE (encourages new cell growth to the wound, and encourages removal of infected and dead tissue) TO WOUND BED .COVER FOAM DRESSING AND WRAP WITH ROLL GAUZE .Every Two Days . Review of the Weekly Non-Ulcer Reports for Resident #4 showed the following: a. 5/9/2020-5/15/2020 report, showed, .LEFT HEEL ARTERIAL .5.0 (centimeter (cm)) x (by) 4.0 (cm) x 0.2 (cm) . collagen/cal (calcium) alg (alginate) . on the left heel. b. 5/16/2020-5/22/2020 report, showed, .LEFT HEEL ARTERIAL .5.0 (cm) x 4.2 (cm) x 0.2 (cm) . c. 6/6/2020-6/12/2020 report, showed .LEFT HEEL ARTERIAL .5.0 (cm) x 4.5 (cm) x 0.1 (cm) . d. 6/27/2020-7/3/2020 report, showed, .LEFT HEEL ARTERIAL .6.0 (cm) x 5.0 (cm) x 0.1 (cm) . Review of the June 2020 Treatment Administration Record (TAR), showed there was no treatment with Collagen Powder and Calcium Alginate performed on the left heel on 6/5/2020 and 6/15/2020. Review of the July TAR, showed there was no weekly skin audit performed on 7/20/2020 and there was no Collagen Powder and Calcium Alginate treatment performed on 7/16/2020, 7/18/2020, 7/20/2020, 7/22/2020, 7/24/2020 and 7/30/2020. Review of the July 2020 through September 2020 recapitulation Physician order [REDACTED].LEFT HEEL WOUND: CLEANSE WITH DAKIN'S SOLUTION (a strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION]) RINSE WITH N. S. (Normal Saline) .PAT DRY APPLY SANTYL OINTMENT (to debride and remove slough and necrotic tissue from the wound bed) TO WOUND BED COVER WITH DRY DRESSING .WRAP WITH ROLL GAUZE .Every One Day (daily) . Review of the July 2020 TAR for Resident #4, showed there was no treatment with Dakin's Solution and Santyl ointment performed on 7/16/2020, 7/17/2020, 7/18/2020, 7/20/2020, 7/22/2020, 7/24/2020, 7/25/2020, and 7/30/2020. The physician's orders [REDACTED]. Both treatments were active orders from 7/6/2020 to present. Review of the Weekly Ulcer Reports for Resident #4's left heel showed the following: a. 7/4/2020-7/10/2020 report, showed, .LEFT HEEL .6.0 (cm) x 5.0 (cm) x 0.1 (cm) .50% NECROSIS . b. 7/11/2020-7/17/2020 report, showed, .LEFT HEEL .6.2 (cm) x 4.8 (cm) x 0.8 (cm) .30% NECROSIS . c. 7/18/2020-7/25/2020, showed, .LEFT HEEL .7.0 (cm) x 6.2 (cm) x 0.5 (cm) .10% NECROSIS . d. 7/26/2020-8/1/2020, showed, .LEFT HEEL .7.0 (cm) x 6.2 (cm) x 0.5 (cm) .10% NECROSIS Review of the August 2020 TAR, showed there was no treatment with Dakin's Solution and Santyl ointment performed on 8/1/2020, 8/3/2020, 8/4/2020, 8/5/2020, 8/6/2020, 8/8/2020, 8/16/2020, 8/22/2020, 8/25/2020, 8/29/2020, and 8/30/2020. Review of Resident #4's August 2020 TAR, also showed there was no Collagen Powder and Calcium Alginate treatment performed to the left heel on 8/1/2020, 8/3/2020, 8/25/2020, and 8/29/2020. Review of the Weekly Ulcer Reports for Resident #4's left heel showed the following: a. 8/2/2020-8/9/2020 report, showed, .LEFT HEEL .7.5 (cm) x 6. 2 (cm) x 0.5 (cm) .10% NECROSIS . The left heel wound had deteriorated and increased in size from 5.0 cm x 4.5 cm x 0.1 cm on the weekly report dated 6/6/2020-6/12/2020. b. 8/10/2020-8/16/2020 report showed, .LEFT HEEL .7.5 (cm) x 6.2 (cm) x 0.5 (cm) . c. 8/17/2020-8/24/2020 report showed, .LEFT HEEL .7.5 (cm) x 6.0 (cm) x 0.5 (cm) .10% NECROSIS . d. 8/25/2020-8/31/2020 report showed, .LEFT HEEL .7.5 (cm) x 6.0 (cm) x 0.5 (cm) .10% NECROSIS . e. 9/3/2020 report showed, .8.5 (cm) x 7.5 (cm) x 0.2 (cm) . The left heel wound deteriorated and increased in size in 1 week. Review of Resident #4's September 2020 TAR, showed the arterial wound to the left heel was not cleansed with Dakin's solution on 9/3/2020, 9/8/2020, 9/10/2020 and no Santyl/Ointment treatment was performed on 9/3/2020 and 9/10/2020. Review of the September TAR, showed there was no weekly skin assessment on 9/7/2020. Observation in Resident #4's room on 9/10/2020 at 4:10 PM, showed Resident #4 in bed with a dressing to his bilateral lower extremities. His heels were lying flat on the bed with a pillowcase under the heels and the heels were not floated (free of pressure from the bed). The dressing on the left heel wound had a large amount of dark green purulent drainage with a strong odor. Observation in Resident #4's room on 9/13/2020 at 9:30 AM, showed Resident #4's left heel had a large amount of purulent drainage on the dressing dated 9/11/2020. Observation in Resident #4's room on 9/14/2020 at 5:49 PM, showed Resident #4's left heel had a foul odor and a large amount of green purulent drainage on the dressing. The left heel also had bruising on the outer aspect of the left heel. The Wound Care Physician identified a new wound to the left medial leg, a triangle shaped wound with 100% eschar and measured 1.5 cm x 2.5 cm x 0 cm. Review of the (Named Company) Wound Evaluation & Management Summary (Physician Wound Progress Notes) dated 9/24/2020, showed, .ARTERIAL WOUND OF THE LEFT HEEL .8 (cm) X 7.5 (cm) X 0.1 cm .Thick adherent devitalized necrotic tissue .10 % (percent) .Granulation tissue .90 % .Wound progress: Deteriorated . Review of the Physician Telephone Orders dated 9/14/2020, showed, .Heel wound culture & (and) sensitivity .RE (regarding) infection/[MEDICAL CONDITION] .L (left) Leg wound culture & sensitivity .Bactrim .BID (twice a day) x (for) 7 days . Review of the (Named Company) Wound Evaluation & Management Summary (Physician Wound Progress Notes) dated 9/21/2020, showed, .PLEASE NOTE: THIS NEW LEFT MEDIAL LEG ARTERIAL WOUND LEFT OFF NOTE DATED 9/14/2020 . During an interview on 9/14/2020 at 5:49 PM, the Wound Care Physician confirmed that Resident #4's heel looked worse, had an odor and purulent drainage. The Wound Care Physician confirmed the staff should have identified the new area to Residents #4's left medial leg. The facility's failure to assess Resident #4's skin and provide treatments as ordered placed Resident #4 in Immediate Jeopardy when the Arterial wound deteriorated and a new wound was discovered with 100% eschar. Review of the medical record, showed Resident #5 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Care Plan dated 5/20/2020 and updated 9/9/2020, showed, .At risk for infection R/T (related to) .Suprapubic catheter (a tube placed through the abdomen into the bladder to drain urine) .Clean around catheter with soap and water daily and as needed .Report any sign of infection .Catheter care . The 5-day MDS dated [DATE], showed a BIMS of 3, which indicated Resident #5 had severe cognitive impairment and the resident was at risk for developing pressure ulcers/injury. Review of the (Named Company) Wound Physicians Progress Evaluation dated 9/14/2020, showed a newly identified wound, .WOUND ABDOMEN .5.5 (cm) x 2.5 (cm) 2.0 .cm .Maceration .Antifungal apply every two days for 30 days .Alginate calcium w (with)/silver apply every two days for 30 days . Review of the Weekly Ulcer Report dated 9/13/2020 did not identify the wound on the abdomen. Observation in Resident #5's room on 9/14/2020 at 10:35 AM, the Wound Care Physician identified a new area to Resident #5's suprapubic catheter site to the abdomen with a large amount of redness. During an interview on 9/14/2020 at 10:49 AM, the Wound Care Physician confirmed that the maceration should have been identified so a treatment could be put in place. The Wound Care Physician confirmed that the maceration should have been identified on the weekly skin assessment. The facility's failure to assess Resident #5's skin placed Resident #5 in Immediate Jeopardy when the macerated wound at the suprapubic catheter site was discovered by the physician. Review of the medical record, showed Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Initial Skin Injury Assessment (a form for new admissions) dated 8/19/2020, showed, .The location of this area is Left Heel .Right heel . There was no description, stage or measurements of the areas documented on this form. Review of the Physician order [REDACTED].Float heels wit (with) Prevalon boots (boots to reduce pressure on the heels) or pillows .Clean bilateral heel with wipes .Apply [MEDICATION NAME] swab daily to right heel .Cover bilateral heels wit (with) [MEDICATION NAME] border dressing (foam absorbent dressing for wounds) .Change Q (every) 3D (days) . Review of the Clinical Notes Report addendum dated 8/19/2020, showed, .Requires total assistance with ADLs (activity of daily living) and transfers .open area noted to bilateral heels . Review of the Weekly Ulcer Report dated 8/17/2020-8/24/2020, showed Resident #6's bilateral heels had not been measured or staged. Review of the Nursing Admission/Readmission Form dated 8/20/2020 (completed for the admission 8/19/2020), showed, .Ulcer/Injury Present .Yes . There was no description of the wound documented. Review of the admission MDS dated [DATE] showed, Resident #6 had a Brief Interview for Mental Status of 13, which indicated he was cognitively intact and at risk for developing pressure ulcers/injury. Review of the August 2020 TAR showed, there was no treatment documented to float the heels on the 6:00 AM to 6:00 PM shift on 8/23/2020, and on the 6:00 AM to 6:00 PM shift on 8/24/2020 . There was no documentation the treatment to clean the bilateral heels with wipes and apply a [MEDICATION NAME] swab was performed on 8/28/2020 Review of the Weekly Ulcer Report for Resident #6 dated 8/25/2020-8/31/2020, showed no measurements for Resident #6's bilateral heels. Review of the September 2020 TAR showed, the bilateral heels were not cleaned with wipes and a [MEDICATION NAME] swab was not applied as ordered to the right heel on 9/3/2020. Review of the Weekly Ulcer Report dated 9/3/2020, showed, .lt (left) heel .ustag (unstageable) .5 (cm) x 4 (cm) x 0.1 (cm) .100 % (percentage) eschar .rt (right) heel .unstag .7.5 (cm) x 5 (cm) x 0.1 (cm) .100 % eschar . Review of the WOUND AND PRESSURE INJURY INFORMATION, dated 9/3/2020, showed, .lt (left) heel .length .5 cm .X Width .4 cm . X Depth 0.1 cm .unstageable (full thickness skin or tissue loss with unknown depth) .Necrotic/Eschar .rt (right) heel .Length 7.5 cm .X Width 5 cm . X Depth 0.1 cm .Necrotic/Eschar . Review of the (Named Company) Wound Physicians Wound Evaluation & Management Summary (Wound physician progress notes [REDACTED].ARTERIAL WOUND OF THE LEFT HEEL .1 (cm) X 0.7 (cm) X 0.1 cm .Dried [MEDICATION NAME] exudate (scab) ARTERIAL WOUND OF THE RIGHT HEEL .4.5 (cm) X 5.5 (cm) X Not Measurable cm .Thick adherent black necrotic tissue (eschar) . Review of the medical record showed nursing staff assessed the wound as a pressure ulcer and the Physician documented the same wound as an arterial wound. Observation in Resident #6's room on 9/10/2020 at 5:04 PM, showed Resident #6 resting in bed without heel boots. The lower extremities were elevated on one pillow and there were no dressings on the heels. The right and left heel had a large amount of black hard eschar. Observation in Resident #6's room on 9/14/2020 at 12:11 PM, showed Resident #6's left heel had a large amount of black hard necrotic eschar that measured 5.0 cm x 3.5 cm x 0 cm. After the Wound Care Physician removed the eschar, she staged the left heel at a stage 3 (full thickness skin loss and fat is visible) with the measurement of 0.7 cm x 0.4 cm x 0.1 cm and 100 % granulation. The right heel had 100% dry necrotic eschar, and was 6.5 cm x 4.5 cm x 0 cm. The Wound Care Physician identified a new wound with black eschar that measured 1.0 cm x 1.7 cm x 0 cm. on Resident #6's right medial ankle. During an interview on 9/14/2020 at 12:15 PM, the Wound Care Physician stated the heels had declined due to the eschar on the bilateral heels and the heels had not been properly off-loaded (direct pressure removed from the heels). During an interview on 9/16/2020 at 9:12 AM, the Medical Director confirmed that he would expect the staff to complete accurate skin assessments. The Medical Director confirmed that he would expect the staff members to properly identify, assess, monitor and provide the treatments as ordered for the wounds. The facility's failure to provide preventive measures and treatments resulted in actual Harm and Immediate Jeopardy for Resident #6 when the arterial wound deteriorated and a new wound on the right medial ankle was identified by the Wound Care Physician . During a telephone interview on 9/24/2020 at 1:59 PM, Wound Care Nurse #1 (the former Wound Care Nurse) confirmed that she was told by the Administrator and Human Resources (HR) that she had to go to an as needed position. Wound Care Nurse #1 confirmed that she assumed the as needed status in late summer, June or July. Wound Care Nurse #1 stated she completed the weekly skin assessments with measurements until she was forced to go to the as needed status. Wound Care Nurse #1 confirmed that the floor nurses were responsible for the wound care treatments if she was not available. Wound Care Nurse #1 stated that the facility took her position away and refused to work with her schedule at school. Wound Care Nurse #1 confirmed that she last made rounds with the Wound Care Physician on July 20, 2020 and that she was not available to round with the Wound Care Physician during the daytime due to her school schedule. Wound Care Nurse #1 stated she was not able to complete the treatments and the paperwork. The Surveyor verified the Removal Plan by: 1. The facility staff will complete weekly skin assessments and perform treatments and evaluations of wounds. Certified Nursing Assistants (CNAs) will identify and report changes in skin. Nursing staff will provide appropriate documentation and treatment of [REDACTED]. The nursing staff will identify and provided needed care and services that are resident centered, that will meet the resident's physical, mental, and psychosocial needs. The surveyors interviewed the management staff and reviewed in-service records. 2. Nurse manager oversight will be provided to ensure competent staffing to facilitate effective wound care management and to promote healing. The surveyors interviewed the management staff and reviewed in-service records. 3. On 9/23/2020, the Nurse Managers including the ADON, the Admission Coordinator, the MDS Coordinator, and the evening shift supervisor were educated by the Regional Nurse Consultant and Certified Wound Specialist on appropriate documentation and treatment of [REDACTED]. The surveyors reviewed the in-service training and interviewed the Nurse Managers. 4. On 9/23/2020, the CNAs were educated on observing for skin changes, reporting of skin changes and pressure injury prevention. The surveyors interviewed staff on all shifts, attended the in-service training, and reviewed the in-service records. 5. Residents will be assessed upon admission and weekly by a licensed nurse and an assessment will be documented on the initial skin injury form on admission and weekly on the weekly ulcer/non-ulcer assessment form, in the electronic health record. The resident's physician and responsible party will be notified of newly identified skin injuries and this will be documented on the treatment administration record after completion. Care plans will be reviewed and revised. The surveyors reviewed the records in the Electronic Health Record and the Care Plans. 6. On 9/23/2020, the Nurse Managers were educated by the Regional Nurse Consultant and Certified Wound Specialist on policies and procedure for pressure injury prevention and on pressure injury management, skin assessment, and documentation of wound treatments. The Nurse Managers and licensed nurses were educated on consistent and accurate weekly wound assessments related to the measurement and descriptions of wounds, identifying and providing needed care and services that are resident centered, that will meet the residents' physical, mental and psychosocial needs. The surveyors interviewed the Nurse Managers and nursing staff on all shifts and reviewed the in-service records. 7. On 9/23/2020, all residents with current wounds were audited for appropriate and complete assessment and documentation in the electronic health record, physician and family notification, current physician order [REDACTED]. Concerns were identified in the audit that was completed on 9/23/2020. Education and training plans were initiated on 9/23/2020 and will be ongoing. The surveyors reviewed the audit sheets and interviewed the Nurse Managers. 8. The facility treatment nurse will provide consistent wound care and weekly wound assessments. If circumstances prevent rounding by the designated treatment nurse, licensed nurses will provide wound care and nurse management will complete weekly wound assessments. The facility hired a full-time treatment nurse that rounded with the Wound Care Specialist on 9/21/2020. The surveyors interviewed the full time Treatment Nurse, and nurses on all shifts. 10. (Named Company) Wound Care Physician was consulted on 9/21/2020 and will continue to be consulted weekly for residents with wounds as needed. If circumstances prevent on site rounds, (Named Company) Wound Care Physician will be contacted by phone or telehealth. The surveyors interviewed the Wound Care Physician and observed her on site on 9/21/2020 making rounds and providing treatments for the residents. 11. On 9/23/2020, education was completed by Nurse Managers for on duty licensed nurses on consistent and accurate weekly wound assessments related to the measurement and description of wounds, identifying and providing needed wound care and services that are resident centered and will meet the resident's physical, mental, and psychosocial needs. On duty licensed nurses were educated on 9/23/2020 on policies and procedures for pressure injury prevention and non-pressure injury management, skin assessment and documentation of wound treatments. The surveyors reviewed the in-service training records and interviewed nurses on all shifts. 12. Upon returning to work off duty licensed nurses will be educated by the Nurse Managers on consistent and accurate weekly wound assessments related to the measurements and descriptions of wounds, identifying and providing needed care and services that are resident centered and that will meet the resident's physical, mental, and psychosocial need. Off duty licensed nurses, upon returning to work will be educated on policies and procedures for pressure injury prevention and non- pressure injury management, skin assessment, and documentation of wound treatments. The surveyors interviewed the Regional Nurse Consultant on the training process. 13. Off duty Certified Nursing Assistants, upon returning to work will be educated by the Nurse Manager on observing for skin changes, reporting of skin changes, and pressure injury prevention. The surveyors interviewed the Regional Nurse Consultant on the training process. 14. Newly hired licensed nurses will be educated during orientation on consistent and accurate weekly wound assessments related to the measurement and descriptions of wounds, identifying and providing needed care and services that are resident centered, that will meet the resident's physical, mental, and psychosocial need. All newly hired licensed nurses will be educated on policies and procedures for pressure injury prevention and non-pressure injury management, skin assessments, and documentation. The surveyors interviewed the Regional Nurse Consultant on the training process. 15. Newly hired Certified Nursing Assistants will be educated during orientation on observing for skin changes, reporting of skin changes, and pressure injury prevention. The surveyors interviewed the Regional Nurse Consultant on the training process. 16. Staff training for licensed nurses will be ongoing, related to consistent and accurate weekly wound assessments with the measurement and description of the wounds, identifying and providing needed care and services that are resident centered, and will meet the resident's physical, mental, and psychosocial needs will be provided bi-annually. Ongoing staff training for licensed nurses on policies and procedures for pressure injury prevention and non-pressure injury management, skin assessment, and documentation of wound treatments will be provided bi-annually. The surveyors interviewed the Regional Nurse Consultant on the training process. 17. Ongoing staff training for Certified Nursing Assistants on observing for skin changes, reporting of skin changes, and pressure injury prevention will be provided bi-annually. The surveyors interviewed the Regional Nurse Consultant on the training process. 18. On 9/23/2020 the QAPI committee which includes the Administrator, ADON, and Medical Director discussed mechanisms to address the immediate concerns for residents with wounds and all other residents identified as having the potential to be affected. The Medical director is in agreement with the current Removal Plan. The surveyors reviewed the QAPI minutes and interviewed the QAPI members. 19. On 9/22/2020, the QAPI Committee and the Medical Director were notified of the Immediate Jeopardy Deficiencies by the Administrator. The surveyors reviewed the QAPI meeting minutes that included the sign in sheet. 20. The Nurse Managers which includes the DON, ADON, Staffing Coordinator, MDS Coordinator, Admissions Coordinator, and Medical Records will audit electronic health record on all new admissions, hospital readmissions, and weekly wound assessments for pressure injuries, non-pressure wounds, and new pressure injuries for appropriate and completed identification and assessment, documentation, treatment, following physician orders, and physician and family notification of pressure injuries or changes in status to ensure a resident with pressure injuries and non-pressure wounds receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing daily for 7 days, weekly for three weeks, then monthly for two months, and quarterly ongoing. The findings of the audit will be reported to the QAPI Committee which consists of the Administrator, Medical Director, DON, ADON, Staffing Coordinator, Medical Records, MDS Coordinators, Social Services Director, Activities Director, Dietary Supervisor, Maintenance Supervisor, Business Office Coordinator, Admissions Coordinator, and Infection Preventionist. If compliance is not met, staff will be re-educated, and the audits will continue until substantial compliance is met. The Medical Director is in agreement with the current Removal Plan. The surveyors reviewed the QAPI agenda and meeting minutes, reviewed the audit forms, and interviewed the Medical Director, Administrator, and the ADON. Noncompliance of F-684 continues at a scope and severity of E for the monitoring and effectiveness of the corrective action. The facility is required to submit a Plan of Correction.

Based on The National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [REDACTED].#4, #5, #8, and #12) reviewed with pressure ulcers. The facility's failure to identify, assess, report, and treat wounds as ordered resulted in Immediate Jeopardy when Resident #4 developed an Unstageable pressure ulcer, Resident #5 developed a Stage 3 pressure ulcer, Resident #8 developed an Unstageable pressure ulcer that progressed to a Stage 4 pressure ulcer, and Resident #12 developed Deep Tissue Injuries (DTI). The facility failed to ensure treatments were performed as ordered for 1 of 11 sampled residents (Resident #13) reviewed with pressure ulcers. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, Regional Nurse Consultant, and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 9/22/2020 at 11:30 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-686. The facility was cited at F-686 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective 8/2/2020 through 9/24/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/24/2020 at 4:30 PM, and was validated onsite by the surveyors on 9/25/2020 through review of assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) meeting minutes, observations, and staff interviews. The findings include: Review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [REDACTED].Conduct a comprehensive skin and tissue assessment for all individuals at risk of pressure injuries: As soon as possible after admission/transfer to the healthcare service .As a part of every risk assessment .Periodically as indicated by the individual's degree of pressure injury risk .For individuals at risk of heel pressure injuries and/or with Category/Stage I or II pressure injuries, elevate the heels using a specifically designed heel suspension device or a pillow foam cushion .For individuals with a Category/Stage III or greater heel pressure injury, elevate the heels using a specifically designed heel suspension device offloading (to remove direct pressure) the heel completely .Conduct a comprehensive reassessment of the individual if the pressure injury does not show some signs of healing within two weeks .Stage I pressure ulcer: Non-blanchable (skin does not lose redness when pressure applied) [DIAGNOSES REDACTED] (redness of skin) Intact skin with non-blanchable redness of a localized area usually over a bony prominence .Stage II pressure ulcer: Partial thickness skin loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed .May also present as an intact or open/ruptured serum-filled blister .Stage III: Full thickness skin loss Full thickness loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough (dead tissue) may be present .May include undermining and tunneling .Category/Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (a thick crust) may be present .Unstageable: Depth unknown Full thickness tissue loss in which the base of the ulcer is covered by a slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in the wound bed .Suspected Deep Tissue Injury: Depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure . Review of the Lippincott Manual of Nursing Practice 10th Edition, page 183, showed, .Pressure Ulcers .They (pressure ulcers) most commonly result from prolonged periods of bed rest in acute- or long- term care facilities; they can develop within hours in the compromised individual .Stage the ulcer so appropriate treatment can be started .Inspect skin several times daily . Review of the facility's policy titled, Pressure Ulcer Prevention and Non-Pressure Ulcer Management, revised 11/20/2019, showed, .This facility is committed to the prevention of avoidable pressure injuries .healing of existing pressure injuries .promote wound healing of various types of wounds in accordance with current standard of practice and Physicians orders .The facility shall establish and utilize a systematic approach for pressure injury prevention and management .starting with prompt assessment and treatment .including effort to identify risk .stabilize reduce or remove underlying risk factors .monitor the impact of the interventions .Licensed nurses will conduct a full body assessment on all residents upon admission/re-admission and weekly .Findings will be documented in the medical record .Assessments of pressure injuries will be performed by a licensed nurse, and documented on the Weekly PU (Pressure Ulcer) / PI (Pressure Injury) Assessment form in the EHR (Electronic Health Record) .The staging of pressure injuries will be clearly identified .Nursing assistants will report any skin concerns to the resident's nurse .Interventions will be documented in the care plan . Review of the facility's policy titled, Skin Assessment, revised 6/2020, showed, .It is our policy to perform a full body skin assessment as part of our systematic approach for pressure ulcer/injury prevention and for the promotion of healing of various skin conditions .including pressure ulcers/injuries .A full body .head to toe .skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission .the day following admission/re-admission .and weekly .e. documentation of the skin assessment .complete the wound assessment form in the electronic health record (EHR) . Review of the facility's policy titled, Documentation of Wound Treatments, revised 11/2019, showed, .The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are .1. Complete .2. Accurately documented .3. Readily accessible .4. Systematically organized .Documentation should provide a picture of the resident's progress .including response to treatment .change in condition .changes in treatment .treatment and documentation guidelines .Complete Weekly Wound Form which includes the type .anatomical location (location on the body) .stage .measurements .complete description of the wound .including tunneling (an open pocket or tract under the skin that results from infection or destroyed tissue) .undermining .odor .if non-pressure .partial .full thickness . Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE], showed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment, was at risk for developing pressure ulcers/injury, and there was nothing marked to indicate Resident #4 had any pressure ulcers. Review of Resident #4's Care Plan dated 1/15/2020 and updated 9/9/2020, showed .Tunneling Abscess to sacrum .wear Prevalon boots (boots to reduce pressure on the heels) .check skin for redness .skin tears .swelling .pressure areas .report signs of breakdown .see doctor's orders and treatment notes for current interventions . Review of the March to present (September) 2020 Physician order [REDACTED].(start date 3/3/2020) CLEANSE WITH WOUND CLEANSER .PAT DRY .APPLY BARRIER CREAM .COLLAGEN POWDER .CALIUM (calcium) ALIGATE (alginate) (encourages new cell growth to the wound, and encourages removal of infected and dead tissue) TO WOUND BED .PACK WITH DRY 4X4 GAUZE .COVER WITH DRY DRESSING .CHANGE DRESSING EVERY DAY .PRN . Review of the Weekly Non-Ulcer Reports for Resident #4 showed the following: a. 5/9/2020-5/15/2020, showed, .SACRUM ABSCESS .5.5 (centimeters (cm) x (by) 8.5 (cm) x 2.5 (cm) . b. 5/16/2020-5/22/2020, showed, .SACRUM ABSCESS .5.5 (cm) x 8.5 (cm) x 2.5 (cm) . Review of Resident #4's June 2020 Treatment Administration Record (TAR), showed the Collagen Powder and Calcium Alginate treatments to the sacrum wound were not performed on 6/5/2020, 6/6/2020, 6/12/2020, and 6/15/2020. Review of Weekly Non-Ulcer Report dated 6/6/2020-6/12/2020, showed, .SACRUM ABSCESS .5.5 (cm) x 8.5 (cm) x 2.5 (cm) . Review of the (Named Company) Wound Evaluation & Management (Physician Wound Progress Notes) Summary for Resident #4 dated 6/18/2020, showed, .POST-SURGICAL WOUND OF THE RIGHT SACRUM .5.5 (cm) X 8.5 (cm) X 2.5 cm .undermining (occurs when the tissue under the wound edges become eroded, resulting in a pocket beneath the skin) 3 cm at 3 o'clock .Moderate Serous (drainage) . On 6/18/2020, the Physician wrote to continue the Collagen and Alginate orders to the sacral wound once daily. Review of the WOUND EVALUATION & MANAGEMENT (physician progress notes [REDACTED].Wound size .10.5 (cm) x 4 (cm) x 2.5 cm . with odor and heavy purulent drainage. The Quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 99, which indicated the resident had severe cognitive impairment, was at risk for developing pressure ulcers/injury, and one Stage 3 pressure ulcer was present. Review of the Weekly Ulcer Reports for Resident #4, showed the following: a. 7/11/2020-7/17/2020, showed, .SACRUM ABSCESS .4.0 (cm) x 10.3 (cm) x 2 (cm) . b. 7/18/2020-7/25/2020, showed, .SACRUM ABSCESS .4.0 (cm) x 9.0 (cm) x 2.2 (cm) . c. 7/26/2020-8/1/2020, showed, .SACRUM ABSCESS .4.0 (cm) x 9.0 (cm) x 2.2 (cm) . Review of Resident #4's July 2020 TAR showed there were no Collagen Powder and Calcium Alginate treatments to the sacral wound on 7/16/2020, 7/17/2020, 7/18/2020, 7/20/2020, 7/22/2020, 7/24/2020, 7/25/2020 and 7/30/2020. Review of the (Named Company) Wound Evaluation & Management (physician progress notes [REDACTED]. a. 7/13/2020, showed, .POST-SURGICAL WOUND OF THE RIGHT SACRUM .4 (cm) X 10.3 (cm) X 2.0 cm .undermining 3.0 cm at 12 o'clock .Heavy Serous . b. 7/20/2020, showed, .POST-SURGICAL WOUND OF THE RIGHT SACRUM .4 (cm) X 9 (cm) X 2.2 cm .undermining 3.5 cm at 12 o'clock .Moderate Serous . Review of the Weekly Ulcer Report for Resident #4, showed the following: a. 8/2/2020-8/9/2020, showed, .SACRUM ABSCESS .4.5 (cm) x 9.0 (cm) x 2.2 (cm) . b. 8/17/2020-8/24/2020, showed, .SACRUM ABSCESS .4.5 (cm) x 9.0 (cm) x 2.2 (cm) . c. 8/25/2020, showed, .SACRUM ABSCESS .14.5 (cm) x 12.0 (cm) x 2.5 (cm) . During an interview on 9/14/2020 at 5:49 PM, the Wound Care Physician stated the wound to the sacrum had been an abscess, but Resident #4 had been to the hospital in the past, an Incision and Drainage was performed, and she identifies this wound as a Post-Surgical wound. Review of Resident #4's August 2020 TAR, showed there were no Collagen Powder and Calcium Alginate treatments performed to the sacral wound on 8/1/2020, 8/3/2020, 8/4/2020, 8/5/2020, 8/6/2020, 8/8/2020, 8/16/2020, 8/22/2020, 8/25/2020, 8/29/2020, and 8/30/2020. There was no weekly skin audit performed on 8/20/2020. Review of Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review, dated 8/26/2020, showed there were no wounds identified. The facility failed to provide additional documentation of shower review forms. Review of the Weekly Ulcer Report dated 9/3/2020, showed, .SACRUM STAGE 4 .10.0 (cm) x 5.0 (cm) x < (less than) 0.5 (cm) .undermining 12 to 5 . The abscess/Post Surgical wound had deteriorated to a Stage 4 Pressure Ulcer. Review of the WOUND AND PRESSURE INJURY INFORMATION dated 9/8/2020, showed no rash, no abrasions, no bruise, and no skin tears present. There was no documentation of the Sacral pressure ulcer. Review of Resident #4's SEPTEMBER 2020 TAR, showed no treatment to the sacral wound on 9/3/2020, 9/8/2020, and 9/12/2020. There was no skin audit on 9/7/2020. Observation in the resident's room on 9/10/2020 at 4:10 PM showed, Resident #4 was resting in bed. When Resident #4 was repositioned on the side, there was no dressing to the sacral area. During an interview on 9/10/2020 at 4:10 PM, the DON confirmed that the wound should be covered as ordered. Review of the (Named Company) Wound Evaluation & Management (physician progress notes [REDACTED].POST-SURGICAL WOUND OF THE RIGHT SACRUM .7 (cm) X 6 (cm) X 2.5 (cm) .undermining 5.5 cm at 9 o'clock .Moderate sanguineous .Wound progress: Deteriorated . Observation in the resident's room on 9/14/2020 at 5:49 PM with the Wound Care Physician, showed Resident #4 had a Stage 4 wound to the sacrum. The Wound Care Physician measured the pressure ulcer and the measurements were 8.5 (cm) x 4.0 (cm) x 3.0 (cm) with undermining of 4.5 cm at 12 o'clock. The Wound Care Physician verbalized these measurements to the surveyor. During an interview on 9/16/2020 at 11:13 AM, CNA #3 confirmed that they are supposed to complete their skin assessment on the shower sheet each day. Review of the Physician order [REDACTED]. During an interview on 9/16/2020 at 3:30 PM, CNA #4 confirmed that on 9/10/2020 she had not been in Resident #4's room from 6:00 AM until 10:00 AM and she had not turned Resident #4 in 4 hours. CNA #4 confirmed she was unaware Resident #4's dressing was off the sacral area. The facility's failure to assess Resident #4's skin and provide treatments as ordered resulted in actual Harm to Resident #4 and placed Resident #4 in Immediate Jeopardy when an abscess/Post Surgical wound deteriorated to a Stage 4 pressure ulcer. Review of the medical record, showed Resident #5 was admitted to the facility on [DATE] with a readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the 5-day MDS dated [DATE], showed Resident #5 had a BIMS of 3, which indicated severe cognitive impairment and the resident was at risk for developing pressure ulcers/injury. Review of the Weekly Ulcer Report dated the week of 9/3/2020, showed, .lt (left) buttock stage 3 .2 (cm) x 1 (cm) x 0.1 (cm) .(with an onset date 9/4/2020) . Review Resident #5's Initial Skin Injury Assessment (a form for new wounds) dated 9/4/2020, showed, .lt buttock .Length .2 CM Width .1.5 CM .Depth > (greater than) 0.5 CM . There was no Stage of the pressure ulcer documented. Review of Resident #5's Care Plan dated 5/20/2020 and updated 9/9/2020, showed, .Wound Care and Management ST (stage) 3 to left Buttocks .Assess and monitor wound healing .Assess and monitor wound treatment plan for effectiveness and complications .Notify the physician if current wound treatment is not effective .record wound measurements . Review of the Physician order [REDACTED].Clean with wound cleaner .pat dry .apply iodosorb (when applied to a wound it removes pus and debris from the wound and forms a gel surface over the wound bed) .0.9 % (percent) topical gel .to stage 2 .lt (left) buttocks wound .every 1 day . There was no treatment ordered for the Stage 3 Pressure Ulcer until 9/6/2020 and the pressure ulcer was identified on 9/4/2020. Review of the WOUND AND PRESSURE INJURY INFORMATION, for Resident #5 dated 9/8/2020, showed, .lt buttock .Onset Date 09/04/2020 .For Pressure Injury: 3 (Stage) .Length 2 CM x Width 1.5 CM x Depth 0.1 CM . Observation in the resident's room on 9/11/2020 at 10:02 AM, showed Resident #5 had a large grape size pressure ulcer to his left buttock, with a large amount of slough to the wound bed, there was no dressing covering the pressure ulcer. During an interview on 9/11/2020 at 10:36 AM, the DON confirmed that the wound was identified on 9/4/2020 at a Stage 3. The DON confirmed that the wound should be covered with a dressing. Review of the (Named Company) Wound Evaluation & Management (physician progress notes [REDACTED].#5 dated 9/14/2020, showed, .STAGE 3 PRESSURE WOUND OF THE LEFT BUTTOCK .1.4 (cm) X 0.8 (cm) X 0.4 (cm) .100% granulation . Review of the Treatment/Order Update/Change in Condition, dated 9/15/2020, showed .Clean with cleanser .pat dry .apply iodosorb 0.9 % topical gel to stage 3 lt buttocks wound . During an interview on 9/15/2020 at 10:53 AM, the DON confirmed that the original order dated 9/6/2020 documented an incorrect wound assessment and the stage of the wound to the left buttock was not a Stage 2. The DON confirmed that the left buttock pressure ulcer discovered on 9/4/2020 was discovered at a Stage 3. Review of the Physician order [REDACTED]. The facility's failure to assess Resident #5's skin, failure to identify a pressure ulcer before it became a Stage 3 pressure ulcer, and a delay in treatment to the pressure ulcer resulted in actual Harm to Resident #5 and placed Resident #5 in Immediate Jeopardy. Review of the medical record, showed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's Care Plan dated 5/11/2020, showed, .at risk for pressure ulcer .check skin for redness .pressure areas .Report any signs of skin breakdown .Use pillow .to reduce pressure on heels .turn/reposition at least every two hours .Monitor skin integrity while providing care . The quarterly MDS dated [DATE] showed a BIMS of 4, which indicated severe cognitive impairment and the resident was at risk for developing pressure ulcers/injury. Review of the Initial Skin Injury Assessment, (form for new wounds) performed by a Registered Nurse dated 9/4/2020, showed, .Skin injury identified on 09/04/2020 .rt (right) heel .Length .5.5 cm Width .5 cm with a Depth of: Depth 0.2 cm . There was no stage of the wound identified on this form. Review of the Treatment/Order Update/Change in Condition dated 9/7/2020 showed, .Santyl 250 unit/gram topical ointment (apply) OINTMENT Topical Every 1 Day (daily) .Apply Santyl TOP (topical) to right heel and apply protective dressing QD (every day) . There was no treatment ordered to the unstageable pressure ulcer until 9/7/2020. The pressure ulcer was discovered on 9/4/2020. Review of the WOUND AND PRESSURE INJURY INFORMATION, dated 9/9/2020, showed, .Location rt heel .Onset Date: 09/04/2020 .Unstageable-slough and/or eschar (Known but not stageable due to coverage of wound bed by slough and/or eschar) .5.3 cm X Width 4.3 cm X Depth 0.2 cm . Observation in the resident's room on 9/10/2020 at 3:49 PM, showed Resident #8 in bed with a dressing to the right heel and left lower extremity. The resident's heels were positioned flat on top of one pillow and the heels were not off loaded. Observation in the resident's room on 9/10/2020 at 4:07 PM, showed Resident #8 had a large wound to the back of the right heel and ankle, with a pea size white area at the top of wound, and a large amount of bloody drainage. The DON confirmed the pressure ulcer was now reclassified as a Stage 4. Observation in the resident's room on 9/11/2020 at 10:29 AM, 11:47 AM, and 9/13/2020 at 10:36 AM, showed Resident #8 in bed with a dressing to his right heel and left lower extremity. His heels were positioned flat on the pillow and were not off loaded (to remove direct pressure from the heels). Interview with the DON on 9/11/2020 at 2:15 PM, the DON confirmed the pressure ulcer was identified on 9/4/2020 as an Unstageable pressure ulcer. Review of the (Named Company) Wound Evaluation & Management (physician progress notes [REDACTED].#8 dated 9/14/2020, showed, .STAGE 4 PRESSURE WOUND OF THE RIGHT HEEL .4.5 (cm) X 2.0 (cm) X 0.1 (cm) .5% Tendon, 20% slough, 75% granulation . This wound progressed from an unstageable wound to a Stage 4 pressure ulcer. The facility's failure to assess Resident #8's skin, failure to identify a pressure ulcer before it became an unstageable pressure ulcer, and failure to provide timely preventive measures and treatments caused actual Harm to Resident #8 and placed Resident #8 in Immediate Jeopardy. Review of the medical record, showed Resident #12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #12's Care Plan dated 4/27/2020, showed, .at risk for pressure ulcer .has DTI to left greater toe .check skin for redness .pressure areas .Report any signs of skin breakdown .Use pillow .to reduce pressure on heels .see doctor's orders .treatment notes for current interventions .turn/reposition at least every two hours .Monitor skin integrity while providing care . The quarterly MDS dated [DATE], showed a BIMS of 2, which indicated severe cognitive impairment, was at risk for developing pressure ulcers/injury, and had 1 Stage 3 pressure ulcer. There was no documentation between 8/31/2020 and 9/3/2020 to indicate the development of a new wound. Review of the Weekly Ulcer Report dated for the week of 9/3/2020, showed, .Date Developed .9/4/2020 .lt great toe .1 (cm) x 0.5 (cm) x 0 .eschar . Review of an Initial Skin Injury Assessment, (form for new wounds) dated 9/4/2020, showed, a wound on Resident #12's left great toe with measurements of .Length .1.0 CM Width .0.5 CM With a Depth of: Depth 0 CM . There was no stage documented of the wound identified on this form. Review of the Physician order [REDACTED].Skin Prep Wipes .apply skin prep to lt (left) great toe qd (daily) . The pressure ulcer was discovered on 9/4/2020. There was no treatment ordered for the DTI until 9/6/2020. Review of the WOUND AND PRESSURE INJURY INFORMATION, for Resident #12 dated 9/9/2020, showed, .Location lt great toe .Onset Date: 09/04/2020 .Type of Wound Pressure .For Pressure Injury: Unstageable - Deep Tissue Injury .Length 1 cm X Width 1 cm X Depth 0.1 cm . Review of the (Named Company) Wound Evaluation & Management Summary (physician progress notes [REDACTED].UNSTAGEABLE DTI OF THE LEFT TOE .0.5 (cm) X 1.2 (cm) X 0.0 cm .Dry Blister .skin prep (preparation) apply once daily for 30 days . Review of a corrected (Named Company) WOUND PHYSICIANS FOLLOW UP EVALUATION, dated 9/14/2020, showed, .MEASUREMENTS L (Left) MEDIAL GREAT TOE SHOULD BE 0.7 (cm) X 0.8 (cm) X 0 . Review of the weekly skin audit completed on 9/16/2020, showed Licensed Practical Nurse (LPN) #2 did not document Resident #12's DTI to his left greater toe. During an interview on 9/16/2020 at 6:16 PM, LPN #2 confirmed that he did not look at Resident #12's toes during his weekly skin audit on 9/16/2020. LPN #2 confirmed that he did not do a complete head to toe skin audit. The facility's failure to assess Resident #12's skin, failure to identify a pressure ulcer before it became an Unstageable DTI, and failure to provide timely treatments to the pressure ulcer caused actual Harm to Resident #12 and placed Resident #12 in Immediate Jeopardy. Review of the medical record, showed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident #13's Care Plan dated 6/12/2020, showed, .at risk for pressure ulcer .check skin for redness .skin tears .pressure area .wedges to reduce pressure on heals heels) .Turn/reposition .Wound Care and Management of Stage 4 sacral wound .assess .monitor wound healing .notify physician if current wound treatment is not effective .record wound measurements . The MDS assessment dated [DATE], showed a BIMS of 1, which indicated severe cognitive impairment, was at risk for developing pressure ulcers/injury, and had 1 Stage 4 pressure ulcer. Review of the June-August 2020 recapitulation Physician order [REDACTED].Skin Audit Weekly .One Time Weekly (Start date 6/5/2020) . Review of the June 2020 TAR, showed there was no skin audit performed the week of 6/16/2020. Review of the NURSING ADMISSION READMISSION FORM, for Resident #13 dated 7/29/2020, showed, .Ulcer/Injury Present .Yes . Review of the Weekly Ulcer Report, dated 8/2/2020-8/9/2020 and 8/10/2020-8/16/2020, showed, .SACRUM .STAGE 4 .7.5 (cm) x 5.5 (cm) x 0.4 (cm) . Review of the Initial Skin Injury assessment dated [DATE], showed no measurements or staging of the newly identified pressure ulcer on readmission. Review of the July through August 2020 recapitulation Physician Orders, showed, .(Start Date 7/30/2020) Triple Helix Collagen 100% topical power .SACRAL WOUND: CLEANSE WITH WOUND CLEANSER, PAT DRY .APPLY COLLAGEN POWER TO WOUND BED, PACK WITH CALCIUM ALIGNATE AND COVER WITH FOAM DRESSING .Every One Day (daily) .Skin Audit Weekly .Tuesday 6p (6:00 PM)-6a (6:00 AM) . Review of the July TAR, showed there was no treatment to the sacral pressure ulcer performed on 7/30/2020. Review of the Weekly Ulcer Report showed the following: a. 8/2/2020-8/9/2020, showed, .SACRUM .STAGE 4 .7.5 (cm) x 5.5 (cm) x 0.4 (cm) . b. 8/10/2020-8/16/2020, showed, .SACRUM .STAGE 4 .7.5 (cm) x 5.5 (cm) x 0.4 (cm) . c, 8/17/2020-8/24/2020, showed, .SACRUM .STAGE 4 .7 (cm) x 5.5 (cm) x 0.4 (cm) . Review of the Wound Care/Skin Integrity/Evaluation, dated 8/25/2020, showed the pressure ulcer to the sacrum as, .Pressure Ulcer-Stage IV (four) .7.0 (cm) x 5.5 (cm) x 0.4 (cm) . Review of Weekly Ulcer Report dated 8/25/2020-8/31/2020 showed, .SACRUM .stage 4 .7 (cm) x 5.5 (cm) x 0.4 (cm) . Review of the August 2020 TAR, showed there was no skin audit performed the week of 8/4/2020. Review of the August 2020 TAR, showed there were no treatments performed on the sacral pressure ulcer on 8/1/2020, 8/3/2020, 8/4/2020, 8/5/2020, 8/8/2020, 8/9/2020, 8/10/2020, 8/16/2020, 8/17/2020, 8/18/2020, 8/20/2020, 8/21/2020, 8/22/2020, 8/23/2020, 8/26/2020, 8/27/2020, 8/29/2020, and 8/31/2020. Review of the Weekly Ulcer Report dated 9/3/2020, showed the pressure ulcer to the sacrum as, .STAGE 4 .7.5 (cm) x 5.5 (cm) x 0.4 (cm) . Medical record review, showed Resident #13 was transferred to the hospital on [DATE] for a possible feeding tube placement. Observation in the resident's room on 9/3/2020 at 2:30 PM, showed Resident #13 was in bed with a dry and intact dressing to the sacral area. During an interview on 9/10/2020 at 3:05 PM, the Clinical Director of Wound Management confirmed the nursing staff should follow the doctor's orders for wound care treatments. The Clinical Director of Wound Management confirmed the DON and the ADON are responsible for monitoring wound care management. The Clinical Director of Wound Management confirmed that the CNAs should notify the charge nurse with any new skin issue, the charge nurse should notify the wound care nurse, and the wound care nurse should notify the Physician/ Family Nurse Practitioner (FNP) for orders and treatment. During an interview on 9/13/2020 at 12:01 PM, the Regional Nurse Consultant stated that the Wound Care Nurse was responsible for providing the wound care. The Regional Nurse Consultant stated that the skin assessments should be done daily by the CNAs when providing incontinence care and during baths or shower. The Regional Nurse Consultant confirmed that the CNAs should report any skin changes to the nurse. The Regional Nurse Consultant confirmed that she had given the surveyors all the medical records she could locate for the residents and that one of the issues she had identified was incomplete documentation in the electronic records. The Regional Nurse Consultant stated that the skin audits should be signed off weekly on the TAR, and documented in the electronic record if there is a skin concern. During a telephone interview on 9/14/2020 at 5:49 PM, the Wound Care Physician stated that she was told by the Administrator that she could not make rounds in the facility from 7/24/2020 through 9/14/2020 because the facility did not have anyone to round with her. The Wound Care Physician confirmed that she reached out to the Administrator twice and was told that the ADON would contact her as to when she could return and make rounds in the facility. The Wound Care Physician confirmed Resident #4's sacral pressure ulcer started out as an abscess and declined to a Stage 4 pressure ulcer. The Wound Care Physician confirmed that Resident #8's right heel breakdown could be due to staff not off loading the heels. The Wound Care Physician stated it is not expected to find a pressure ulcer at a Stage 3, Stage 4, DTI, or Unstageable. The Wound Care Physician confirmed there should be accurate documentation of all wounds. The Wound Care Physician confirmed that the staff should assess, monitor, and document any changes in the skin condition of the residents. The Wound Care Physician confirmed the staff should follow the treatment order for wound management. The Wound Care Physician confirmed the wounds should be covered with a dressing. During an interview on 9/15/2020 at 2:27 PM, the DON confirmed that Resident #5, #8 and #12's pressure ulcers were identified on 9/4/2020. The DON confirmed there was a delay in treatment for [REDACTED].#8, and #12's wound treatments. The DON confirmed that there should not be any missing documentation on the Treatment Administration Records or the Medication Administration Records. The DON stated the skin audits should be completed weekly. The DON confirmed the wounds should be identified before a Stage 3, Stage 4, or Unstageable. The DON confirmed that she would expect the CNAs to notify the nurse if a pressure ulcer does not have a dressing, had an odor, or there were changes in the pressure ulcer condition. The DON confirmed the wound care nurse should complete the measurements and the staging of the pressure ulcers. The DON confirmed that in the absence of a wound care nurse, there should be someone to manage the wound care of residents. The DON confirmed the wound care(TRUNCATED)

Based on review of job descriptions, facility staff orientation, facility computerized training, and interview, the facility failed to ensure that licensed nurses had the skills and knowledge to identify pressure and non-pressure ulcers, follow orders for treatments of wounds, perform treatment of [REDACTED].#2, and RN #3), 7 of 12 Licensed Practical Nurses (LPN) (LPN #1, #3, #5, #8, #9, #10, and #11) received no training related to pressure ulcers and non-pressure wounds and when 11 of 33 Certified Nursing Assistants (CNA) (CNA #4, #5, #9, #12, #13, #14, #15, #16, #17, #18, and #19) received no training to detect and report changes in residents' skin in the facility's computerized training system. The facility's failure to ensure that the licensed nurses had skills and knowledge related to the care and services of pressure ulcers and non-pressure wounds and reporting deterioration of existing wounds to the Medical Doctor (MD) resulted in Immediate Jeopardy for Resident #4, #5, #6, #8, and #12. The facility's failure to ensure licensed nurses had the competencies to provide the care and services for pressure ulcers and non-pressure wounds and CNAs had specific competencies for the detection and reporting of resident wounds resulted in Immediate Jeopardy when Resident #4 developed an unstageable pressure ulcer, developed a new non-pressure wound, and a non-pressure wound deteriorated, Resident #5 developed a Stage 3 pressure ulcer, and developed a new non-pressure wound, Resident #6's arterial wound deteriorated, Resident #8 developed an unstageable pressure ulcer, and Resident #12 developed a Deep Tissue Injury. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, Regional Nurse Consultant, and ADON were notified of the Immediate Jeopardy on [DATE] at 11:30 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-580, F-656, F-684, F-686, F-726, F-835, F-841 and F-867. The facility was cited F-684 and F-686 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 4:30 PM, and was validated onsite by the surveyors on [DATE] through review of the assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) minutes, observations, and staff interviews. The findings include: Review of the facility's undated Regional Nurse Manager job description showed, .The Regional Nurse Manager is responsible for providing professional nursing exposure, evaluation and support for skilled nursing facilities throughout the assigned region. In addition, this role is responsible for providing clinical resources, tools, and education both remotely and on-site .Provides guidance to assist facility leaders in maintaining compliance with State and Federal regulations for long term care .Monitors, mentors, coaches, and empowers facility Directors of Nursing and other clinical leaders to assist with problem solving, improve performance, identify, solve and correct problems, improve Resident care .Provide education and training and in-service opportunities to community Directors of Nursing and other Nursing Leaders . Review of the facility's undated Director of Nursing (DON) job description showed, .The purpose of this job is to manage the nursing department and administer the nursing programs in compliance with state and federal regulations .Plan, develop, organize, implement, evaluate and direct the Nursing Services Department .in compliance with rules and regulations governing long term care facilities .Facilitate the coordination of nursing services .to maintain quality care for patients .Prepare reports and recommendations for the Administrator regarding the operation of the Nursing Services Department . Review of the facility's undated Skilled Nursing Facility (SNF) ADON RN job description showed, .The purpose of this position is to administer the Nursing Services under the direction of the Director of Nursing Services with the established policies and procedures of the facility, and local state and federal regulations, to maximize the fulfillment of care giving needs of the residents .recognize and respond to the changes in resident's condition and document observations, interventions and outcomes .Orient, instruct and supervise other nursing personnel .Assist in facilitating the coordination of nursing services .with interdisciplinary team .Assist in organizing managing, reviewing, monitoring, authorizing and administering nursing care functions for residents within the facility .Attend and participate in orientation programs, on-going training and educational classes .Assist the DON with evaluating the competencies of nursing staff .Assist in the planning, developing and conducting in-service education for staff on related Nursing Services functions . Review of the facility's undated Treatment Nurse - LPN job description showed, .The purpose of this position is to administer house and physician/physician assistant/nurse practitioner prescribed treatments to residents, as well as supporting the charge nurse in the care giving needs of the residents .Administer treatments, house or physician/physician assistant/nurse practitioner orders to residents .Accurately record in the electronic health record treatments and change in condition of area being treated .Observe for changes in resident's condition and take appropriate action .Document and chart facts and information in a professional, clear, and comprehensive manner .Recognize and respond to changes in resident's conditions and document observations, interventions, and outcomes .Attend and participate in orientation programs, on-going training and educational classes .Complete medical forms, reports, evaluations, studies, charting, etc .Communication skills and active listening .Responds promptly to residents' needs .Must be willing and able to work flexible hours .Analytical Thinking .Able to gather and analyze data and reach appropriate conclusion, Solve problems in a timely manner .Attendance .Is consistently at work .Ensures work responsibilities are covered . Review of the facility's Charge Nurse - RN job description revised [DATE], showed, .The Charge Nurse-RN shall direct the day-today functions of nursing aides and other staff being supervised .Give direct nursing care to patients .Notify physician when patient's condition warrants. Perform administrative duties, such as documenting of: Nurses' notes. Doctors' orders .Reports .Chart pertinent facts and information in a professional, clear and comprehensive manner .Recognize and respond to changes in patients' conditions and document observations, interventions and outcomes .Conduct and/or monitor prescribed treatments, such as dressing changes .Monitor and update care plans on each shift as appropriate .Attend and participate in orientation programs, on-going training and educational classes . Review of the facility's CNA job description revised [DATE], showed, .Recognize and respond to the needs of residents .Assist in lifting, turning, moving, positioning and transporting residents into and out of beds .Observe residents' conditions .report changes to the charge/ staff nurse as soon as possible. Complete appropriate documentation that is organized, clear, complete, current and legible .Uses logic and reasoning to identify changes in patients' conditions and determine the correct plan of action .Communicates with co-workers at all levels to adequately meet the needs of patients . Review of the facility's undated New Hire Packet Checklist, showed, .Contingent Offer .Copies of IDs (Identifications), Copies of Clinical Licenses, References, CPR (Cardiopulmonary Resuscitation) .Signed Job Description, Application .Resume . Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated [DATE], showed, .At risk for impaired skin integrity .see doctor's orders and treatment notes for current interventions .assist .encourage/assist him to turn .reposition every 2 hours .Monitor for discoloring .Has Arterial wound to left Heel .May wear Prevalon boots to provide pressure relief on heels .feet . Review of the Resident #4's March-[DATE] Recapitulation Physician order [REDACTED].PAT DRY .APPLY BARRIER CREAM .COLLAGEN POWDER .CALIUM (calcium) ALIGATE (alginate) TO WOUND BED .PACK WITH DRY 4X4 GAUZE .COVER WITH DRY DRESSING .CHANGE DRESSING EVERY DAY .PRN . Review of Resident #4's June-[DATE] Treatment Administration Record (TAR) showed treatments to the sacrum wound were not performed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the Skin Monitoring: Comprehensive CNA Shower Review, dated [DATE], showed there were no wounds identified. During an interview on [DATE] at 11:13 AM, CNA #3 confirmed they were supposed to complete their skin assessment on the shower sheet each day. There was no weekly skin audit performed on [DATE]. Observation in Resident #4's room on [DATE] at 5:49 PM, showed Resident #4's left heel had a foul odor and a large amount of green purulent drainage on the dressing. The left heel also had bruising on the outer aspect of the left heel. The Wound Care Physician identified a new wound to the left medial leg, a triangle shaped wound with 100% eschar and measured 1.5 cm (centimeter) x 2.5 cm x 0 cm. During an interview on [DATE] at 5:49 PM, the Wound Care Physician confirmed that Resident #4's heel looked worse, had an odor and purulent drainage. The Wound Care Physician confirmed the staff should have identified the new area to Residents #4's left medial leg. During an interview on [DATE] at 3:30 PM, CNA #4 confirmed that on [DATE] she had not been in Resident #4's room from 6:00 AM until 10:00 AM and she had not turned Resident #4 in 4 hours. CNA #4 confirmed she was unaware Resident #4's dressing was off the sacral area. The facility's failure to assess Resident #4's skin and provide treatments as ordered placed Resident #4 in Immediate Jeopardy when the Arterial wound deteriorated, a new wound was discovered with 100% eschar, and the sacral wound deteriorated to a Stage 4 pressure ulcer. Refer to F-580, F-656, F-684, and F-686. Review of the medical record, showed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5-day Minimum Data Set ((MDS) dated [DATE], showed Resident #5 had a Brief Interview for Mental Status (BIMS) of 3, which indicated severe cognitive impairment and the resident was at risk for developing pressure ulcers/injury. Review of Resident #5's Care Plan dated [DATE], showed, .Wound Care and Management ST (stage) 3 to left Buttocks .Assess and monitor wound healing .Assess and monitor wound treatment plan for effectiveness and complications .Notify the physician if current wound treatment is not effective .record wound measurements . Review of Resident #5's Initial Skin Injury Assessment (a form for new wounds) dated [DATE], showed, .lt (left) buttock .Length .2 CM (centimeter) Width .1.5 CM .Depth > (greater than) 0.5 CM . The stage of the pressure ulcer was not documented. Review of the Physician order [REDACTED].Clean with wound cleaner .pat dry .apply iodosorb .0.9% (percent) topical gel .to stage 2 .lt buttocks wound .every 1 day . The pressure ulcer was identified on [DATE] but there was no treatment ordered for the Stage 3 Pressure Ulcer until [DATE]. Review of the (Named Company) Wound Physicians Progress Evaluation dated [DATE], showed a newly identified wound, .WOUND ABDOMEN .5.5 (cm) x 2.5 (cm) 2.0 .cm .Maceration .Antifungal apply every two days for 30 days .Alginate calcium w (with)/silver apply every two days for 30 days . Review of the Weekly Ulcer Report dated [DATE] did not identify the wound on the abdomen. Observation in Resident #5's room on [DATE] at 10:35 AM, the Wound Care Physician identified a new area to Resident #5's suprapubic catheter site on the abdomen with a large amount of redness. During an interview on [DATE] at 10:49 AM, the Wound Care Physician confirmed that the maceration should have been identified so a treatment could be put in place. The Wound Care Physician confirmed that the maceration should have been identified on the weekly skin assessment. The facility's failure to assess Resident #5's skin and provide the treatment placed Resident #5 in Immediate Jeopardy when the macerated wound at the suprapubic catheter site was discovered by the physician. Refer to F-684 and F-686. Review of the medical record, showed Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Initial Skin Injury assessment dated [DATE], showed, .The location of this area is Left Heel .Right heel . There was no description, stage or measurements of the areas documented on this form. Review of the Clinical Notes Report addendum dated [DATE], showed, .Requires total assistance with ADLs (activity of daily living) and transfers .open area noted to bilateral heels . Review of the Weekly Ulcer Report dated [DATE]-[DATE], showed Resident #6's bilateral heels had not been measured or staged. Observation in Resident #6's room on [DATE] at 12:11 PM, showed Resident #6's left heel had a large amount of black hard necrotic eschar that measured 5.0 cm x 3.5 cm x 0 cm. After the Wound Care Physician removed the eschar, she staged the left heel at a stage 3 (full thickness skin loss and fat is visible) with the measurement of 0.7 cm x 0.4 cm x 0.1 cm and 100 % granulation. The right heel had 100% dry necrotic eschar, and was 6.5 cm x 4.5 cm x 0 cm. The Wound Care Physician identified a new wound with black eschar that measured 1.0 cm x 1.7 cm x 0 cm. on Resident #6's right medial ankle. During an interview on [DATE] at 12:15 PM, the Wound Care Physician stated the heels had declined due to the eschar on the bilateral heels and the heels had not been properly off-loaded (direct pressure removed from the heels). The facility's failure to provide preventive measures and treatments resulted in actual Harm and Immediate Jeopardy for Resident #6 when the arterial wound deteriorated and a new wound on the right medial ankle was identified by the Wound Care Physician . Refer to F-684. Review of the medical record, showed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's Care Plan dated [DATE], showed, .at risk for pressure ulcer .check skin for redness .pressure areas .Report any signs of skin breakdown .Use pillow .to reduce pressure on heels .turn/reposition at least every two hours .Monitor skin integrity while providing care . Review of the Treatment/Order Update/Change in Condition dated [DATE] showed, .Santyl 250 unit/gram topical ointment (apply) OINTMENT Topical Every 1 Day .Apply Santyl TOP (topical) to right heel and apply protective dressing QD (every day) . The unstageable pressure ulcer was discovered on [DATE] but there was no treatment ordered for the unstageable pressure ulcer until [DATE]. Review of the WOUND AND PRESSURE INJURY INFORMATION, for Resident #8 dated [DATE] showed, .Skin injury identified on [DATE] .rt heel .5.3 x 4.3 x 0.2 .unstageable . Review of the (Named Company) Wound Evaluation & Management Summary for Resident #8 dated [DATE], showed, .STAGE 4 PRESSURE WOUND OF THE RIGHT HEEL .4.5 X 2.0 X 0.1 cm .5% Tendon, 20% slough, 75% granulation . Observation in the resident's room on [DATE] at 3:49 PM, showed Resident #8 in bed with a dressing to the right heel and left lower extremity. The resident's heels were positioned flat on top of one pillow and the heels were not off loaded (to remove direct pressure from the heels). Observation in the resident's room on [DATE] at 4:07 PM, showed Resident #8 had a large wound to the back of the right heel and ankle, with a pea size white area at the top of wound, and a large amount of bloody drainage. The DON confirmed the pressure ulcer was now reclassified as a Stage 4. Observation in the resident's room on [DATE] at 10:29 AM, 11:47 AM, and [DATE] at 10:36 AM, showed Resident #8 in bed with a dressing to his right heel and left lower extremity. His heels were positioned flat on the pillow and were not off loaded. Interview with the DON on [DATE] at 2:15 PM, the DON confirmed the pressure ulcer was identified on [DATE] as an Unstageable pressure ulcer. The facility's failure to assess Resident #8's skin, failure to identify a pressure ulcer before it became an unstageable pressure ulcer, and failure to provide timely preventive measures and treatments placed Resident #8 in Immediate Jeopardy. Refer to F-686. Review of the medical record, showed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's Care Plan dated [DATE], showed, .at risk for pressure ulcer .has DTI (Deep Tissue Injury) to left greater toe .check skin for redness .pressure areas .Report any signs of skin breakdown .Use pillow .to reduce pressure on heels .see doctor's orders .treatment notes for current interventions .turn/reposition at least every two hours .Monitor skin integrity while providing care . There was no documentation between [DATE] and [DATE] to indicate the development of a new wound. Review of an Initial Skin Injury Assessment, (form for new wounds) dated [DATE], showed, a wound on Resident #12's left great toe with measurements of .Length .1.0 CM Width .0.5 CM With a Depth of: Depth 0 CM . There was no stage of the wound identified on this form. Review of the Physician order [REDACTED].Skin Prep Wipes .apply skin prep to lt (left) great toe qd (daily) . The pressure ulcer was discovered on [DATE]. There was no treatment ordered for the DTI until [DATE]. Review of the (Named Company) Wound Evaluation & Management Summary for Resident #12 dated [DATE], showed, .UNSTAGEABLE DTI OF THE LEFT TOE .0.5 X 1.2 X 0.0 cm .Dry Blister .skin prep (preparation) apply once daily for 30 days . Review of the weekly skin audit completed on [DATE] showed Licensed Practical Nurse (LPN) #2 did not document Resident #12's DTI to his left greater toe. Observation in Resident #12's room on [DATE] at 4:17 PM with the Wound Care Physician, showed Resident #12 had a DTI to the left great toe. The Wound Care Physician measured the DTI with measurements of 0.7 cm x 0.8 cm x 0 cm. During an interview on [DATE] at 6:16 PM, LPN #2 confirmed that he did not look at Resident #12's toes during his weekly skin assessment on [DATE]. LPN #2 confirmed that he did not do a complete head to toe skin assessment. The facility's failure to assess Resident #12's skin, failure to identify a pressure ulcer before it became an Unstageable DTI, and failure to provide timely treatments to the pressure ulcer placed Resident #12 in Immediate Jeopardy. Refer to F-686 The facility was unable to provide documentation of training provided on the prevention, detection, identification, assessment, implementation and treatment of [REDACTED].#2, and #3, LPN #1, #3, #5, #8, #9, #10, and #11), and for the training on the detection and reporting of wounds for CNAs (CNA #4, #5, #9, #12, #13, #14, #15, #16, #17, #18, and #19) Review of the Pressure Ulcer Prevention training dated [DATE] in the facility's electronic training and documentation system, showed there had been no training provided since the last survey on [DATE]. During an interview on [DATE] at 9:35 AM, the DON confirmed that it was her responsibility to ensure that staff received continuing education. During an interview on [DATE] at 9:33 AM, the Wound Care Physician confirmed that staff in the facility were not competent in providing wound care. The Wound Care Physician confirmed there could have been better wound care administered to the residents since her visit to the facility on [DATE]. Her next visit to the facility was on [DATE]. The Wound Care Physician confirmed that staff had not been properly trained on the identification and care of pressure ulcers and non-pressure related wounds. During an interview on [DATE] at 1:12 PM, CNA #6 confirmed she had not received any training on identification of wounds, wound care or reporting of wounds. During an interview on [DATE] at 4:08 PM, LPN #2 stated he was unable to remember if he had received training on identifying or providing treatments for pressure ulcers and non-pressure related wounds. During an interview on [DATE] at 4:29 PM, LPN #3 confirmed she had not received any training from the facility on pressure ulcers and non-pressure related wounds. During an interview on [DATE] at 1:19 PM, the Staff Development Coordinator confirmed it was his responsibility to provide education to licensed staff members. The Staff Development Coordinator confirmed he had not provided training or education on pressure and non pressure related wounds. During an interview on [DATE] at 10:31 AM, the Regional Nurse Consultant confirmed her role in the facility included the oversight of the nursing staff, to assist with policies and procedures, provide education and insight into nursing matters, to provide resources, and be a resource for the facility on any nursing concerns. During an interview on [DATE] at 11:30 AM, the Administrator confirmed it was her responsibility in conjunction with the nursing staff to ensure that all care and services related to the resident was completed and all staff were competent to complete their job assignments. The facility failed to ensure Licensed Nursing Staff had the specific competencies and skill sets necessary to care for the residents' needs, assess, treat and detect deterioration in a resident's condition related to pressure ulcers and non-pressure related wounds placing Residents #4, #5, #6, #8, and #12 in Immediate Jeopardy. The surveyors verified the Removal Plan by: 1. On [DATE], the ADON, Admissions Coordinator, Minimum Data Set (MDS) Coordinator, and the Evening Shift Supervisor were educated by the Regional Nurse Consultant and Certified Wound Specialist on appropriate documentation and treatment of [REDACTED]., mental, and psychosocial needs. The surveyors interviewed staff on all shifts, reviewed the in-service handouts and sign in sheets. 2. On [DATE], the CNAs were educated on observing for skin changes, reporting of skin changes and pressure injury prevention. The surveyors interviewed CNAs on all shifts and reviewed the in-service handouts and sign in sheets. 3. On [DATE], the Nurse Managers were educated by the Regional Nurse Consultant and the Certified Wound Specialist on policies and procedures for pressure injury prevention and non-pressure injury management, skin assessment, and documentation of wound treatments. The Nurse Managers and Licensed Nurses were educated on consistent and accurate weekly wound assessments related to the measurement and description of wounds, obtaining timely orders for treatments, identifying and providing needed care and services that are resident centered and will meet the resident's physical, mental and psychosocial needs. The surveyors interviewed Nurse Managers, nurses on all shifts, and the Regional Nurse Consultant and reviewed the in-service handouts and sign in sheets. 4. On [DATE], the facility residents with current wounds were reviewed for appropriate and complete assessments, documentation of the wounds in the electronic health record, Medical Director and family notification of wounds, implementation of the current physician order, and treatment initiated by the Nurse Manager. The surveyors interviewed the Nurse Manager and reviewed the facility skin audits which also included a copy of the electronic health record for residents identified with wounds and included notification, documentation, implementation of orders and treatment. 5. On [DATE], the (Named Company) Wound Physician was consulted and will continue to be consulted weekly for residents with wounds and as needed. If circumstances prevent on site rounds, the physician will be contacted by telephone and/or telehealth. The surveyors interviewed the (Named Company) Wound Physician to confirm consultation for care and services related to wound care. 6. On [DATE], education was completed by Nurse Managers for the on duty licensed nurses regarding consistent, accurate weekly wound assessments related to the measurements and description of wounds, identifying and providing needed care and services that are resident centered and will meet the resident's physical, mental, and psychological needs. The licensed nurses were educated on policies and procedures for pressure injury prevention and non-pressure injury management, skin assessment, and documentation of wound treatments. Off duty licensed nurses are to be educated by the Nurse Manager upon their return to work. Newly hired licensed nurses will be educated during orientation. Ongoing staff training for licensed nurses will be provided bi-annually. The surveyors interviewed licensed nurses on all shifts, reviewed power point slides, and reviewed in-service sign in sheets with the topic of discussion. 7. On [DATE], Nurse Managers provided education on observing for skin changes, reporting of skin changes, and pressure injury prevention to the CNAs that were currently working. Off duty CNAs will be educated on their next scheduled day to work. Newly hired CNAs will be educated during orientation. Ongoing staff training for CNAs will be provided bi-annually. The surveyors interviewed CNAs on all shifts and the Nurse Managers, and reviewed in-service sign in sheets. 8. On [DATE], the Medical Director was notified of the Immediate Jeopardy Deficiencies by the Administrator. The surveyors interviewed the Medical Director. 9. On [DATE], the QAPI Committee which included the Administrator, ADON, and Medical Director discussed action plans to address the immediate concerns for residents with wounds and all other residents identified as having the potential to be affected. The DON, ADON, Staffing Coordinator, MDS Coordinator, Admissions Coordinator, and Medical Records personnel will audit the electronic health records on all new admissions, hospital readmissions, and weekly wound assessments for pressure injuries, non-pressure wounds, and new pressure injuries for appropriate and completed identification, assessment, documentation, treatment, following physician orders, and MD and family notification of pressure injuries and non-pressure wounds or changes in status to ensure a resident with pressure injuries and non-pressure wounds receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing daily for 7 days, weekly for three weeks, then monthly for two months, and quarterly ongoing. The findings of the audit will be reported to the QAPI Committee which consists of the Administrator, Medical Director, DON, ADON, Staffing Coordinator, Medical Records, MDS Coordinators, Social Services Director, Activities Director, Dietary Supervisor, Maintenance Supervisor, Business Office Coordinator, Admissions Coordinator, and Infection Preventionist. If compliance is not met, staff will be re-educated, and the audits will continue until substantial compliance is met. The Medical Director is in agreement with the current removal plan. The surveyors reviewed the QAPI agenda and meeting minutes, audit forms, and interviewed the Medical Director, Administrator and ADON. Noncompliance of F-726 continues at a scope and severity E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on the Board of Examiners of Nursing Home Administrators (BENHA) form review, job description review, observation, and interview, the facility administration failed to manage the facility in a manner that enabled the facility to utilize its resources effectively and efficiently to attain and maintain the highest practicable well-being of the residents. Administration failed to ensure nurse management provided oversight, review, and completion of resident shower sheets, provide training of staff to complete the resident shower sheets and weekly skin assessments, ensure the training of staff to prevent, identify, and report the development and deterioration of pressure ulcers and non-pressure wounds and administer treatment for [REDACTED]. Administration's failure resulted in Immediate Jeopardy for Resident #4, #5, #6, #8, and #12 when staff failed to implement preventive measures, identify new pressure ulcers and non-pressure wounds, assess the wounds, report, and treat pressure ulcers and non-pressure wounds. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Regional Nurse Consultant, and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 9/22/2020 at 11:30 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-580, F-656, F-684, F-686, F-726, F-835, F-841 and F-867. The facility was cited F-684 and F-686 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 8/2/2020 through 9/24/2020. An acceptable Removal Plan, which removed the immediacy of the IJ, was received on 9/24/2020 at 4:30 PM, and was validated onsite by the surveyors on 9/25/2020 through review of the assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) minutes, observations, and staff interviews. The findings include: Review of the facility's BENHA form revealed the facility had employed 2 Administrators since the last annual survey conducted on 5/21/2019. Review of the facility's Administrator Job Description revised 9/21/2020, showed, .The Administrator is responsible for establishing and directing the facility's overall day-to-day operations, both internal and external, and coordinate and maintain compliance to maximize high standards of care to patients .Meet with personnel as required and scheduled to assist in identifying and correcting issues, and/or the improvement of services .Assist in compliance efforts regarding state and/or federal requirements .monitor procedures to ensure compliance with state and federal guidelines, laws, regulations and company policies .Attend and participate in orientation programs, on-going training and educational classes .organize work flow; ensure employees understand their duties or delegated tasks .monitor employee productivity . Review of the facility's undated Regional Nurse Manager job description showed, .The Regional Nurse Manager is responsible for providing professional nursing exposure, evaluation and support for skilled nursing facilities throughout the assigned region. In addition, this role is responsible for providing clinical resources, tools, and education both remotely and on-site .Provides guidance to assist facility leaders in maintaining compliance with State and Federal regulations for long term care .Monitors, mentors, coaches, and empowers facility Directors of Nursing and other clinical leaders to assist with problem solving improve performance, identify, solve and correct problems, improve Resident care .Provide education and training and in-service opportunities to community Directors of Nursing and other Nursing Leaders . Review of the facility's undated Director of Nursing (DON) job description showed, .The purpose of this job is to manage the nursing department and administer the nursing programs in compliance with state and federal regulations .Plan, develop, organize, implement, evaluate and direct the Nursing Services Department .in compliance with rules and regulations governing long term care facilities .Facilitate the coordination of nursing services .to maintain quality care for patients .Prepare reports and recommendations for the Administrator regarding the operation of the Nursing Services Department . Review of the facility's undated Skilled Nursing Facility (SNF) ADON Registered Nurse (RN) job description showed, .The purpose of this position is to administer the Nursing Services under the direction of the Director of Nursing Services with the established policies and procedures of the facility, and local state and federal regulations, to maximize the fulfillment of care giving needs of the residents .recognize and respond to the changes in resident's condition and document observations, interventions and outcomes .Orient instruct and supervise other nursing personnel .Assist in facilitating the coordination of nursing services leave with interdisciplinary team .Assist in organizing managing, reviewing, monitoring, authorizing and administering nursing care functions for residents within the facility .Attend and participate in orientation programs, on-going training and educational classes .Assist the DON with evaluating the competencies of nursing staff .Assist in the planning, developing and conducting in-services education for staff on related nursing Services functions . During an interview on 9/11/2020 at 9:35 AM, the DON confirmed that it was her responsibility to oversee the daily operations of the nursing department and to ensure that staff were educated. During an interview on 9/17/2020 at 1:30 PM, the Administrator confirmed that her job duties included, but was not limited to, communication with state and federal entities, oversight of the day to day operations of the facility, to delegate duties to staff members, and to ensure that all residents received the care and services needed. She confirmed that it was her responsibility to ensure all department managers completed their duties. The Administrator confirmed that the facility conducted morning and afternoon meetings to discuss any concerns in the facility and confirmed it was her responsibility to ensure that the concerns were resolved by the assigned department manager. She confirmed it was her responsibility to have a monthly Quality Assurance (QA) meeting that included all department managers and the Medical Director. In this meeting they discussed concerns in the facility and developed a systematic approach to resolving the concerns as a team. The Administrator confirmed that in the morning stand up meeting staff discussed skin, weight and wounds. In this meeting the nurses discuss any weight loss that had not been discussed in the last meeting, any changes in wounds or orders for the treatment of [REDACTED]. The Administrator confirmed that Wound Care Nurse #1 (the former Wound Care Nurse) was hired the last part of January 2020 to work Monday through Friday from 8:00 AM to 5:00 PM. The Administrator acknowledged that she was unaware that Wound Care Nurse #1 was not working the scheduled hours and days she was hired to work. The Administrator confirmed that Wound Care Nurse #1 thought she could work flexible hours or as needed hours because she had discussed it with the previous DON. The Administrator confirmed she never saw Wound Care Nurse #1 during working hours. The Administrator confirmed she was unaware of newly developed wounds or deterioration of existing wounds on residents until last week as a result of the building wide skin sweep that was conducted since Wound Care Nurse #1 had not been working the scheduled hours of her employment. The Administrator confirmed she did not consistently attend the weekly pressure ulcer meetings and was unaware that Wound Care Nurse #1 did not attend the meetings until she was informed that Wound Care Nurse #1 was in school and she was unable to identify the date she was made aware of this. The Administrator confirmed she was responsible for ensuring that all staff worked their assigned hours and completed the job for which they were hired. The Administrator confirmed that all nursing staff were expected to complete weekly skin assessments on all residents in the building and that the ADON, DON, and Administrator had the responsibility for ensuring the assessments were completed. During an interview on 9/21/2020 at 10:31 AM, the Regional Nurse Consultant confirmed her role in the facility included oversight of the nursing staff, assistance with development of policies and procedures, provide education and insight regarding nursing concerns, to provide resources for the nursing staff, and be a nursing resource for the facility. The Regional Nurse Consultant confirmed it was the DON's responsibility to ensure that all nursing staff were provided with education and were qualified to perform their job, and it was the Administrator's responsibility to ensure the DON was efficient and completed her responsibility to educate staff and oversee the day to day management of the nursing department. The Regional Nurse Consultant confirmed the Administrator was ultimately responsible for the entire building and the day to day operation in correlation with the DON. The Regional Nurse Consultant confirmed she had completed the Pressure Sore/Clinical Condition Record (for unavoidable skin conditions) dated 9/14/2020 for Resident #4, gave the form to the Administrator to present to the Medical Director for his signature. The Regional Nurse Consultant confirmed that the form should have been completed by the Medical Director and not Regional Nurse Consultant. The Regional Nurse Consultant also confirmed that when the form was presented to the Administrator this was not explained to the Administrator. The Regional Nurse Consultant also confirmed that the Medical Director was not provided any explanation of why the form was needed for Resident #7. The Regional Nurse Consultant confirmed the Administrator had no nursing knowledge. During an interview conducted on 9/22/2020 at 11:30 AM, the Administrator confirmed it was her responsibility and the nursing staff responsibility to ensure that all care and services related to the resident was completed and all staff were competent to complete the job for which they were hired. During a telephone interview on 9/24/2020 at 1:04 PM, the former DON stated that she did not tell the Wound Care Physician she could not round in the facility. The former DON confirmed that it was the responsibility of the Wound Care Nurse to complete the admission/readmission forms. The former DON confirmed that the CNAs should complete the shower sheets and the charge nurse should sign off on them daily. The former DON confirmed that the nursing staff had not received training on wound care management on hire or annually. Administration failed to ensure that education and oversight were provided to staff for the completion of their job related to the care and services for detection, prevention, implementation and treatment of [REDACTED]. Refer to F-656, F-684, and F-686. Administration failed to ensure services were provided to attain or maintain the highest physical, mental, and psychosocial well-being in accordance with the plan of care for wounds by failing to implement and follow interventions on the care plan, failed to perform weekly skin assessments, conduct wound assessments, obtain physician orders [REDACTED]. Refer to F-656, F-684, and F-686. Administration failed to provide oversight and orientation to staff, provide training and in-services for the detection, prevention, treatment and care of pressure ulcers and non-pressure wounds. Refer to F-684, F-686 and F-726. Administration failed to ensure services were provided to attain or maintain the highest practical, physical, mental and psychosocial well-being of residents when Administration's QAPI Program failed to implement and monitor an effective program for the detection, prevention and treatment of [REDACTED]. Refer to F-684, F-686 and F-867. The surveyors verified the Removal Plan by: 1. On 9/23/2020, the Administrator was educated by the Regional Director of Operations on the facility's Pressure Injury Prevention and Non-Pressure Ulcer Management policy, Documentation of Wound Treatment Policy, Skin Assessment Policy, Comprehensive Care Plan Policy, Medical Director Responsibilities Policy and Medical Director Contract/Job Description, Quality Assurance and Performance Improvement Policy, and Administrator Job Description. The surveyors interviewed the Administrator and reviewed the in-service sign in sheet. 2. The Administrator will educate the DON upon her return to work on the facility's Pressure Injury Prevention and Non-Pressure Ulcer Management policy, Documentation of Wound Treatment Policy, Skin Assessment Policy, Comprehensive Care Plan Policy, and DON job description. The surveyors interviewed the Administrator and the Regional Nurse Consultant. 3. Administration will oversee the facility's wound management program. The Regional Director of Operations and Regional Nurse Consultant will monitor Administration by reviewing reports on the wound management program, the audit findings, any concerns identified, and the corrective actions taken. The survey team interviewed the Administrator and the Regional Nurse Consultant. 4. On 9/22/2020, the Administrator notified the QAPI Committee and the Medical Director of the Immediate Jeopardy Deficiencies. The surveyors reviewed the QAPI agenda and the meeting minutes that included the sign in sheet. The Regional Nurse Consultant confirmed that the Medical Director was present via telephone conference call for the QAPI meeting. 5. On 9/23/2020, the QAPI Committee which included the Administrator, ADON, and Medical Director discussed action plans to address the immediate concerns for residents with wounds and all other residents identified as having the potential to be affected. The DON, ADON, Nurse Managers, Staffing Coordinator, Minimum Data Set (MDS) Coordinator, Admissions Coordinator, and Medical Records will audit electronic health records on all new admissions, hospital readmissions, and weekly wound assessments for pressure injuries, new pressure injuries, and non-pressure wounds for appropriate and complete identification, assessment, documentation, treatment, following physician orders, Medical Doctor (MD) and family notification of wounds or changes in resident status to ensure a resident with wounds receives the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing daily for 7 days, weekly for three weeks, then monthly for two months, and quarterly ongoing. The findings of the audit will be reported to the QAPI Committee which consists of the Administrator, Medical Director, DON, ADON, Staffing Coordinator, Medical Records, MDS Coordinators, Social Services, Activities, Dietary Supervisor, Maintenance Supervisor, Business Office Coordinator, Admissions Coordinator, and the Infection Preventionist. If compliance is not met, staff will be re-educated, and the audits will continue until substantial compliance is met. The Medical Director approved the IJ removal action plan. The surveyors reviewed the QAPI agenda and meeting minutes and interviewed the Medical Director, Administrator and the ADON. Noncompliance of F-835 continues at a scope and severity of E for the monitoring and the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction

Based on review of the Medical Director's job description and interview, the Medical Director failed to provide oversight of the nursing staff to prevent the development and deterioration of wounds, failed to provide guidance to nursing administration in drafting policies according to the standards of practice of the National Pressure Ulcer Advisory Panel (NPUAP), failed to effectively assist with the Quality Assurance Performance Improvement (QAPI) meetings to monitor pressure ulcer and non-pressure wound progress, and failed to ensure orders were implemented for wound treatments for 5 of 13 sampled residents (Residents #4, #5, #6, #8, and #12) reviewed placing those residents in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Regional Nurse Consultant, and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 9/22/2020 at 11:30 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-580, F-656, F-684, F-686, F-726, F-835, F-841 and F-867. The facility was cited F-684 and F-686 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 8/2/2020 through 9/24/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/24/2020 at 4:30 PM, and was validated onsite by the surveyors on 9/25/2020 by review of the assessments, auditing tools, in-service training records, policies, QAPI minutes, observations, and staff interviews. The findings include: The facility's Medical Director Agreement dated 1/18/2018, showed, .This MEDICAL DIRECTOR AGREEMENT .is made and entered into this 18th day of January by and among Harbor View Nursing and Rehabilitation Center .and (Named Physician), MD (Medical Doctor), (Named Physician) who together are the Parties to this Agreement .MEDICAL DIRECTOR'S RESPONSIBILITIES .The Medical Director shall be responsible for patient care policies .The Medical Director shall be responsible for the implementation of patient care policies and coordination of medical care in the nursing home .in compliance with .applicable state and federal regulations .Advise and provide consultation on matters regarding medical care, standards of care, surveillance .Assist in coordinating medical care in the Facility to ensure that adequate and appropriate medical services are provided to the patients in the Facility and making periodic rounds to evaluate the adequacy of nursing care furnished to Facility patients. The Medical Director will collaborate with the facility leadership, staff, and other practitioners and consultants to help develop, implement and evaluate resident care policies and procedures that reflect current standards of practice .attend meetings and help ensure adherence to Facility by-laws, rules and policies .Develop and participate in effective patient care utilization review; the effect of which is to promote the most effective and efficient use of Services consistent with patient needs .Advise and participate in the development of the Facility's .training programs, including the Facility's in-service education training programs and advising or serving upon any related committees .By signing below, (Named Physician) agrees to perform personally the duties of the Medical Director as set forth herein . During an interview on 9/16/2020 at 9:12 AM, the Medical Director confirmed that he only assessed wounds when asked by the staff and that he did not typically make wound rounds. The Medical Director confirmed that he is not consistently in the weekly weight and pressure wound meetings and only attends when requested by staff. During an interview on 9/18/2020 at 12:48 PM, the Medical Director confirmed that he was unaware of any skin issues in the building. The Medical Director failed to provide oversight of the nursing staff to prevent the development and deterioration of wounds. Refer to F-580, F-684, F-686, F-726, and F-835. The Medical Director failed to provide guidance to nursing administration in developing policies according to the standards of practice of the NPUAP. Refer to F-835. The Medical Director failed to effectively collaborate with the facility QAPI committee to monitor pressure ulcers and non-pressure wound progress. Refer to F-684, F-686, F-867, and F-835. The Medical Director failed to ensure orders were implemented for wound treatments. Refer to F-580, F-684, and F-686. The surveyors verified the Removal Plan by: 1. On 9/23/2020, the Medical Director was educated by the Regional Director of Operations on the facility's Medical Director Responsibilities Policy, job description, and contract for services. The surveyors interviewed the Medical Director. 2. On 9/23/2020, the QAPI Committee and the Medical Director were notified of the Immediate Jeopardy Deficiencies by the Administrator. The surveyors interviewed the Medical Director and the QAPI Committee. 3. On 9/23/2020, the QAPI Committee discussed the action plans to address the immediate concerns for residents with wounds and all other residents identified as having the potential to be affected. The Director of Nursing (DON), ADON, Staffing Coordinator, Minimum Data Set (MDS) Coordinator, Admissions Coordinator, and Medical Records Director will audit electronic health records for pressure injuries and new pressure injuries, and non-pressure wounds on all new admissions, hospital readmissions, and weekly wound assessments for identification and assessment, documentation, treatment, following physician orders, MD and family notification of pressure injuries or changes in status to ensure a resident with pressure injuries and non-pressure wounds receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing daily for 7 days, weekly for three weeks, then monthly for two months, and quarterly ongoing. The findings of the audit will be reported to the QAPI Committee which consists of the Administrator, Medical Director, DON, ADON, Staffing Coordinator, Medical Records, MDS Coordinators, Social Services Director, Activities director, Dietary Supervisor, Maintenance Supervisor, Business Office Coordinator, Admissions Coordinator, and Infection Preventionist. If compliance is not met, staff will be re-educated, and the audits will continue until substantial compliance is met. The Medical Director was in agreement with the IJ removal plan. The surveyors reviewed the QAPI agenda and meeting minutes and interviewed the Medical Director, Administrator and the ADON. Noncompliance of F-841 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Corrections.

Based on the Quality Assessment and Performance Improvement (QAPI) policy review, job description review, and interview, the QAPI committee failed to ensure an effective QAPI program that recognized ongoing problems related to the prevention, detection, care and services of pressure ulcers and non- pressure wounds, following care plans related to pressure ulcers and non-pressure wounds, physician notification of the deterioration of a wound or the omission of wound care for pressure ulcers and non-pressure ulcer wounds, failed to ensure staff were educated on pressure ulcers and non-pressure wounds including the appropriate use of the bath/shower sheets by Certified Nursing Assistants (CNA), weekly skin assessments by the licensed nurses, to identify newly developed wounds, assessment and treatments for the existing wounds. The QAPI Committee failed to identify the root cause of the problems, failed to develop appropriate plans of action, failed to ensure systems and processes were in place and consistently followed by staff to address, correct, and maintain acceptable standards of care for quality concerns. The QAPI committee failed to ensure that the Medical Director assisted the facility with identifying, evaluating and addressing clinical concerns, coordinating the medical care and provided clinical guidance for the implementation of resident care policies and procedures. The failure of the QAPI Committee to implement and/or provide oversight and review for pressure ulcers and non-pressure wounds, assessments and changes in wound status, implementation of care plans, monitor staff performance of wound care, and the failure to identify and provide wound care treatments resulted in an Immediate Jeopardy (IJ) when 5 of 13 sampled residents (Resident #4, #5, #6, #8, and #12) reviewed developed pressure ulcers and non-pressure wounds or the wounds became worse. The failure of the QAPI committee to monitor wound care assessments and/or treatments resulted in an Immediate Jeopardy (IJ) when the facility failed to provide proof of training and education for 34 of 56 licensed and certified staff members and had the potential to affect 92 residents residing in the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Regional Nurse Consultant, and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 9/22/2020 at 11:30 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-580, F-656, F-684, F-686, F-726, F-835, F-841 and F-867. The facility was cited F-684 and F-686 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective from 8/2/2020 through 9/24/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy was received on 9/24/2020 at 4:30 PM, and was validated onsite by the surveyors on 9/25/2020 by review of the assessments, auditing tools, in-service training records, policies, QAPI minutes, observations, and staff interviews. The findings include: Review of the facility's policy titled, Quality Assurance Performance Improvement Plan, revised 11/2019, showed, .The Quality Assurance Performance Improvement (QAPI) Plan is designed to establish and maintain an organized facility-wide program that is data driven and utilizes a proactive approach to improving the quality of life and services throughout the facility .Addresses gaps in systems and processes .Continually improve the quality of care and services provided to our Residents .PURPOSE .The purpose of the QAPI Program is to facilitate a review of systems and processes and their impact on our Residents .GUIDING PRINCIPLES .The outcome of the QAPI Program is the quality of care and quality of life of our Residents .The QAPI Program includes all employees, all departments and all services provided .The QAPI Program .emphasis is on identifying system gaps . Review of the facility's Administrator Job Description revised 9/21/2020, showed, .The Administrator is responsible for establishing and directing the facility's overall day-to-day operations, both internal and external, and coordinate and maintain compliance to maximize high standards of care to patients .Meet with personnel as required and scheduled to assist in identifying and correcting issues, and/or the improvement of services .Assist in compliance efforts regarding state and/or federal requirements .monitor procedures to ensure compliance with state and federal guidelines, laws, regulations and company policies .Attend and participate in orientation programs, on-going training and educational classes .organize work flow; ensure employees understand their duties or delegated tasks .monitor employee productivity . The facility's undated Director of Nursing (DON) job description showed, .The purpose of this job is to manage the nursing department and administer the nursing program in compliance with state and federal regulations .Plan, develop, organize, implement, evaluate and direct the Nursing Services Department .in compliance with rules and regulations governing long term care facilities .Facilitate the coordination of nursing services .to maintain quality care for patients .Prepare reports and recommendations for the Administrator regarding the operation of the Nursing Services Department . During an interview on 9/11/2020 at 9:35 AM, the DON confirmed that it was her responsibility to ensure that staff were educated and it is her responsibility to oversee the day to day operations of the nursing department. During an interview on 9/23/2020 at 11:30 AM, the Administrator confirmed that in coordination with the Wound Care Physician, the facility nursing staff should carry out all orders and treatments as ordered related to both pressure ulcers and non-pressure wounds. The Administrator confirmed that the day to day operations of the facility required the DON and nursing staff to ensure that all orders, treatments, and care and services related to residents was provided. The Administrator confirmed that prior to September 3, 2020, she did not consistently receive updates on the progress or development of both pressure ulcers and non-pressure wounds. The Administrator confirmed that the facility did not have consistent weekly meetings to discuss pressure ulcers and non-pressure wounds. The Administrator confirmed that it was her responsibility to ensure there was qualified staff, educated to assess, identify, and treat wounds in the facility. The Administrator confirmed that the resident's Medication Administration Record [REDACTED]. The Administrator confirmed that prior to September 4, 2020, the facility failed to identify any concerns related to wound care provided the residents or skin observations. As a result of identifying there was a concern on September 4, 2020, the facility conducted a facility wide skin sweep and found skin breakdown that was not identified prior to the facility wide skin sweep. During an interview on 9/17/2020 at 1:30 PM, the Administrator confirmed that her job duties included but were not limited to communication with state and federal entities, to oversee the day to day operations of the facility, assign duties to the staff members, and ensure that all residents received the care and services needed. The Administrator confirmed that it was her responsibility to ensure all department managers were completing their duties. The Administrator confirmed that the facility conducted morning and afternoon meetings related to the care and services provided in the facility. She acknowledged it was her responsibility to ensure issues were addressed by the assigned department managers and to conduct a monthly QAPI meeting that included all department managers and the Medical Director. In this meeting they discussed concerns identified in the facility and a systematic approach to solving the issues as a team. The Administrator was unable to tell the surveyors what QAPI plans the facility had discussed. The Administrator stated the facility had not discussed pressure ulcer/non pressure related wounds in QAPI. During an interview on 9/22/2020 at 11:30 AM, the Administrator confirmed it was her responsibility to ensure that all care and services related to residents were completed. Administration failed to ensure that educational services were provided to staff for the oversight and the completion of the job duties related to the care and services for the detection, prevention, implementation and treatment of [REDACTED]. The facility was unable to provide a QAPI plan related to pressure ulcers and non-pressure wounds prior to September 4th, 2020. The QAPI Committee failed to recognize issues with physician notification related to the detection, care and treatment of [REDACTED].#4, #5, #6, #8, and #12. Refer to F-580 The QAPI Committee failed to recognize the facility had an issue with implementation of the resident's plan of care for pressure ulcers and non-pressure wounds which resulted in Immediate Jeopardy for Resident #4, #6, and #8. Refer to F-656 The QAPI Committee failed to recognize the facility had an issue with pressure ulcers and non-pressure wounds and failed to implement a plan of action to provide consistent measures for the prevention, detection, identification, and implementation of treatments for pressure ulcers and non-pressure wounds which resulted in Immediate Jeopardy for Resident #4, #5, #6, #8, and #12. Refer to F-684 and F-686 The QAPI Committed failed to recognize the facility had a concern with nursing staff competencies related to the prevention and identification of wounds, implementation of treatments for wounds, documentation, the use of the facility's shower sheets and weekly skin audits for newly identified pressure ulcers and non-pressure wounds which resulted in an Immediate Jeopardy. Refer to F-726 The QAPI Committee failed to ensure the Medical Director assisted with identifying, evaluating and addressing clinical concerns, coordinated the medical care and provided clinical guidance and oversight to address concerns related to care and services/treatment for [REDACTED]. This resulted in IJ for Resident #4, #5, #6, #8, and #12 related to the detection, identification, and care and services of pressure ulcers and non-pressure wounds and had the potential to affect the 92 residents residing in the facility. Refer to F-841 The surveyors verified the Removal Plan by: 1. On 9/23/2020, the QAPI Committee was educated by the Regional Director of Operations on the QAPI Policy and the responsibilities of the committee. The QAPI Committee was educated on monitoring, assessing and maintaining an effective wound care management program to include staff education to assess, document, and report changes in wound status. The surveyors reviewed in-service sheets, interviewed QAPI Committee members, and interviewed staff on all shifts. 2. On 9/22/2020, the QAPI Committee and the Medical Director were notified of the IJ Deficiencies by the Administrator. The surveyors reviewed the QAPI agenda and meeting minutes that included the sign in sheet, The Regional Nurse Consultant confirmed that the Medical Director was present via telephone conference call for the QAPI meeting. 3. On 9/23/2020, the QAPI Committee discussed action plans to address the immediate concerns for residents with wounds and all other residents identified as having the potential to be affected. The DON, ADON, Staffing Coordinator, Minimum Data Set Coordinator (MDS), Admissions Coordinator, and Medical Records personnel will audit electronic health record on all new admissions, hospital readmissions, and weekly wound assessments for pressure injuries, new pressure injuries, and non-pressure wounds for appropriate and completed assessment, documentation, treatment, following physician orders, and Medical Doctor and family notification of pressure injuries or changes in status to ensure a resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing daily for 7 days, weekly for three weeks, then monthly for two months, and quarterly ongoing. The findings of the audit will be reported to the QAPI Committee which consists of the Administrator, Medical Director, DON, ADON, Staffing Coordinator, Medical Records, MDS Coordinators, Social Services Director, Activities Director, Dietary Supervisor, Maintenance Supervisor, Business Office Coordinator, Admissions Coordinator, and Infection Preventionist. If compliance is not met, staff will be re-educated, and the audits will continue until substantial compliance is met. The Medical Director was in agreement with the current removal plan. The surveyors reviewed the QAPI agenda and meeting minutes, the audit forms, and interviewed the Medical Director, Administrator and the ADON. Noncompliance of F-867 continues at a scope and severity of E for the monitoring the effectiveness of the corrective action plan. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to notify the physician of newly developed pressure and non-pressure related wounds, missed wound treatments, missed medications related to wound care, and changes in wound status for 5 of 13 sampled residents (Resident #4, #8, #12, #10, and #13) reviewed for pressure and non-pressure related wounds. The facility's failure to notify the physician of wound treatments that were not done resulted in an Immediate Jeopardy when Resident #4's arterial wound deteriorated, Resident #8 developed an Unstageable (full thickness tissue loss in which the depth of the ulcer is completely obscured by slough and/or eschar) Pressure Ulcer, and Resident #12 developed a Deep Tissue Injury (DTI) ( Purple or maroon localized area of discolored intact skin or blood filled blister). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, Assistant Director of Nursing (ADON), and the Regional Nurse Consultant were notified of the Immediate Jeopardy on 9/22/2020 at 11:30 AM, in the Conference Room. The facility was cited an Immediate Jeopardy at F-580 at a scope and severity of J. The IJ was effective 8/2/2020 through 9/24/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/24/2020 at 4:30 PM, and was validated onsite by the surveyors on 9/25/2020 by review of the assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) minutes, observations, and staff interviews. The findings include: Review of the facility's policy titled, Pressure Ulcer Prevention and Non-Pressure Ulcer Management, revised 11/2019, showed, .This facility is committed to the prevention of avoidable pressure injuries (pressure ulcers) and the promotion of healing of existing pressure ulcers .and to promote wound healing of various types of wounds in accordance with current standards of practice and Physicians orders .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, starting with prompt assessment and treatment .Nursing assistants (Certified Nursing Assistants (CNA)) will report any skin concerns to the resident's nurse .The attending physician/NP (Nurse Practitioner)/PA (Physician Assistant)/CNS (Certified Nurse Specialist) will be notified for the following but not limited to: Presence of a new pressure ulcer/injury; Presence of a new non-pressure ulcer or other skin damage; Lack of healing of any pressure injuries, non-pressure ulcers, or other skin damage; Development of complications . Review of the facility's policy titled, Skin Assessment, revised 11/2017, showed, .It is our policy to perform a full body skin assessment as part of our systematic approach for pressure ulcer/injury prevention and for the promotion of healing of various conditions including pressure ulcers/injuries .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, the day following admission/re-admission and weekly thereafter . Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the June through August 2020 recapitulation Physician order [REDACTED].CLEANSE (Left Heel Arterial Wound) WITH WOUND CLEANSER, PAT DRY, APPLY COLLAGEN POWDER AND CALCIUM ALGINATE (encourages new cell growth to the wound, and encourages removal of infected and dead tissue) TO WOUND BED .COVER FOAM DRESSING AND WRAP WITH ROLL GAUZE .Every Two Days . Review of Resident #4's Treatment Records for June through August 2020, showed these treatments to the left heel were not performed on 6/5/2020, 6/15/2020, 7/16/2020, 7/18/2020, 7/20/2020, 7/22/2020, 7/24/2020, 7/30/2020, 8/1/2020, 8/3/2020, 8/25/2020, and 8/29/2020. Review of Resident #4's July through August 2020 recapitulation Physician order [REDACTED].LEFT HEEL WOUND: CLEANSE WITH DAKIN'S SOLUTION (a strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION]) RINSE WITH N. S. (Normal Saline) .PAT DRY APPLY SANTYL OINTMENT (to debride and remove slough and necrotic tissue from the wound bed) TO WOUND BED. COVER WITH DRY DRESSING .WRAP WITH ROLL GAUZE .Every One Day (daily) . Review of Resident #4's July through August 2020 Treatment Records, showed these treatments to the left heel wound were not performed on 7/16/2020, 7/17/2020, 7/18/2020, 7/20/2020, 7/22/2020, 7/24/2020, 7/25/2020, 7/30/2020, 8/1/2020, 8/3/2020, 8/4/2020, 8/5/2020, 8/6/2020, 8/8/2020, 8/16/2020, 8/22/2020, 8/25/2020, 8/29/2020 and 8/30/2020. The physician's orders [REDACTED]. Both treatments were active orders from 7/6/2020 to August 2020. Review of the medical record showed, there was no documentation the physician, NP, PA, and CNS was notified that Resident #4 did not receive the treatments as ordered. Review of the (Named Company) Wound Evaluation & Management Summary (Physician Wound Progress Notes) dated 9/24/2020, showed, .ARTERIAL WOUND OF THE LEFT HEEL .8 (centimeters (cm)) X 7.5 (cm) X 0.1 cm .Thick adherent devitalized necrotic tissue .10 % (percent) .Granulation tissue .90 % .Wound progress: Deteriorated . Review of the Physician Telephone Orders dated 9/14/2020, showed, .Heel wound culture & (and) sensitivity .RE (regarding) infection/[MEDICAL CONDITION] .L (left) Leg wound culture & sensitivity .Bactrim .BID (twice a day) x (for) 7 days . The facility's failure to notify the physician of missed treatments resulted in Immediate Jeopardy when the arterial wound became infected and deteriorated in status. Refer to F-684 Review of the medical record, showed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Initial Skin Injury Assessment, (form for new wounds) performed by a Registered Nurse dated 9/4/2020, showed, .Skin injury identified on 09/04/2020 .rt (right) heel .Length .5.5 cm Width .5 cm with a Depth of: Depth 0.2 cm . There was no stage of the wound identified on this form. Review of the Treatment/Order Update/Change in Condition, for Resident #8's right heel dated 9/7/2020, showed, .Santyl 250 unit/gram topical ointment (apply) OINTMENT Topical Every 1 Day (daily) .Apply Santyl TOP (topical) to right heel and apply protective dressing QD (every day) . Review of the WOUND AND PRESSURE INJURY INFORMATION, dated 9/9/2020, showed, .Location rt heel .Onset Date: 09/04/2020 .Unstageable-slough and/or eschar (Known but not stageable due to coverage of wound bed by slough and/or eschar) .5.3 cm X Width 4.3 cm X Depth 0.2 cm . Review of the medical record, showed the physician, NP, PA, or CNS was not notified of Resident #8's Unstageable Pressure Ulcer wound until 9/7/2020 when the order for the Santyl treatment of [REDACTED]. Observation in Resident #8's room on 9/10/2020 at 4:07 PM with the Director of Nursing (DON) present, showed Resident #8 had a large wound to the back of the right heel and ankle, with a pea size white area at the top of the wound, and a large amount of bloody drainage. The DON confirmed the pressure ulcer was now a reclassified Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present). During an interview on 9/15/2020 at 1:47 PM, the DON confirmed the right heel pressure ulcer was discovered on 9/4/2020 as an Unstageable Pressure Ulcer, and the order for treatment was not written until 9/7/2020. The facility's failure to notify the physician of Resident #8's Unstageable Pressure Ulcer caused a delay in treatment and placed Resident #8 in Immediate Jeopardy when a pressure ulcer was identified as an Unstageable ulcer. Refer to F-686 Review of the medical record, showed Resident #12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. There was no documentation between 8/31/2020 and 9/3/2020 to indicate the development of a new wound. Review of an Initial Skin Injury Assessment (form for new wounds) dated 9/4/2020, showed, a wound on Resident #12's left great toe with measurements of .Length .1.0 CM Width .0.5 CM With a Depth of: Depth 0 CM . There was no stage of the wound identified on this form. Review of Resident #12's Physician order [REDACTED].Skin Prep (preparation) Wipe .apply skin prep to lt (left) great toe qd (every day) . Review of the medical record, showed the physician, NP, PA, or CNS were not notified of Resident #12's DTI until 9/6/2020, when the order for treatment of [REDACTED]. Review of the September 2020 TAR, showed treatment for [REDACTED]. Review of the WOUND AND PRESSURE INJURY INFORMATION, dated 9/9/2020, showed, .Location lt great toe .Onset Date: 09/04/2020 .Unstageable-Deep Tissue Injury .1 cm X Width 1 cm X Depth 0.1 cm . Observation in Resident #12's room on 9/14/2020 at 4:17 PM with the Wound Care Physician, showed Resident #12 had a DTI to the left great toe. The Wound Care Physician measured the DTI with measurements of 0.7 cm x 0.8 cm x 0 cm. The facility's failure to notify the physician of Resident #12's DTI caused a delay in treatment and placed Resident #12 in Immediate Jeopardy when a pressure ulcer was identified as a DTI. Refer to F-686 During an interview on 9/14/2020 at 2:55 PM, the Wound Care Physician confirmed that staff should follow physician orders [REDACTED]. The Wound Care Physician confirmed that nursing staff should notify the physician for any signs or symptoms of infections related to pressure ulcers and non-pressure wounds. During an interview on 9/15/2020 at 2:27 PM, the DON and Regional Nurse Consultant stated the physician would .want to be notified of missed treatments, missed medications, and there should be no blanks on the Medication Administration Record [REDACTED] During an interview on 9/16/2020 at 9:12 AM, the Medical Director confirmed that nursing staff should notify him or the Nurse Practitioner of any changes in the wound condition, development of new wounds and for any missed treatments or medications. During an interview on 9/16/2020 at 10:45 AM, the Family Nurse Practitioner (FNP) confirmed that nursing staff should notify the Medical Director or the FNP for any changes in wound status, development of new wounds, and missed medications or treatments. Review of the medical record, showed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#10 was ordered, .[MEDICATION NAME] 500 mg (milligrams) po TID (three times a day) x 6 weeks.[MEDICATION NAME] mg tablet (1) TABLET Oral Every Twelve Hours for Seven Days Starting 09/18/2020 (for a Stage 4 pressure ulcer to the left foot in an [MEDICAL CONDITION] stage and biofilm present) . Review of the September 2020 Medication Administration Record [REDACTED]. Review of the medical record, showed the physician, NP, PA, or CNS were not notified the [MEDICATION NAME] not administered on 9/18/2020 for Resident #10. Review of the medical record, showed Resident #13 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the August 2020 recapitulation Physician order [REDACTED].Triple Helix Collagen 100% (percent) topical power .SACRAL WOUND: CLEANSE WITH WOUND CLEANSER, PAT DRY, APPLY COLLAGEN POWER TO WOUND BED, PACK WITH CALCIUM ALIGNATE AND COVER WITH FOAM DRESSING .Every One Day (daily) .Skin Audit Weekly .Tuesday 6p (PM)-6a (AM) . Review of the Resident #13's August 2020 Treatment Records, showed these treatments were not done on 8/1/2020, 8/3/2020, 8/4/2020, 8/5/2020, 8/8/2020, 8/9/2020, 8/10/2020, 8/16/2020, 8/17/2020, 8/18/2020, 8/20/2020, 8/21/2020, 8/22/2020, 8/23/2020, 8/26/2020, 8/27/2020, 8/29/2020, and 8/31/2020. Review of the medical record, showed the physician, NP, PA, or CNS were not notified the treatments were not performed as ordered for Resident #13. Review of the Weekly Ulcer Reports for Resident #13 dated 8/2/2020-8/9/2020 and 8/10/2020-8/16/2020, showed, .SACRUM .STAGE 4 .7.5 (cm) x 5.5 (cm) x 0.4 (cm) . Observation in Resident #13's room on 9/3/2020 at 2:30 PM, showed the resident in bed with a dry and intact dressing to the sacral area. Medical record review showed Resident #13 was transferred to the hospital on [DATE] for a possible feeding tube placement. The surveyors verified the Removal Plan by: 1. On 9/23/2020, residents with current wounds were audited for appropriate and complete assessments, documentation in the electronic health record, Medical Doctor (MD) and Family notification, implementation of current physician orders, and treatment initiated. The surveyors confirmed the audits for complete assessments, documentation in the electronic health record, MD and Family notification, current physician's orders [REDACTED]. 2. On 9/21/2020, the (Named Company) Wound Care Physician was consulted and will continue to be consulted weekly for residents with wounds as needed. If circumstance prevents on site rounds, (Named Company) Wound Care Physician will be contacted by phone and/or via telehealth. The surveyors conducted an interview with the Wound Care Physician and Regional Nurse Consultant who confirmed the Wound Care Physician was consulted and will continue to be consulted weekly for residents with wounds as needed. 3. On 9/22/2020, the Quality Assessment and Performance Improvement (QAPI) Committee and the Medical Director were notified of the Immediate Jeopardy Deficiencies by the Administrator. The surveyors interviewed the QAPI members and the Medical Director. 4. On 9/23/2020, the QAPI Committee discussed action plans to address the immediate concerns for residents with wounds and all other residents identified as having the potential to be affected. The DON, ADON, Staffing Coordinator, Minimum Data Set (MDS) Coordinator, Admissions Coordinator, and Medical Records will audit electronic health record on all new admissions, hospital readmissions, weekly wound assessments for pressure injuries, non-pressure wounds, and new pressure injuries for appropriate and completed identification and assessment, documentation, treatment, following physician orders, and Medical Doctor (MD) and family notification of pressure injuries or changes in status to ensure a resident with pressure injuries and non-pressure wounds receives the necessary treatment and services, daily for 7 days, weekly for 3 weeks, monthly for 2 months, and quarterly. The findings of the audit will be reported to the QAPI Committee which consists of the Administrator, Medical Director, DON, ADON, Staffing Coordinator, Medical Records, MDS Coordinators, Social Services Director, Activities Director, Dietary Supervisor, Maintenance Supervisor, Business Office Coordinator, Admissions Coordinator, and Infection Preventionist. If compliance is not met, staff will be re-educated, and the audits will continue until substantial compliance is met. The Medical Director is in agreement with the Removal Plan. The surveyors reviewed the QAPI agenda and meeting minutes and interviewed the Medical Director, Administrator and the ADON. The noncompliance continues at F-580-E continues at a scope and severity of E for monitoring of effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to implement Care Plan interventions for 4 of 13 sampled residents (Resident #4, #6, #8, and #13) reviewed for pressure ulcers and non-pressure wounds. The facility's failure to implement Care Plan interventions resulted in Immediate Jeopardy when Resident #4's wound deteriorated from an avoidable Unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough) pressure ulcer that progressed to a Stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present) pressure ulcer, Resident #6's arterial wound deteriorated when the wound developed eschar (dry dark scab) and a new arterial wound was discovered on Resident #6's right medial ankle, and Resident #8 developed an avoidable Unstageable Pressure Ulcer. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, Regional Nurse Consultant, and Assistant Director of Nursing (ADON), were notified of the Immediate Jeopardy on 9/22/2020 at 11:30 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-656 at a scope and severity of J. The IJ was effective 8/2/2020 through 9/24/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/24/2020 at 4:30 PM, and was validated onsite by the surveyors on 9/25/2020 through review of assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) meeting minutes, observations, and staff interviews. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 12/2019, showed, .It is the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe .the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #4 dated 1/15/2020 and updated 9/9/2020, showed, .Tunneling Abscess to sacrum .See doctor's orders and treatment notes for current interventions . Review of the March-September 2020 recapitulation Physician order [REDACTED].CLEANSE WITH WOUND CLEANSER .PAT DRY .APPLY BARRIER CREAM .COLLAGEN POWDER .CACIUM (calcium) ALIGATE (Alginate) (encourages new cell growth to the wound, and encourages removal of infected and dead tissue) TO WOUND BED .PACK WITH DRY 4X4 GAUZE .COVER WITH DRY DRESSING .CHANGE DRESSING EVERY DAY .PRN (as needed) .WEEKLY SKIN AUDITS (assessments) . Review of Resident #4's June-September 2020 Treatment Administration Record (TAR), showed treatments to the sacrum wound were not performed as ordered on [DATE], 6/6/2020, 6/12/2020, 6/15/2020, 7/16/2020, 7/17/2020, 7/18/2020, 7/20/2020, 7/22/2020, 7/24/2020, 7/25/2020, 7/30/2020, 8/1/2020, 8/3/2020, 8/4/2020, 8/5/2020, 8/6/2020, 8/8/2020, 8/16/2020, 8/22/2020, 8/25/2020, 8/29/2020, 8/30/2020, 9/3/2020, 9/8/2020, and 9/12/2020. There were no weekly skin assessments performed on 8/20/2020 and 9/7/2020. Review of the Weekly Ulcer Report dated 8/25/2020, showed, .SACRUM ABSCESS .14.5 (centimeters (cm)) x (by) 12.0 (cm) x 2.5 (cm) . Review of the Weekly Ulcer Report dated 9/3/2020, showed, .SACRUM STAGE 4 .10.0 (centimeter (cm)) x 5.0 (cm) x < (less than) 0.5 (cm) .undermining (occurs when the tissue under the wound edges become eroded, resulting in a pocket beneath the skin) 12 to 5 . The facility's failure to ensure the Care Plan interventions were implemented to provide treatments as ordered placed Resident #4 in Immediate Jeopardy when the abscess deteriorated to a Stage 4 pressure ulcer. Refer to F-686 Review of the medical record, showed Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #6's Care Plan dated 8/27/2020, showed, .Use pillows, pads, or wedges to reduce pressure on heal (heel) and pressure points. Turn/reposition .Pressure relief boots .See doctor's orders and treatment notes for current interventions . Review of the Initial Skin Injury Assessment (form for new wounds) dated 8/19/2020, showed, .The location of this area is Left Heel .Right heel . There was no description or measurements of the areas on this form. Review of the Physician order [REDACTED].Float heels wit (with) Prevalon boots (boots to reduce pressure on the heels) or pillows .Clean bilateral heel with wipes .Apply [MEDICATION NAME] swab daily to right heel .cover bilateral heels wit (with) [MEDICATION NAME] border (foam) dressing .change Q3D (every 3 days) . Review of the Nursing Admission/Readmission Form dated 8/20/2020 (completed for the admission 8/19/2020), showed, .Ulcer/Injury Present .Yes . Review of the August 2020 TAR showed, there was no treatment performed on 8/28/2020 to clean the bilateral heels with wipes and apply a [MEDICATION NAME] swab. Review of the September 2020 TAR showed, the bilateral heels were not cleaned with wipes and a [MEDICATION NAME] swab was not applied as ordered on [DATE]. Review of the Weekly Ulcer Report dated 9/3/2020, showed, .lt (left) heel .ustag (unstageable) .5 (cm) x 4 (cm) x 0.1 (cm) .100 % (percentage) eschar .rt (right) heel .unstag .7.5 (cm) x 5 (cm) x 0.1(cm) .100 % eschar . Review of the (Named Company) Wound Physicians Wound Evaluation & Management Summary (Wound physician progress notes [REDACTED].ARTERIAL WOUND OF THE LEFT HEEL .1 (cm) X 0.7 (cm) X 0.1 cm .Dried [MEDICATION NAME] exudate (scab) ARTERIAL WOUND OF THE RIGHT HEEL .4.5 (cm) X 5.5 (cm) X Not Measurable cm .Thick adherent black necrotic tissue (eschar) . Review of the medical record showed nursing staff assessed the wound as a pressure ulcer and the Physician documented the same wound as an arterial wound. Observation in the resident's room on 9/10/2020 at 5:04 PM, showed Resident #6 in bed and not wearing the heel boots. The lower extremities were elevated on one pillow. There were no dressings on the heels. The right heel had a large amount of black hard eschar (a dry dark scab) and the left heel had a large amount of hard black eschar. Observation in the resident's room on 9/14/2020 at 12:11 PM with the Wound Care Physician, showed Resident #6's left heel had a large amount of black hard necrotic (dead tissue) eschar that measured 5.0 cm x 3.5 cm x 0 cm. The right heel had 100% dry necrotic eschar and was 6.5 cm x 4.5 cm x 0 cm. The Wound Care Physician identified a new wound with black eschar on Resident #6's right medial ankle that measured 1.0 cm x 1.7 cm x 0 cm. These measurements were obtained by the Physician in the presence of the surveyor. During an interview on 9/14/2020 at 12:15 AM, the Wound Care Physician stated Resident #6's heels had declined due to the eschar on the bilateral heels and the heels were not being properly off-loaded. The facility's failure to ensure Care Plan interventions were implemented to provide preventive measures and treatments resulted in actual Harm and Immediate Jeopardy for Resident #6 when the arterial wound deteriorated, and a new wound was discovered. Refer to F-684 Review of the medical record, showed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's Care Plan dated 5/11/2020, showed, .at risk for pressure ulcer .check skin for redness .pressure areas .Report any signs of skin breakdown .Use pillow .to reduce pressure on heels .turn/reposition at least every two hours .Monitor skin integrity while providing care . Review of the Initial Skin Injury Assessment, (form for new wounds) performed by a Registered Nurse dated 9/4/2020, showed, .Skin injury identified on 09/04/2020 .rt (right) heel .Length .5.5 cm Width .5 cm with a Depth of: Depth 0.2 cm . There was no stage of the wound on this form. Review of the WOUND AND PRESSURE INJURY INFORMATION, dated 9/9/2020, showed, .Location rt heel .Onset Date: 09/04/2020 .Unstageable-slough and/or eschar (Known but not stageable due to coverage of wound bed by slough and/or eschar) .5.3 cm X Width 4.3 cm X Depth 0.2 cm . During an interview on 9/15/2020 at 1:47 PM, the Director of Nursing (DON) confirmed the right heel pressure ulcer was discovered on 9/4/2020 as an Unstageable Pressure Ulcer, and now reclassified as a Stage 4 Pressure Ulcer. Observation in Resident #8's room on 9/10/2020 at 3:49 PM, showed Resident #8 resting in bed. The resident's heels were lying flat on top of one pillow and were not off loaded (to remove direct pressure from the heels). Observation in the resident's room on 9/10/2020 at 4:07 PM with the Director of Nursing (DON), showed Resident #8 had a large wound to the back of the right heel and ankle, with a pea size white area at the top of the wound, and a large amount of bloody drainage. The DON confirmed the pressure ulcer was now reclassified as a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle). Observation in Resident #8's room on 9/11/2020 at 10:29 AM, 11:47 AM, and 9/13/2020 at 10:36 AM, showed Resident #8 resting in bed. His heels were lying flat on the pillow and were not off loaded. The facility's failure to ensure Care Plan interventions were implemented for reducing pressure to the heels caused actual Harm to Resident #8 when he developed an Unstageable pressure ulcer that progressed to a Stage 4 and placed Resident #8 in Immediate Jeopardy. Refer to F-686 Review of the medical record, showed Resident #13 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #13 dated 6/12/2020 and last updated 8/27/2020, showed, .at risk for pressure ulcer .check skin for redness .skin tears .pressure area .wedges to reduce pressure on heals (heels) .Turn/reposition .Wound Care and Management of Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle)sacral wound .assess .monitor wound healing .notify physician if current wound treatment is not effective .record wound measurements .Assess and monitor wound treatment plan for effectiveness and complications . Review of the June-August 2020 recapitulation Physician Orders, showed, .Skin Audit Weekly .One Time Weekly (Start date 6/5/2020) . Review of the June 2020 TAR for Resident #13, showed there was no skin audit performed the week of 6/16/2020. Review of the July-August 2020 recapitulation Physician Orders, showed, .(Start Date 7/30/2020) Triple Helix Collagen 100% topical power .SACRAL WOUND: CLEANSE WITH WOUND CLEANSER, PAT DRY, APPLY COLLAGEN POWER TO WOUND BED, PACK WITH CALCIUM ALIGNATE AND COVER WITH FOAM DRESSING .Every One Day (daily) .Skin Audit Weekly .Tuesday 6p (6:00 PM)-6a (6:00 AM) . Review of Resident #13's July and August TARs, showed there were no treatments performed to the sacral pressure ulcer on 7/30/2020, 8/1/2020, 8/3/2020, 8/4/2020, 8/5/2020, 8/8/2020, 8/9/2020, 8/10/2020, 8/16/2020, 8/17/2020, 8/18/2020, 8/20/2020, 8/21/2020, 8/22/2020, 8/23/2020, 8/26/2020, 8/27/2020, 8/29/2020, and 8/31/2020. Review of the August 2020 TAR, showed there was no documentation for a weekly skin assessment on 8/4/2020. Review of the Weekly Ulcer Reports for Resident #13 dated 8/2/2020-8/9/2020 and 8/10/2020-8/16/2020, showed, .SACRUM .STAGE 4 .7.5 (cm) x 5.5 (cm) x 0.4 (cm) . During an interview on 9/15/2020 at 2:27 PM, the DON confirmed staff should follow Care Plans related to the care and services of pressure and non-pressure ulcers. During an interview on 9/16/2020 at 9:12 AM, the Medical Director confirmed the nursing staff should follow the Care Plan. The surveyor verified the Removal Plan by: 1. On 9/22/2020, the Minimum Data Set (MDS) Coordinators and Interdisciplinary Team (IDT) initiated an audit of Comprehensive Care Plans related to wounds for appropriate interventions and to ensure interventions are in place according to the care plan. The surveyors conducted an interview with the MDS Coordinators and reviewed the audits of the Care Plans. 2. On 9/23/2020, the Nursing staff was educated by the Regional Nurse Consultant on implementation of the process for accessing and reviewing the resident centered care plans through the charting kiosks. The surveyors attended an in-service conducted by the Regional Nurse Consultant and reviewed the in-service on the implementation process for accessing and reviewing the resident centered care plans through charting in the kiosks. 3. On 9/23/2020, MDS Coordinator(s) were educated by the Regional Nurse Consultant to include the nursing staff in the care planning process in conjunction with the IDT by attending scheduled care planning meetings and providing input into the development of the comprehensive care plans. The surveyors conducted an interview with the Regional Nurse Consultant and MDS Coordinators. 4. Off duty nursing staff, upon returning to work, and newly hired nursing staff will be educated on implementation of the process for accessing and reviewing the resident centered care plans through the charting kiosks. The surveyors conducted an interview with the Regional Nurse Consultant and reviewed the new hire process. 5. On 9/23/2020, the Quality Assurance Performance Improvement (QAPI) Committee discussed action plans to address the immediate concerns for residents with wounds and all other residents identified as having the potential to be affected. The surveyors reviewed the QAPI minutes and interviewed QAPI members. 6. The DON, ADON, Staffing Coordinator, MDS Coordinator, Admissions Coordinator, and Medical Records staff will audit electronic health record on all new admissions, hospital readmissions, and weekly wound assessments for pressure injuries, non-pressure wounds, new pressure injuries for appropriate and completed identification and assessment, documentation, treatment, following physician orders, physician and family notification of pressure injuries or changes in status daily for 7 days, weekly for 3 weeks, then monthly for 2 months, and quarterly ongoing. This will ensure a resident with pressure injuries and non-pressure wounds receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The findings of the audit will be reported to the QAPI Committee which consists of the Administrator, Medical Director, DON, ADON, Staffing Coordinator, Medical Records, MDS Coordinators, Social Services Director, Activities Director, Dietary Supervisor, Maintenance Supervisor, Business Office Coordinator, Admissions Coordinator, and Infection Preventionist. If compliance is not met, staff will be re-educated, and the audits will continue until substantial compliance is met. The Medical Director is in agreement with the current Removal Plan. The surveyors reviewed the QAPI agenda and meeting minutes and interviewed the Medical Director, Administrator and the ADON. The facility's noncompliance of F-656 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective action. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, and interview, the facility failed to implement interventions for constipation and activities of daily living (ADLs) for 6 of 7 (Resident #1, 2, 3, 4, 5 and #7 ) sampled residents. The failure to follow the care plan for constipation revealed Resident #1 suffered abdominal pain and was sent to the emergency room related to Severe Constipation resulting in actual harm to Resident #1. The findings included: 1. The facility's Care Plans policy documented .Care Planning is an essential part of healthcare providing a road map of sorts, to guide all who are involved with the patient's care .The care plan must describe the services that are to be furnished to attain and maintain the patient's highest practicable physical, mental and psychosocial wellbeing .Must address problems identified . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The care plan dated 7/5/16 documented Resident #1 was at risk for constipation related to decreased mobility with the goal of .will not experience constipation . The interventions included to assess and document Resident #1's usual bowel movement history to include medication use, laxative use, diet, fluids, exercise, and personal remedies, and intervene with laxatives or stool softeners as ordered. The care plan dated 7/5/16 documented Resident #1 required extensive assistance with personal hygiene related to weakness and [MEDICAL CONDITION] with goals to have personal hygiene needs met daily. The Clinical Pathway (physician's standing orders) dated 7/20/16 documented, .Constipation: Check Bowel Movement record; Notify Provider of any abdominal distention. If no abdominal distention and no BM (bowel movement) in last 3 days: Milk of Magnesia (MOM) 30 cc (cubic centimeters) po (by mouth) .prn (as needed) constipation . a. The Activities of Daily living (ADL) Verification Worksheet revealed there was no documentation Resident #1 had a bowel movement on 8/19/16, 8/20/16, 8/21/16, 8/22/16, and 8/23/2016 and the facility was unable to provide documentation the bowel protocol was followed as outlined in the care plan. The ADL Verification Worksheet revealed there was no documentation Resident #1 had a bowel movement on 8/25/16, 8/26/16, 8/27/16, 8/28/16, and 8/29/2016. The facility was unable to provide documentation the bowel protocol was followed as outlined in the care plan. A Clinical Note dated 8/29/16 documented, .1200 Resident complained of abdominal pain. Resident's family called wanting her to be transported to ER (emergency room ) immediately. Nurse Practitioner called and gave verbal order to send resident to the hospital . A Physician Telephone Order dated 8/29/16 documented, .Send resident to ER for evaluation for complaints of abdominal pain . The (Named Hospital) Emergency Department Physician Documentation dated 8/29/16 documented, .Diagnosis: [REDACTED].History of Present Illness .The patient presents with abdominal pain. The course/duration of symptoms is constant. The character of symptoms is crampy. The degree at onset was moderate .The degree at present is moderate .Review of Symptoms .Gastrointestinal Symptoms: Abdominal pain, nausea, vomiting. No diarrhea .Differential Diagnosis: [REDACTED]. A (Named Long Term Care Facility (LTC) Vital Signs/Pain Assessment dated 8/29/16 at 13:33 (1:33 PM) documented, .Pain .Yes .Pain Intensity .5 .Primary pain location .Other: ABD (abdominal) pain/buttocks pain .Primary pain character .Aching .Primary pain onset .gradual .Primary pain pattern .Constant . The (Named Hospital) History Forms dated 8/29/16 documented, .Chief complaint .pt (patient) brought in by (Named Ambulance Service) from (Named LTC facility) for c/o (complaints of) ABD pain. pt (patient) has history of ABD (abdominal) aneurysm . A (Named LTC Facility) Clinical Data Flowsheets .GASTROINTESTINAL ASSESSMENT dated 8/29/16 at 14:15 .Stool Character .Hard .GI (gastrointestinal) symptoms .Constipation . The (Named LTC Facility) Clinical Data Flowsheets .GASTROINTESTINAL ASSESSMENT dated 8/29/16 at 18:06 .Stool Character .Hard .GI symptoms .Constipation . The (Named Hospital) History Form dated 8/29/16 documented, .this nurse removed a very large, formed stool from patient's rectum . b. The ADL Verification Worksheet revealed there was no documentation Resident #1 received oral care on the following dates: August : 8/18/16, 8/19/16, 8/20/16, 8/23/16, 8/27/16, and 8/31/16 September: 9/2/16, 9/10/16, 9/12/16, 9/16/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/22/16, 9/23/16, 9/25/16, 9/27/16, and 9/28/16 October: 10/1/16, 10/3/16, 10/7/16, 10/13/16, 10/15/16, 10/16/16, 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/23/16, 10/24/16, 10/28/16, 10/29/16, and 10/30/16 November: 11/3/16, 11/4/16, 11/5/16, 11/6/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/13/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/21/16, 11/22/16, 11/24/16, 11/25/16, and 11/26/16 December: 12/3/16, 12/5/16, 12/6/16, 12/9/16, 12/10/16, 12/11/16, 12/12/16, 12/15/16,12/17/16,12/18/16, 12/19/16, and 12/20/2016 c. The ADL Verification Worksheet revealed there was no documentation Resident #1 received a bath or shower on the following dates: September: 9/16/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/22/16, and 9/23/16 November: 11/3/16, 11/4/16, 11/5/16, 11/6/16, 11/7/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, and 11/20/16 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 was cognitively intact and required extensive assistance for personal hygiene and bathing. The quarterly MDS dated [DATE], revealed Resident #2 had moderate cognitive impairment and required extensive assistance for personal hygiene and bathing. The care plan dated 6/22/16, and updated on 9/6/16, documented, .Problems .Self-care deficit .Assistance required with .bathing, hygiene .grooming .Interventions .Bathe/shower .Frequency .3 Times Weekly Starting 06/22/2016 .Interventions .Clean mouth, brush teeth/dentures after meals and at bedtime .Frequency 4 times Daily Starting 06/22/2016 . The ADL Verification Worksheet revealed there was no documentation that baths and oral care were provided for the following dates: August: 8/27/16, 8/28/16,8/29/16, 8/30/16, and 8/31/16 September: 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, 9/27/16, 9/28/16, 9/29/16, and 9/30/16 October: 10/6/16, 10/7/16, 10/8/16, 10/9/16,10/11/16, 10/12/16, 10/13/16, 10/14/16, 10/15/16, 10/16/16, 10/17/16, 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/22/16, 10/23/16, 10/24/16, 10/25/16, 10/26/16,10/27/16, 10/28/16, 10/29/16, 10/30/16, and 10/31/16 November: 11/1/16,11/2/16, 11/3/16, 11/4/16, 11/6/16, 11/7/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/12/16,11/13/16, 11/14/16,11/15/16, 11/16/16, 11/17,16, 11/18/16, 11/19/16, 11/20/16, 11/22/16, 11/23/16, 11/24/16, 11/25/16, 11/26/16, 11/27/16, 11/28/16, and 11/29/16 December: 12/2/16, 12/3/16, 12/4/16, 12/5/16, 12/6/16, 12/7/16, 12/8/16, 12/11/16, 12/12/16, 12/13/16, 12/14/16, 12/16/16,12/17/16, 12/18/16 and 12/19/16 4. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE], and the quarterly MDS dated [DATE], revealed Resident #3 was cognitively intact, required extensive assistance for oral care and bathing, and was always incontinent of bowel. The care plan documented, .6/20/16 .and updated on 11/28/16 .Problem .Requires extensive to total assistance with personal hygiene related to .[MEDICAL CONDITION] .Interventions .set-up items for personal hygiene .will have oral hygiene .daily .is always incontinent of bowel movement .administer medications as ordered . The facility was unable to provide documentation that baths and oral care were provided for the following dates: August: 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/19/16, 8/20/16, and 8/21/16 September: 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/16/16, 9/17/16, 9/18/16, 9/27/16, 9/28/16, 9/29/16, and 9/30/16 October: 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/28/16, 10/29/16, 10/30/16, and 10/31/16 November: 11/6/16, 11/7/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/12/16, 11/13/16, 11/14/16, 11/15/16, 11/17/16, 11/18/16, 11/19/16, 11/24/16, 11/25/16, 11/26/16, and 11/27/16 December: 12/5/16, 12/6/16, 12/7/16, 12/9/16, 12/10/16, 12/11/16, 12/12/16, 12/14/16, 12/15/16, 12/17/16, 12/18/16 and 12/19/16 The ADL Verification Worksheet revealed there was no documentation Resident #3 had a bowel movement on the following days: August: 8/2/16, 8/3/16, 8/4/16, 8/5/16, 8/6/16, and 8/7/16, 8/9/16, 8/10/16, 8/11/16, 8/12/16, and 8/13/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheet did not document Resident #3 had a bowel movement on the following days: 10/4/16, 10/5/16, 10/6/16, 10/7/16, 10/8/16, 10/9/16, and 10/10/16. The facility was unable to provide documentation the bowel protocol was followed. 5. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE], revealed Resident #4 was cognitively intact and required extensive assistance for personal hygiene. The annual MDS dated [DATE], revealed Resident #4 had moderate cognitive impairment, required extensive assistance for personal hygiene, and was occasionally incontinent of bowel. The care plan dated 11/29/16 documented, .11/29/2016 .Problems .Requires extensive assistance with personal hygiene related to generalized weakness .Interventions .Set-up items for personal hygiene. Allow .to complete as much of the task as possible .at risk for constipation .will have a bowel movement every three days .Intervene with laxatives or stool softeners .Monitor bowel movements . The facility failed to provide documentation that baths and oral care were provided for the following dates of 10/6/16, 10/7/16, 10/8/16, 10/9/16, 10/10/16, 10/11/16, 10/12/16, 10/13/16, 10/14/16, 10/15/16, 10/16/16, 10/17/16, 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/22/16, 10/23/16, 10/25/16, 10/26/16, and 10/27/16. The ADL Verification Worksheet revealed there was no documentation Resident #4 had a bowel movement on the following days 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/9/16, 8/10/16 and 8/12/16, 8/13/16, 8/14/16, and 8/15/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheet revealed there was no documentation Resident #4 had a bowel movement on the following days: 8/17/16, 8/18/16, 8/19/16, 8/20/16, 8/21/16, and 8/22/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheet revealed there was no documentation Resident #4 had a bowel movement on the following days: 9/5/16, 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/12/12, 9/13/16 and 9/20/16, 9/21/16, 9/22/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, 9/27/12, 9/28/16, and 9/29/16. The facility was unable to provide documentation the bowel protocol was followed. 6. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 5/18/16 documented Resident #5 required extensive assistance with personal hygiene with the goal to have oral and personal hygiene needs met daily. The ADL Verification Worksheet revealed there was no documentation Resident #5 had oral care on the following dates: August: 8/21/16, 8/23/16, 8/27/16, 8/28/16, 8/29/16, and 8/31/16 September: 9/1/16, 9/3/16, 9/6/16, 9/7/16, 9/9/16, 9/11/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, 9/27/16, and 9/30/16 October: 10/1/16, 10/2/16, 10/7/16, 10/11/16, 10/12/16, 10/13/16, 10/18/16, 10/21/16, 10/22/16, 10/23/16, 10/24/16, 10/25/16, 10/26/16, 10/27/16, and 10/28/16 November: 11/2/16,11/3/16, 11/8/16, 11/9/16, 11/13/16, 11/14/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/21/16, 11/22/16, 11/23/16, 11/24/16, 11/26/16, 11/28/16 and 11/29/16 December: 12/2/16, 12/3/16, 12/4/16, 12/5/16, 12/7/16, 12/14/16, 12/15/16, 12/18/16, and 12/19/16 The facility was unable to provide documentation that Resident #5 had received oral care. The ADL Verification Worksheet revealed there was no documentation Resident #5 received a bath or shower on the following dates: September: 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, and 9/27/16 October: 10/21/16, 10/22/16, 10/23/16, 10/24/16, 10/25/16, 10/27/16, and 10/28/16 November: 11/13/16, 11/14/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/21/16, 11/22/16, 11/23/16, and 11/24/16. The facility was unable to provide documentation that Resident #5 received personal hygiene. 7. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] documented Resident #7 had severe cognitive deficits, required extensive to total assistance with ADLs including oral care and bathing, and was always incontinent of bowel and bladder. The quarterly MDS dated [DATE] documented severe cognitive impairment, required total assistance for ADLs including oral care and bathing, and was always incontinent of bowel and bladder. Resident #7 was also impaired on both sides of upper and lower extremities. The care plan dated 9/19/16 revealed Resident #7 was totally dependent on staff for toileting needs, and required extensive assistance with personal hygiene with goals to have hygiene needs meet daily. The August 2016 ADL Verification Worksheet revealed there was no documentation Resident #7 received oral care on 8/2/16, 8/4/16, 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/9/16, 8/10/16, 8/11/16, 8/12/16, 8/14/16, 8/15/16, 8/17/16, 8/19/16, 8/20/16, 8/22/16, 8/24/16, 8/25/16, 8/27/16, 8/28/16, 8/29/16, 8/30/16, and 8/31/16. The August 2016 ADL Verification Worksheet revealed there was no documentation Resident #7 received a bath on 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/9/16, 8/10/16, 8/17/16, 8/18/16, 8/19/16, 8/20/16, 8/27/16, 8/28/16, 8/29/16, 8/30/16, and 8/31/16. The September 2016 ADL Verification Worksheet revealed there was no documentation Resident #7 received oral care on 9/1/16, 9/2/16, 9/3/16, 9/4/16, 9/5/16, 9/7/16, 9/8/16, 9/9/16, 9/18/16, 9/20/16, 9/21/16, and 9/26/16. The September 2016 ADL Verification Worksheet revealed there was no documentation Resident #7 received a bath on 9/2/16, 9/3/16, 9/4/16, and 9/5/16 . The October 2016 ADL Verification Worksheet revealed there was no documentation Resident #7 received oral care on 10/2/16, 10/10/16, 10/17/16, 10/18/16, 10/19/16, 10/21/16, 10/23/16, 10/24/16, 10/25/16, and 10/31/16. The November 2016 ADL Verification Worksheet revealed there was no documentation Resident #7 received oral care on 11/2/16, 11/3/16, 11/4/16, 11/6/16, 11/7/16, 11/10/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/22/16, 11/23/16, 11/24/16, 11/25/16, 11/27/16, and 11/28/16. The ADL December 2016 Verification Worksheet revealed there was no documentation Resident #7 received oral care on 12/2/16, 12/4/16, 12/5/16, 12/8/16, 12/10/16, 12/11/16, 12/14/16, 12/17/16, and 12/19/16. The facility was unable to provide documentation that Resident #7 received oral care , a bath or shower on these dates. 8. Interview with the Director of Nursing (DON) on 12/20/16 at 7:00 PM, in the conference room, the DON was asked how the Certified Nursing Assistants (CNAs) knew what they were to do for their assigned residents. The DON stated, .the kiosk lists the resident care needs, and it's updated as things change for the resident . The DON was asked what the blanks on the ADL records meant. The DON stated, The blanks mean the care was not given, or it wasn't documented that it was given. The DON was asked if the care plans document that ADL needs are to be met daily, were the care plans followed. The DON stated, No.

Based on policy review, Job Description NURSING ASSISTANT AND ORDERLY, medical record review, and interview, the facility failed to provide care and treatment for constipation for 3 of 6 (Resident #1, 3, and 4) sampled residents. The facility failed to provide recommended and ordered interventions for Resident #1, resulting in avoidable pain, constipation, and hospitalization requiring manual removal, which resulted in actual harm to Resident #1. The findings included: 1. The facility's PHYSICIAN STANDING ORDERS policy documented, .Physician standing orders or protocol orders are pre-authorized orders conditioned upon the occurrences of certain clinical events . The facility's Care Plans policy documented .Care Planning is an essential part of healthcare providing a road map of sorts, to guide all who are involved with the patient's care . The facility's Job Description NURSING ASSISTANT AND ORDERLY documented, .The following job functions have been determined to be essential to the position of nursing assistant .3. Report changes in the resident's condition to the charge/staff nurse as soon as possible. Document in records . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #1 had severe cognitive deficits, required extensive assistance with activities of daily living (ADLs), was always incontinent of bowel and bladder, and received antidepressant and antibiotic medications. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #1 had moderate cognitive deficits, and was always incontinent of bowel and bladder. The care plan dated 7/5/16 documented Resident #1 was at risk for constipation related to decreased mobility, with interventions to assess and document Resident #1's usual bowel movement history to include medication use, laxative use, diet, fluids, exercise, and personal remedies, and intervene with laxatives or stool softeners as ordered. The Physician order [REDACTED].Q (every) pm with supper .7/14/16 Multivitamins (1) tablet oral .QD (everyday) .8/4/16 [MEDICATION NAME] .25 mg (1) tablet oral .QID (four times daily) .8/4/16 [MEDICATION NAME] 5-325 mg (1) tablet oral .bid (twice daily) PRN (as needed) .8/9/16 [MEDICATION NAME] .0.1 mg (1) tablet oral .QID PRN . These medications have the side effect of constipation. The Clinical Pathway (physician's standing orders) dated 7/20/16 documented, .Constipation: Check Bowel Movement record; Notify Provider of any abdominal distention. If no abdominal distention and no BM (bowel movement) in last 3 days: Milk of Magnesia (MOM) 30 cc (cubic centimeters) po (by mouth) .prn (as needed) constipation; or [MEDICATION NAME] tablet 1 po .or 1 suppository PR (per rectum) daily prn constipation. Fleets enema if MOM or [MEDICATION NAME] not effective in 24 hours .Notify provider if Fleets enema not effective within 24 hours . The ADL Verification Worksheets were requested and provided for Resident #1. The ADL Worksheet did not document that Resident #1 had a bowel movement on 8/19/16, 8/20/16, 8/21/16, 8/22/16, and 8/23/2016. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #1. The ADL Worksheet did not document that Resident #1 had a bowel movement on 8/25/16, 8/26/16, 8/27/16, 8/28/16, and 8/29/2016. The facility was unable to provide documentation the bowel protocol was followed. A Clinical Note dated 8/29/16 documented, .1200 Resident complained of abdominal pain. Resident's family called wanting (Resident #1) to be transported to ER (emergency room ) immediately. Nurse Practitioner called and gave verbal order to send resident to the hospital . A Physician Telephone Order dated 8/29/16 documented, .Send resident to ER for evaluation for complaints of abdominal pain . The (Named Hospital Emergency Department) Physician Documentation dated 8/29/16 documented, .Diagnosis: [REDACTED].History of Present Illness .The patient presents with abdominal pain. The course/duration of symptoms is constant. The character of symptoms is crampy. The degree at onset was moderate .The degree at present is moderate .Review of Symptoms .Gastrointestinal Symptoms: Abdominal pain, nausea, vomiting. No diarrhea .Differential Diagnosis: [REDACTED]. The (Named Long Term Care (LTC) Facility) Vital Signs/Pain Assessment dated 8/29/16 at 13:33 (1:33 PM)documented, .Pain .Yes .Pain Intensity .5 .Primary pain location .Other: ABD (abdominal) pain/buttocks pain .Primary pain character .Aching .Primary pain onset .gradual .Primary pain pattern .Constant . The (Named Hospital) History Forms dated 8/29/16 documented, .Chief complaint .pt (patient) brought in by (Named Ambulance Service) from (Named Long Term Care Facility) for c/o (complaints of) ABD pain. pt has history of ABD aneurysm . The (Named LTC Facility) Clinical Data Flowsheets .GASTROINTESTINAL ASSESSMENT dated 8/29/16 at 14:15 (2:15 PM) documented, .Stool Character .Hard .GI symptoms .Constipation . The (Named LTC Facility) Clinical Data Flowsheets .GASTOINTESTINAL ASSESSMENT dated 8/29/16 at 18:06 (6:06 PM) documented, .Stool Character .Hard .GI (Gastrointestinal) symptoms .Constipation . The (Named Hospital) History Form dated 8/29/16 documented, .this nurse removed a very large, formed stool from patient's rectum . Interview with Certified Nursing Assistant #2 (CNA) on 12/20/16 at 2:30 PM, in the conference room, CNA #2 was asked who was responsible for charting bowel movements. CNA #2 stated, .the CNA's . The facility failed to provide recommended and ordered interventions for Resident #1, resulting in avoidable pain, constipation, and hospitalization , which resulted in actual harm to Resident #1. 3. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE], and the quarterly MDS dated [DATE] revealed Resident #3 was cognitively intact and always incontinent of bowel. The care plan dated 11/28/16 documented Resident #3 was always incontinent of bowel related to [DIAGNOSES REDACTED]. The ADL Verification Worksheets were requested and provided for Resident #3. The ADL Worksheet did not document that Resident #3 had a bowel movement on the following days: 8/2/16, 8/3/16, 8/4/16, 8/5/16, 8/6/16, and 8/7/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Worksheets were requested and provided for Resident #3. The ADL Worksheet did not document that Resident #3 had a bowel movement on the following days 8/9/16, 8/10/16, 8/11/16, 8/12/16, and 8/13/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Worksheets were requested and provided for Resident #3. The ADL Worksheet did not document that Resident #3 had a bowel movement on the following days 10/4/16, 10/5/16, 10/6/16, 10/7/16, 10/8/16, 10/9/16, and 10/10/16. The facility was unable to provide documentation the bowel protocol was followed. 4. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #4 was cognitively intact and occasionally incontinent of bowel. The annual MDS dated [DATE], revealed Resident #4 had moderate cognitive impairment and was occasionally incontinent of bowel. The care plan dated 11/29/16 documented Resident #4 was at risk for constipation related to history of constipation, with interventions to monitor and document Resident #4's bowel movements, intervene with stool softeners and laxatives and to have a bowel movement every three days. The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/9/16, and 8/10/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 8/12/16, 8/13/16, 8/14/16, and 8/15/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 8/17/16, 8/18/16, 8/19/16, 8/20/16, 8/21/16, and 8/22/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 9/5/16, 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/12/12, and 9/13/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 9/20/16, 9/21/16, 9/22/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, 9/27/12, 9/28/16, and 9/29/16. The facility was unable to provide documentation the bowel protocol was followed. 8. Interview with the Director of Nursing (DON) on 12/20/16 at 7:00 PM, in the conference room, the DON was shown the ADL records of Resident #1 and was asked if she would say that the nursing staff followed the Resident #1's care plan. The DON stated, No. The DON was asked if she considered the Clinical Pathways physician orders. The DON stated, .standing orders .yes they would be considered physician orders [REDACTED].#1 and was asked if her nursing staff had followed the physician's orders [REDACTED].I don't see any documentation where they did . The DON was shown the ADL records for Resident #1's oral care and baths. The DON was asked if the nursing staff had followed Resident #1's care plan. The DON stated, No. The DON was asked how the CNA's knew what they were to do for their assigned residents. The DON stated, .the kiosk lists the resident care needs and it's updated as things change for the resident . The DON was asked what the blanks on the ADL records meant. The DON stated, The blanks mean the care was not given or it wasn't documented that it was given.

Based on policy review, medical record review, observation and interview, the Quality Assurance (QA) Committee facility failed to ensure an effective and ongoing QA program that identifies deficient practices related to daily living (ADLs) and infection control practices and implements corrective actions that prevent repeat deficient practices. The QA Committee failed to ensure a system that identified and appropriately treated and prevented constipation for Resident #1. Resident #1 experienced constipation, pain and had to be transferred to the hospital emergency room , resulting in actual harm for Resident #1. The findings included: 1. The QA program failed to ensure a system to ensure all residents' with constipation were treated appropriately and in accordance with facility orders and protocol. The failure to ensure Resident #1's constipation resulted in the resident developing pain and constipation. Resident #1 was sent to the hospital emergency room for treatment of [REDACTED]. Refer to F309. 2. The QA program failed to ensure all residents are provided privacy during personal care. Refer to F164. 3. The QA program failed to ensure all residents' that required assistance with ADLs, received ADLs as appropriate. Refer to F312. The deficient practice of F312 is a repeat deficient practice. The facility failed to provide ADLs to all residents that required assistance with ADLs on the 4/21/16 recertification survey. 4. The QA program failed to ensure infection control practices and facility policies were followed. Refer to F441. The deficient practice of F441 is a repeat deficient practice. The facility failed to follow infection control practices on the 3/31/15 recertification survey. 5. The QA program failed to ensure documentation that care for bowel movements and ADLs were provided as appropriate. Interview with the Director of Nursing (DON) on 12/20/16 at 7:00 PM, in the conference room, the DON stated, The blanks mean the care was not given or it wasn't documented the care was given. The DON was asked if the care plans document that ADL needs are to be met daily, was the care plans followed. The DON stated, No. The facility's Certified Nurse Aide policy documented, .CNAs (Certified Nursing Assistant) are responsible for basic care services such as bathing, toileting, grooming . Refer to F514.