Every finding on record at Harborview Tifton

Based on staff and resident interviews, record review, and review of the policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, the facility failed to report an allegation of sexual abuse for one resident (R) (R14) of a total of 17 sampled residents. The deficient practice had the potential for continued episodes of unreported abuse, which posed potential for physical harm and/or mental anguish.Findings include:Review of the facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation with a revision date of August 1, 2024, documented the following: Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Documented under, Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and all necessary corrective actions depending on the results of the investigation.Record review identified a Facility Reported Incident (FRI) dated 06/16/2026 documenting an allegation of illegal activity involving R8. According to the FRI, R8 told staff that she had received money from male visitors from the community in exchange for sexual activity. Review of the facility's investigation included an email dated 06/16/2026 from the Director of Nursing (DON) reporting to the Medical Director, Nurse Practitioner (NP), Ombudsman and Behavioral Health Services NP. The email documented a verbal altercation between R8 and R14 during which R8 made verbal threats towards R14. The email also stated that both residents admitted to inviting men to the facility for sexual activity.During an interview on 06/18/2026 at 2:54 PM, R14 stated that R8 invited a man she met through a dating app into the facility. R14 stated she started giving the man oral sex but did not finish and R8 had to take over.During an interview on 06/18/2026 at 3:28 PM, R8 stated that R14 met a man through a dating app and invited him into the facility and performed oral sex on him.During an interview on 06/22/2026 at 11:46 AM with R14, the Administrator, and the Director of Nursing (DON), R14 stated she performed oral sex on the man because R8 did it. The Administrator stated they were not aware that R14 was involved in the incident until 06/19/2026. However, the 06/16/2026 email from the Director of Nursing (DON) documented that R14 admitted to inviting men into the facility for sexual activity. The Administrator and the DON confirmed that the facility did not include R14 in the Facility Reported Incident (FRI) dated 06/16/2026.

Based on observations, interviews, facility document review and facility policy review, the facility failed to ensure food was monitored and served at appropriate temperatures to prevent food borne illness. This deficient practice had the potential to affect 80 of 80 residents receiving meals prepared in the kitchen. Findings include:Record review of the October 2025, November 2025, and December 2025 Hot/Cold Temperature Logs revealed that only four temperatures were taken at meal service, on average. Only the temperatures of the main items, at regular texture, were documented. Further review of the log procedure revealed the dietary staff failed to document all food items. Additionally, the dietary staff failed to ensure they had functioning thermometers, and knew how to calibrate thermometers correctly, as noted below.During a meal service observation in the kitchen on 12/02/25 from 12:00 pm to 12:40 pm revealed the following:-On the steam table was rice, barbeque chicken, black eyed peas, mashed potatoes, and beef patties.-The Dietary Manager (DM) was asked to calibrate the thermometer before taking temperatures on the steam table. The DM placed the manual probe thermometer into a cup of ice water. The needle on the thermometer was stuck between the high temperature and the 0, pointing at the F. The DM said she was going to wait until the needle pointed at the 0. At 12:06 PM, the DM said the thermometer was getting there (to reach 0 F), but was still pointing straight down at the F, and was not properly functioning. This observation revealed the DM, responsible for the kitchen process, was not aware of the appropriate process to calibrate thermometers.During an interview on 12/02/25 at 12:08 PM, Dietary Aide (DA) 3 stated that the thermometer should be calibrated to 32 F and confirmed the manual probe thermometer was not working correctly and was reading 0 F. DA3 stated that she had another thermometer and removed a digital thermometer from her pocket. The digital thermometer read LL. She confirmed it was broken. The DM said she would go look for another thermometer. This failure revealed the dietary staff failed to have appropriate equipment to ensure food temperatures were accurately and efficiently monitored for all meals.In an attempt to see if the broken manual probe thermometer that was stuck on F and would function at all, at 12:15 pm, the food on the steam table was tested for temperatures. Adjusting for an estimated 32-degree difference, the food on the steam table read:-rice: 142 F-barbeque chicken: 136 F-black eyed peas: 131 F-mechanical barbeque chicken: 101 F-chopped barbeque chicken: 82 F-mashed potatoes: 122 F-pureed barbeque chicken: 84 F-pureed black eyed peas: 102 F-beef patty: 92 FDA 3 placed the items back into the oven to reach appropriate temperatures while the DM continued to look for a functioning thermometer that could provide accurate temperatures.During an interview on 12/02/25 at 12:22 pm, the DM returned to the kitchen with the radar thermometer used by the maintenance department. The thermometer was calibrated with a cup of ice water, to 36 F.During an interview on 12/02/25 at 12:23 pm with Dietary Aides, DA 3 stated that the steam table did not hold temperatures well. This was agreed upon by DA 2 and DA 4. DA 4 stated that the air conditioning vent blew cool air right across the top of the steam table. After removing the food items from the oven, they were rechecked on the steam table 12/02/25 at 12:26 pm with the maintenance department thermometer. The food items recorded were:-rice: 137 F-barbeque chicken: 145 F-black eyed peas: 110 F-mechanical barbeque chicken: 144 F-chopped barbeque chicken: 144 F-mashed potato: 147 F-pureed black-eyed peas: 139 F-beef patty: 155 FThe DM stated after taking the temperatures that she would ensure that a new thermometer was purchased to ensure food was properly recorded before meal was served.During an additional meal service on 12/03/25 at 7:20 am, breakfast was observed on the steam table. The DM stated that the kitchen staff were still using the Maintenance Department thermometer, since a new dietary thermometer had still not been purchased. The breakfast food temperatures recorded by DA 2:-grits: 124 F-scrambled eggs: 136 F-sausage links: 141 F-pureed sausage: 114 F-pureed eggs: 144 F-mechanical sausage: 142 FThe Dietary Manager had the grits, scrambled eggs, and pureed sausage placed back into the oven.An additional temperature on 12/03/25 at 7:35 am revealed:-grits: 134 F-scrambled eggs: 138 F-pureed sausage: 130 FThese items were again placed in the oven to raise temperatures prior to service.During an interview on 12/03/25 at 7:36 am, DA 3 stated the cooks performed and recorded the temperature checks of the main meal items, but they did not record temperatures for any altered textures on the steam table.A test tray was prepared in the kitchen while breakfast was being plated at the steam table, on 12/03/25 at 7:50 am. The plate was taken to the resident hallway by an unheated, covered meal cart. It was removed at 8:10 am, outside resident room [ROOM NUMBER]. The test tray was taken directly to the nurses' station, and the temperatures were taken with the DM present. The temperatures recorded were:-grits: 117 F-mechanical sausage: 108 F-scrambled eggs: 104 F-pureed sausage: 111 FDuring a concurrent interview on 12/03/25 at 8:12 am, the DM confirmed the breakfast food item temperatures were too low, and the temperatures had not held properly from the kitchen. She confirmed the kitchen used the plate warmer, base and cover. She was not aware of any other elements that could assist in keeping the plates warm during transfer to the resident hallways.During an interview on 12/03/25 at 10:38 am with the Regional Clinical Consultant (RCC) and Director of Nursing (DON), both confirmed that they expected residents to be served food that was hot, and at appropriate temperature.During an interview on 12/03/25 at 10:47 am, the DM confirmed that the facility was having problems with food temperatures during meal service, and that it needed to be addressed. She stated that she would be buying numerous thermometers for future use, to have them readily available.During an interview on 12/03/25 at 11:25 am, the Administrator stated that she expected the food to be served to the residents at the right temperatures whether served in the dining room or in the resident rooms. She confirmed that she would not like to eat food that was too cold either.Review of the facility's policy titled, Food Safety Requirements, dated 06/01/24, revealed Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards.Cooking-foods shall be prepared as directed until recommended temperatures for the specific foods are reached. Staff shall refer to the current FDA Food Code and facility policy for food temperatures as needed.Holding-staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained.Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone.Review of the facility's Hot/Cold Temperature Log used by the Dietary Department documented that:Hot Food should be 135 F [Fahrenheit] or higher, and that Cold Food should be served at 41 F or lower. This log documented the procedure as:1. Check consistency of all mechanically altered menu items following the IDDSI guidelines.2. Calibrate thermometer prior to checking temperatures-thermometer should read 30-34 degrees F for accuracy.3. Check temperature of each food item on the steam table-thermometer should be sanitized in between each food item.4. Document temperatures and time temperatures were taken.5. Take appropriate action and reheat food items if needed.Best practice:1. Check temperature multiple times during meal service. 2.If temperature drops below the 135-degree [F] threshold for hot items, or above the 41-degree threshold from cold items, pull the item from the line and take corrective action.

Based on observations, staff interviews, and policy review, the facility failed to ensure food was dated, labeled, stored properly, not expired, and that the facility's ice machine was maintained in a sanitary manner. These failures had the potential to increase the prevalence and spread of foodborne illness and infection among all 80 residents' receiving meals from the kitchen.Findings include:1. During initial observations of the kitchen on 11/30/25 at 8:30 am, a full-sized can of lemon-lime soda was observed placed inside the facility ice machine, half deep into the ice. During a concurrent interview and observation on 11/30/25 at 8:33 am, Dietary Aide (DA) 2 confirmed the soda can should not be in the facility ice machine. DA 2 went to the ice machine and with bare hands removed the can of soda without washing her hands, touching the ice in the machine during the process.2.Additional initial kitchen observations revealed on 11/30/25 at 8:36 am, in the walk-in refrigerator revealed the following:-Two thawed vanilla Magic Cups in the walk-in refrigerator without thaw dates recorded. The two cartons stated, Store frozen. Serve cold. Consume within 5 days of thawing (under refrigeration).-A bag of sliced turkey, stating Prep 11/24, with no use by date.-A large stack of sliced ham, half wrapped in aluminum. It was not properly covered nor dated.-A large plastic container of chicken noodle soup with Use by 11/28 on the lid.During a concurrent interview and observation on 11/30/25 at 8:43 am, DA 2 stated that the items in the walk-in refrigerator were not properly dated or labeled. 3. During an additional kitchen observation on 12/03/25 at 8:25 am, sugar was observed in the dry storage pantry stored in a large plastic container. The scoop rested directly on the sugar, including the handle.During a concurrent interview and observation on 12/03/25 at 8:25 am, the Dietary Manager (DM) confirmed that the scoops should be placed inside the container in the holder, and not resting directly on the sugar. The DM stated she had reminded staff about this on multiple occasions.During an additional interview on 12/03/25 at 10:47 am, the DM confirmed that the vanilla Magic Cups should have been dated when they were thawed. She stated that she had not been made aware of the soda can in the facility ice machine, nor that it was removed with bare hands. The DM said the dietary staff knew better than to leave anything inside the ice machine. During an interview on 12/03/25 at 11:25 am, the Administrator stated that there should never be any items stored inside the facility ice machine.Review of the facility's policy titled, Dietary Sanitation, dated 06/01/25, revealed Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulation.Review of the facility's policy titled, Food Safety Requirements, dated 06/01/24, revealed Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.Preparation of food, including thawing.Employee hygienic practices.Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date.Keeping foods covered or in tight containers.Staff shall not touch food with bare hands.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure residents were free of verbal and physical abuse for two of two residents (R) (R13 and R 45) reviewed for resident-to-resident altercations from a sample of 34. These failures had the potential to place residents at risk of physical injury and psychosocial harm. Findings include:Review of R13's undated admission Record, located in the EMR under the Profile tab showed an admission date of 06/25/25 with diagnoses which included congestive heart failure (CHF), confusional arousals, and chronic kidney disease.Review of R13's quarterly MDS with an ARD of 09/25/25 and located in the EMR under the MDS tab, showed a BIMS score of 14 out of 15 which indicated R13 was cognitively intact.Review of R13's Nurses Note, dated 11/03/25 and located in the EMR under the Progress Notes tab, documented Writer made aware of altercation between resident and roommate during morning rounds by staff. Staff made aware to keep residents separated, room change initiated. DON [director of nursing] notified, police called to make a report.Review of R13's Care Plan, located in the EMR under the Care Plan tab, documented a focus area of psychosocial well-being related to roommate scratching him and resident slapping roommate on 11/03/25 with interventions to allow the resident time to answer questions and to verbalize feelings, perceptions, and fears, and when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings.Review of the paper Facility Reported Incident Report, dated 11/03/25, and provided by the DON, revealed the resident-to-resident abuse was substantiated due to R12 scratching R13 on his left leg in their shared room and then R13 slapped R12 on the right side of his face in response at 8:30 AM. Certified Nursing Assistant (CNA) 1 heard the slap in the hallway, entered the room, saw two scratches on R13's left leg and R12's face was red, removed R12 from the room, and reported the incident to the DON.During an interview on 11/30/25 at 12:45 pm, R13 stated his former roommate, R12, scratched him on his leg because he was mad at him for talking to the nurse while they were sitting in their wheelchairs in the doorway of their shared room, so he slapped R12 on the face on 11/03/25. R13 stated R12 made grunting noises and would try to scratch staff when he did not want to be bothered or was angry about something. R13 stated R12 was removed from the room by the nurse aide and moved to another room the same day. R13 stated the Social Worker checked on him after the incident and he felt safe in the facility.During an interview on 12/03/25 at 8:39 AM, the DON confirmed CNA1 reported the physical altercation between R13 and R12 on 11/03/25 after she separated the residents. The DON reported the abuse to the state survey agency (SSA) on 11/03/25 at 9:26 am and submitted the follow-up report to the SSA on 11/10/25. The DON stated skin assessments were performed after the residents were separated and the right side of R12's face was red and swollen and R13 had two scratches on his left knee. The DON indicated social services saw them to ensure they had not suffered any ill effects from the incident, the police came and took their statements, and the residents were seen by the behavioral health provider. The DON also indicated no incidents had occurred prior to or after the incident on 11/03/25.During an interview on 12/03/25 at 9:07 am, CNA1 confirmed she heard R13 slap R12 from the hallway as she was picking up meal trays around 8:30 AM on 11/03/25. CNA1 stated she entered the room, R13 stated R12 scratched him on his leg so he slapped him on the face. CNA1 stated she moved R12 out of the room in his wheelchair and reported the incident to the nurse and DON at 8:36 Aam. CNA1 indicated all nurse staff were trained on de-escalation techniques that week. CNA1 also stated there were no witnesses to the incident.3. Review of R45's undated admission Record, located in the EMR under the Profile tab documented an admission date of 08/12/25 with diagnoses which included encephalopathy, heart failure, and chronic kidney disease, stage 3.Review of R45's admission MDS with an ARD of 08/21/25 and located in the EMR under the MDS tab, showed a BIMS score of five out of 15 which indicated R45 was cognitively impaired.Review of R45's Incident Note, dated 10/08/25 and located in the EMR under the Prog Notes tab, showed Called to the room by CNAs after staff noted the door was closed and heard the resident's roommate yelling at him, stating, I'm going to beat your ass. The resident was immediately assisted outside via wheelchair to the front porch with staff supervision. Upon assessment, the resident stated he was okay and was not afraid. He reported that he no longer wished to share a room with his current roommate because the roommate does not sleep, walks around the room throughout the night, and talks to himself, which prevents him from resting. The resident also stated that the strong scent of cologne his roommate frequently sprays makes the room stink. The resident explained that he told his roommate, Open the damn door, it stinks in here, after which the roommate began yelling . Police were called and interviewed both parties. Ombudsman notified and NP [nurse practitioner] in house evaluated both residents. The resident agreed to relocate to a different room on the opposite hall. Staff assisted in moving his belongings. After the transfer, the resident voiced satisfaction with his new room and roommate, stating he was happy with the change.Review of the paper Facility Reported Incident Report, dated 10/08/25 and provided by the DON, showed the resident-to-resident abuse was substantiated due to R17 threatening to physically hurt R45 in their shared room on 10/08/25 at 2:20 PM. Restorative Aide (RA) 2 heard R17 yelling you need to get out of here with your bullshit before I beat your ass at R45 in the hallway outside of their shared room. RA2 entered the room, removed R45 from the room, took R45 outside, and then a room change was made for R45. The NP initiated inpatient psychiatric stabilization at the hospital for R17, and behavioral health services were rendered after R17's return to the facility. The police were called on the same day as the incident. R45 admitted he yelled at R45 for closing the door and then R17 threatened to beat him up as he stood over him while lying in his bed.During an interview on 11/30/25 at 9:10 am, R17 stated he had a verbal altercation with R45 in October when they were roommates, and he was sent to the hospital for treatment. R17 also stated his medications were adjusted and R45 was moved to another room, and he had not talked to him since the incident. During an interview on 12/03/25 at 8:50 am, the DON confirmed RA2 notified her that she heard R17 threaten to hurt R45 in their shared room on 10/08/25 at 2:20 PM. The DON stated RA2 took R45 outside on the front porch. R45 was afraid to go back inside due to R17's threat, a room change was made for R45, and then R17 was sent to the hospital for evaluation and treatment. The DON also stated the social worker checked on R45 and he had not suffered any ill effects. The DON indicated she sent the initial report to the SSA on 10/08/25 at 3:10 PM and the follow-up report on 10/13/25 in which verbal abuse was substantiated.During an interview on 12/03/25 at 9:50 am, RA2 stated she heard R17 yelling at R45 in their shared room on 10/8/25 at 2:20 PM as she was walking down the hallway. RA2 stated when she entered the room, R17 was leaning over and yelling at R45, and R45 looked scared and stated he was not staying in the room with R17. RA2 escorted R45 out of the room and R45 said R17 threatened to beat him up and kill him and he was going to return to the room with him. RA2 indicated she reported the verbal abuse to the DON after she ensured R45 was safe.During an interview on 12/03/25 at 10:21 am, R45 stated R17 was his roommate in the past and R17 got mad at him and threatened to beat and kill him because he told him to leave the door open. R17 stated a nurse aide intervened and moved him to another room, and he felt safe in the building now. Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 07/15/25, provided by the facility revealed It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident alterations . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment . Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.

Based on record review and staff interviews, the facility failed to ensure an appropriate discharge plan for one of four residents (R) (R86) reviewed for transfer and discharge. The facility issued an Against Medical Advice (AMA) discharge but failed to arrange for necessary care and services to include post discharge follow-up. The failure had the potential to affect the well-being and safety of R86.Findings include:Review of the Hospital Discharge Summary located under Documents in the electronic medical record (EMR) revealed R86 was originally admitted to the facility on [DATE] following a hospitalization related to a cardiac arrest. The EMR also revealed the residents' diagnoses included congestive heart failure, chronic obstructive pulmonary disease (COPD), acute respiratory failure, and alcohol and cocaine use. Review of a Progress Note dated 09/16/25 at 5:08PM, found under the Prog Note tab of the EMR revealed, Spoke with resident's significant other.about taking the resident out past midnight. The resident had already signed out and was in the car. I explained that she would need to be back in the facility by midnight per insurance regulations and that if she was not, it would be a DC against medical advice, without meds.Further review of the Progress Note found under the Prog Note tab of the EMT, dated 09/17/25 at 8:33AM, revealed a call from the facility's Social Services Director (SSD) to the residents' significant other, Resident Representative (RR) 1, in which he confirmed R86, who had stayed outside of the facility overnight, stated that she needed to get back, but that since the resident was outside of the facility after midnight she would have to be discharged . Per the note, SSD explained that due to her insurance, we actually have to discharge her. SSD also explained that R86 was told yesterday before she left that she had to be back before midnight last night due to her insurance by the DON [Director of Nursing]. The note continued, stating we cannot give her medications, cannot arrange home health and have to contact APS [Adult Protective Services]. [R86] understood and asked if she was allowed to come and get her belongings. SSD stated that she is able to come and get her belongings.During an interview with the DON and the Regional Clinical Consultant (RCC) on 12/02/25 at 1:33PM, the DON stated that she recalled the resident was discharged from the facility AMA as per her understanding of the resident's managed care insurer required the resident to be discharged , if outside of the facility after midnight. The RCC also concurred with this understanding. When asked if they understood the resident must be given the chance to return, they expressed that they were not aware of that requirement. During an interview with the SSD on 12/02/25 at 4:13PM, and she confirmed that she did contact the resident the day of discharge and per her understanding of the regulation, the facility would not be covered for charges for R86 if she did not arrive prior to midnight. She also stated that she believed the resident was to be discharged from the facility AMA. When asked if the resident was given an opportunity to return, she stated that she was not. She also confirmed that the resident never returned to pick up her belongings. During a follow up interview with the DON and the RCC on 12/03/25 at 11:09AM, and the DON stated that she believed the facility followed their policy. She was asked where they documented the discussion related to the advising the resident of the risks and their right to return to the facility and she advised that the provider, who she could not name, called R86 later the day of the discharge to invite the resident back but the resident declined. On 12/03/25 at 12:22PM the DON provided a Progress Note, dated 09/17/25 at 1:21PM, written by Nurse Practitioner (NP) 2. The note read, [R86] left last night with her boyfriend and did not return. I spoke with her, and she does not plan on coming back. I told her she would be discharged AMA.A review of the facility's Transfer and Discharge (including AMA) policy, with an effective date of 01/01/23, states that the purpose of the policy is to permit each resident to remain in the facility and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. The policy specifically states that for a discharge against medical advice (AMA), The resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives to both. Under no circumstances will the facility force, pressure, or intimidate a resident into leaving AMA.

Based on resident interviews, record review, review of facility policy, the facility failed to ensure two of 32 sampled residents (R) (R16 and R40) were invited to their care plan meeting to review their care plans. This failure created the potential that residents will not obtain their highest practicable level of functioning. Findings include:1.Review of R16's admission Record, found in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included infection and inflammation reaction due to other internal joint prosthesis and idiopathic necrosis of the right femur. The record revealed the resident was her own medical decision-maker. Review of R16's admission Minimum Data Set (MDS) Assessment, with an assessment reference date (ARD) of 10/30/25 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15, which indicated the resident was cognitively intact. Review of a R16's Comprehensive Care Plan, dated 10/31/25 and found in the EMR under the Care Plan tab, revealed a comprehensive care plan with associated problems, goals and interventions, such as infection control and antibiotic administration, Activities of Daily Living (ADL) status, Nutritional Status, etc. had been issued on that date. Review of R16's comprehensive record revealed nothing to indicate an interdisciplinary team care planning meeting had been held for R16 since her admission to the facility on [DATE] or that R16 was invited to a care planning meeting since admission. During an interview with R16 on 11/30/25 at 3:12 pm, she indicated she was aware of what a care planning meeting was, but stated she had not been invited to, or attended, one since her admission to the facility on [DATE]. 2. Review of R40's admission Record, found in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included heart failure and recent fracture of her left fibula. The record revealed the resident was her own medical decision-maker. Review of R40's admission MDS Assessment, with an ARD of 11/03/25 and found in the EMR under the MDS tab, revealed a BIMS assessment score of 15 out of 15, which indicated the resident was cognitively intact. Review of a R40's Comprehensive Care Plan, dated 11/03/25 and found in the EMR under the Care Plan tab, revealed a comprehensive care plan with associated problems, goals and interventions, such as Activities of Daily Living (ADL) status, Physical Therapy Services, Nutritional Status, etc. had been issued on that date. Review of R40's comprehensive record revealed nothing to indicate an interdisciplinary team care planning meeting had been held for R40 since her admission to the facility on [DATE] or that R40 was invited to a care planning meeting since admission. During an interview with R40 on 11/30/25 at 9:19 AM, she indicated she was aware of what a care planning meeting was but stated she had not been invited to or attended one since her admission to the facility on [DATE]. During an interview with the Social Services Director (SSD) on 12/01/25 at 2:20 pm, she indicated she was responsible for scheduling care planning meetings for residents as well as for inviting residents to each meeting. The SSD confirmed she could not locate anything in R16 or R40's record to show either resident had ever been invited to an initial care planning meeting or that such a meeting had ever been held for either resident since their admission to the facility. The SSD indicated each resident was expected to have an initial care planning meeting within 72 hours of their initial admission to the facility. During an interview with the Director of Nursing (DON) on 12/03/25 at 10:52 am, she confirmed her expectation was an initial care planning meeting should be held for each resident admitted to the facility within 72 hours of their admission and each resident was expected to be invited to the meeting.Review of the facility's Care Planning-Resident Participation Policy last reviewed 03/01/25 documented, This facility supports the resident's right to be informed of, and participate in their care planning and treatment (implementation of care); and The facility will honor the resident's right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care; and The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure residents were free of accidents and hazards for two of three sampled residents (R) (R45 and R11) reviewed for smoking at the facility, out of 32 sampled residents. These failures had the potential to cause serious adverse outcomes, including significant injury to all 80 residents residing in the facility.Findings include:1. Review of R45's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R45 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, heart failure, and atherosclerotic heart disease.Review of R45's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/25, located under the MDS tab, showed a Brief Interview for Mental Status (BIMS) score of nine out of 15 indicating R45 had moderate cognitive impairment. The resident was revealed to not reject care, had no behavior, and no delirium. R45 was documented to be independent with mobility.Record review revealed that the Hospital Discharge summary, dated [DATE], located under the Miscellaneous tab of the EMR, revealed the resident was nicotine dependent, prior to admission.Record review of R45's admission Data Collection, dated 08/12/25, and located under the Assessments tab of the EMR, revealed the resident regularly used tobacco, about three cigarettes a day.Review of R45's Care Plan initiated on 08/25/25 and located in the EMR under the Care Plan tab revealed the residents had displayed behaviors which included smoking inside and outside the facility. The care plan documented that the resident had been observed smoking in his bathroom on 08/20/25. The care plan was revised on 11/17/25 to include that R45 was observed smoking on facility grounds. Interventions included to educate R45 on not smoking in the facility, to attempt interventions before behaviors begin, offer the resident something they like as a diversion, and to inform the physician of any resident behaviors that interfere with daily living. An intervention, dated 08/20/25, stated that R45 was educated on not smoking in the facility, the resident verbalized understanding, and that a lighter was found and removed from his room. Additionally, on 11/17/25, R45 was again educated on not smoking on the facility property.Record review revealed a Progress Note, dated 08/13/25, and located under the Progress Note tab of the EMR, .nicotine dependence.Provide information on tobacco cessation. Record review revealed a Progress Note, dated 08/22/25, . R45 adamantly denied smoking in his room last night. SSD [Social Service Director] explained that smoking in the building is prohibited and dangerous. SSD explained the dangers inside the facility. SSD also explained that if [resident name] wants to smoke, he needs to sign out and leave the property. Additional progress notes identified non-compliance with smoking inside and outside the facility.Record review of R45's 30-day notice of discharge, dated 11/19/25, and located under the Miscellaneous tab of the EMR, revealed, As you are aware from out (sic) previous meetings on unacceptable conducts of behaviors, we have discussed R45] continuing to violate the facilities smoking policy. This discharge notice was provided to the resident after multiple warnings. Record review on 11/23/25 revealed a Progress Note in the EMR that R45 was alert and oriented x 3 (person, place, and time).Record review revealed that although there were numerous documents prior to and during the admission process to identify R45 as a regular cigarette smoker, he was nevertheless admitted to a non-smoking facility. There was no documentation in the EMR for R45 that revealed the residents were provided with any education on tobacco cessation programs.Record review revealed there was no assessment documented in the EMR to identify that the resident was evaluated for smoking safety, after observing the resident consistently smoking.During an observation on 11/30/25 at 8:20 AM, R45 was observed standing independently outside the facility, with a door ajar, smoking a cigarette.During an interview on 11/30/25 at 4:07 PM, R45 stated that residents were not allowed to smoke in the facility, so he signed out at the front reception desk, and then went to the side of the facility building to smoke. He said that the facility had residents who used oxygen, so he knew how to follow the rules, and smoked outside.During an interview on 12/02/25 at 8:50 am, the Facility Receptionist (FR) stated that when residents left the facility they were supposed to sign out and then sign back in. FR said that if a resident was going to leave the facility to smoke, they were supposed to go outside off the property, to the dirt road south of the building. She said that when they noticed the R45 was going outside to smoke, they told him he had to sign in and out, and smoke off property at the dirt road. She confirmed he did not always sign in and out and may sometimes wait until she was busy to exit. FR said that the sign out logs were kept at the nurse stations and brought to her the following morning for review.During an interview on 12/02/25 at 9:40 am, Registered Nurse/Unit Manager (RN/UM) stated that there had been some issues with residents that smoked and were not following the rules. She stated that residents were supposed to sign out and go off property to smoke because the facility was non-smoking. There was to be no smoking in the building. She added that off the facility property was like across the street. RN/UM said they had a handful of residents who would go across the street. She said they offered residents nicotine patches. She said R45 was non-compliant with smoking but would go outside to the right location. She said he had been educated, as well. She confirmed that R45 had received a 30-day discharge notice for non-compliant smoking. She said she had not seen him smoke in his room. She added that the facility gave a warning, and then upper management would give a warning. The facility would document the issue and then follow the process to give the 30-day notice. During an additional interview on 12/02/25 at 10:43 am, R45 stated that he was required to sign out to smoke, and that the facility smokers were required to go to the south side of the building, onto the dirt road to smoke. He stated that this was the guidance he was given when he wanted to smoke.During an interview on 12/02/25 at 11:07 am, the facility Ombudsman stated that she was aware that the facility had some residents that were non-compliant with smoking, and most of them had received a 30-day notice to discharge. She said that the last Administrator had been lax, and residents had become used to it. The Ombudsman said that the new Administrator had been trying cessation programs but was not successful with some areas of concerns that included drugs, alcohol, and smoking. She was not aware of any negative outcomes.During an interview on 12/02/25 at 1:23 pm, the Director of Nursing (DON) stated that the facility had a consulting team that assisted with resident referrals. She stated that R45 had received a 30-day notice of discharge due to violations that included smoking in his room, bathroom, the facility premise, and had possession of cigarettes and lighters. She said that the facility did not allow smoking in the facility. She said that if a resident that smoked was admitted to the facility, they could offer cessation products and could offer nicotine patches. She said the resident could use the behavioral group they consult with, if the resident wanted to stop smoking. If the residents violated the policy they would have care plan meetings, and if they continued to violate it, they would then give the discharge notice to the resident, Ombudsman, and the physician. The DON said residents could sign out and leave the building to smoke, but they could not have banned paraphernalia inside the facility. She was not aware of who would do a smoking assessment for residents that were non-compliant with smoking, and that she was not aware of a facility policy regarding smoking in the facility. During an interview on 12/02/25 at 4:28 pm, the SSD stated that if a resident had a concern with substance abuse, they would offer them the mental health practitioner. She said that if a resident was a non-compliant smoker, there would be a verbal warning to tell them the facility was non-smoking and that they could not have banned items, we would set up two separate care plan meetings, then give them the 30-day notice. The SSD said that the former Administrator was more lax with the smoking process. She said the facility had been trying to get the process under control since September 2025 and were trying to go by the non-smoking policy.2. Review of R11's admission Record, found in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included paraplegia and history of spinal cord injury. Review of R11's Quarterly MDS Assessment, with an ARD of 09/22/25 and found in the EMR under the MDS tab, revealed a BIMS assessment score of 15 out of 15, which indicated the resident was cognitively intact. Review of R11's Smoking Care Plan, dated 08/25/25 and found in the EMR under the Care Plan tab, revealed the resident was a daily smoker and indicated the resident was to be reminded the facility was a smoke free facility and reminded he needed to leave the facility property to smoke. The care plan indicated R11 had displayed behaviors (throughout his admission to the facility) which included smoking marijuana in his room and smoking cigarettes in front of facility despite numerous reminders of (the facility) being a nonsmoking facility. The plan indicated staff was to inform the charge nurse immediately if the resident was suspected to be breaking the facility's smoking policy and the resident's clothing and skin was to be observed for signs of cigarette burns. Review of R11's comprehensive record revealed nothing to indicate a smoking assessment had ever been completed for the resident to determine the resident's ability to smoke safely and follow the facility's smoking rules. Review of R11's Progress Notes, dated 08/23/25 and found in the EMR under the Notes tab, revealed, During medication pass, I (the nurse who entered the note) entered the resident room to give him his medication and cigarette smoke came from his mouth. He stated that he was sorry and didn't deny he was smoking. I explained to him he can't smoke in the room and that he has to respect his roommate. He stated he wouldn't do it again.Review of R11's Progress Notes, dated 09/30/25 and found in the EMR under the Notes tab, revealed, R11 smoking in room. Educated resident about not smoking in room and that he has to respected (sic) his roommate. Resident said he didn't feel like going out the door and that's why he smoked in his room.Review of the facility's Accident and Incident Logs, dated 06/01/25 through 12/01/25 and provided directly to the survey team, revealed nothing to indicate an incident had been initiated or investigated related to R11's 08/23/25 or 09/30/25 smoking incidents. Further review of the EMR revealed nothing could be located indicating there had been any follow-up by the facility related to R11's 08/23/25 or 09/30/25 smoking infractions.R11 was observed leaving the facility property to smoke after lunchtime and until suppertime on 11/30/25, 12/01/25 and 12/02/25. The resident was not observed smoking in the facility or on facility property during the survey.During an interview with R11 on 12/01/25 at 10:47 am, he confirmed he was a daily smoker and stated he usually left the facility property to smoke. During an interview with the DON on 12/02/25 at 1:25 pm, she confirmed awareness of R11 having a history of smoking in his room. She confirmed the facility did not initiate or investigate smoking events as incidents and stated the facility was expected to hold a care planning meeting after each incident of violating the facility's smoking rules. The DON confirmed residents were not allowed to smoke on the facility property and were not allowed to have smoking materials in the facility. The DON also confirmed smoking assessments were not completed for residents to ensure safe smoking practices and smoking rules were being followed in the facility because the facility was a non-smoking facility. During a follow-up interview with the DON on 12/03/25 at 10:54 am, she confirmed the facility's process related to smoking infractions was expected to be followed for any resident living in the facility who smoked. The DON could not clearly verbalize, however, what the facility's procedure was related to residents who were found repeatedly violating the facility's smoking rules.

Based on record review, and interviews, the facility failed to ensure a physician's order was obtained for the use of an indwelling urinary catheter device for one of three residents (R) (R69) reviewed for urinary catheter devices. This failure created the potential for R69 to go without appropriate care and services.Findings include:Review of R69's admission Record, found in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included type 2 diabetes and urinary retention. Review of R69's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 11/13/25 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 12 out of 15, which indicated the resident was moderately cognitively impaired. The assessment indicated the resident had an indwelling urinary catheter placed in his bladder. Review of R69's Physician Order Set, dated 12/02/25 and found in the EMR under the Orders tab, revealed there was no physician's order related to the use or care of the resident's urinary catheter.Review of a R69's Catheter Care Plan, dated 11/13/25 and found in the EMR under the Care Plan tab, revealed the resident had an indwelling urinary catheter in place and indicated the resident's intake and output was to be monitored and the resident was to be monitored for potential signs and symptoms of Urinary Tract Infection (UTI) and pain and/or discomfort related to the use of the catheter.During an interview with the Director of Nursing (DON) on 12/03/25 at 11:00 am, she confirmed her expectation was all physician orders related to the use and care of a resident's urinary catheter were to be in place and up to date in the resident's record.The facility's policies and procedures related to the implementation and ongoing use of indwelling urinary catheters were requested by the survey team on 12/02/25 at 2:00 pm and again on 12/02/25 at 5:00 pm, however the policies were not received prior to survey exit on 12/03/25 at 2:30 pm.

Based on observations, interviews, record review, and facility policy review, the facility failed to properly assess and initiate side rails before alternatives were attempted for three of three residents (R) (R10, R25 and R66) reviewed for accidents/hazards out of 34 sampled residents. This failure had the potential to increase their risk of accidents.Findings include:1.Review of R10's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses that included end stage renal failure, major depressive disorder, and generalized anxiety disorder.Review of R10's significant change in status Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/04/25 and located in the EMR under the MDS tab, showed a Brief Interview for Mental Status (BIMS) score of 99. The facility assessed R10 as modified independence in cognitive skills for decision making with no upper and lower extremity impairments. R10 was not coded for side rail use on the MDS.Review of R10's Physician's Orders, dated 03/24/25, and located in the EMR under the Orders tab, revealed an order for mobility bars for repositioning and increased mobility per family request.Review of R10's initial Side Rail/Entrapment Risk Evaluation, dated 03/24/25, and located in the EMR under the Assessments tab, revealed R10 was currently using the side rails for support or positioning, wants the bed rails raised, 1/4 side rail bilaterally initiated, and no alternatives were attempted prior to initiating the side rails. The quarterly Side Rail/Entrapment Risk Evaluation assessment conducted on 08/17/25 showed R10 requested the use of the side rails.Review of R10's Care Plan, revised on 12/02/25, and located in the EMR under the Care Plan tab, revealed a focus area of risk for falls and that R10 requested to have her bed rails in the down position at times.Review of R10's Nurses Note, dated 12/01/25, and located in the EMR under the Prog Notes tab, revealed During rounds, writer adjusted bed rails to an upward assisting position, resident refused to keep bed rails up, stating that she wanted these to be down. Writer lowered the bed rails down to the requested position.Observation on 11/30/25 at 8:39 AM, 12/01/25 at 4:30 PM, and 12/02/25 at 2:45 PM, revealed R10 laying in the bed with bilateral 1/2 side rails raised from her abdomen to her upper thighs.During an interview on 12/01/25 at 4:20 PM, Unit Manager (UM) 1 confirmed side rail assessments were completed on 03/24/25 and 08/17/25 with no alternative attempts prior to initiating them. UM1 stated R10 would not let the staff raise them towards the head of her bed, she preferred them down near her waist and legs.During an interview on 12/03/25 at 9:24 AM, the Director of Nursing (DON) stated the bed rails were applied when R10 was admitted to the facility and a consent was signed by R10's family. The DON also stated the position of the side rails was not optimal, but she preferred them in the down position instead of by her head. 2. Review of R25's undated admission Record, located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, Alzheimer's Disease, gastrostomy status, and other seizures.Review of R25's quarterly MDS assessment with an ARD of 09/26/25 and located in the EMR under the MDS tab, showed a BIMS score of 99. The facility assessed R25 as moderately impaired in decision making with upper and lower extremity impairments. R25 was not coded for bedrail use on the MDS.Review of R25's Physician's Orders, dated 08/01/25, and located in the EMR under the Orders tab, revealed an order for Resident may have mobility bars for repositioning and increased mobility per family request.Review of R25's initial Side Rail/Entrapment Risk Evaluation, dated 08/01/25, and located in the EMR under the Assessments tab, revealed R25 was currently using the side rails for support or positioning, wants the bed rails raised, 3/4 side rail bilaterally initiated, and no alternatives were attempted prior to initiating the side rails. It was documented on the quarterly Side Rail/Entrapment Risk Evaluation assessment conducted on 11/01/25 that a low bed and call light were tried before use of the side rails began.Review of R25's Care Plan, revised on 12/02/25, and located in the EMR under the Care Plan tab, revealed a focus area of at risk for falls and that R25 requested to have her bed rails in the down position at times.Observations on 11/30/25 at 9:23 AM and 3:25 PM, and 12/01/25 at 11:49 AM revealed R25 lying in bed with the bed rails raised bilaterally which extended from her abdomen to her thighs with blue bed bolsters located inside of the bed rails. R25's arms were contracted, and a brace was on the right arm. R25 could not use the bedrails, and the rails were in the wrong position. The rails should be positioned near the head of the bed and not in the middle.During an interview on 12/01/25 at 12:03 PM, Licensed Practical Nurse (LPN) 6 stated she was not certain why the half bed rails were on the bed because the resident could not reach them.During an interview on 12/01/25 at 2:39 PM, Certified Nursing Assistant (CNA) 1 stated R25's family member wanted the bed rails raised for her safety.During an interview on 12/01/25 at 2:52 PM, Restorative Aide (RA) 1 stated R25 could not reach the bed rails because her arms were contracted, and the bed rails were raised because she scooted down in the bed, and they prevented her from falling out of the bed.During an interview on 12/01/25 at 4:18 PM, UM1 confirmed side rail assessments were completed on 08/01/25 with no alternative attempts before raising them until the 11/01/2 assessment. UM1 confirmed the side rails were placed upon admission per family request and alternate interventions were not attempted.During an interview on 12/03/25 at 9:24 AM, the DON stated the bed rails were applied when R25 was admitted to the facility and a consent was signed by the family for her to have them. The DON also stated the position of the side rails was not optimal, but she preferred them in the down position instead of by her head. The DON indicated the Maintenance Director conducted bed rail inspections on the safety of the bed rails and beds on a routine basis.3.Review of R66's admission Record, dated 12/03/25, located in the Electronic Medical Record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke.Review of R66's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 11/13/25 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 12 out of 15, which indicated the resident was moderately cognitively impaired. The assessment indicated bed rails were not in use for the resident.Review of R66's Physician Order Set, dated 12/02/25 and found in the EMR under the Orders tab, revealed an order, with an original order date of 09/20/25, indicating the resident May have mobility bars for repositioning and increased mobility per family request.Review of a R66's Comprehensive Care Plan, dated 11/13/25 and found in the EMR under the Care Plan tab, revealed nothing to indicate the resident's use of bed rails.Review of R66's 09/20/25: Side Rail Assessment in his Admission/readmission Nursing Evaluation, dated 09/20/25 and found in the EMR under the Evaluations Tab, revealed the resident was using quarter rails for mobility bilaterally per the patient and family's request.Review of R66's comprehensive record did not reveal evidence to indicate alternatives to the use of bed rails were assessed for the resident or the reason the alternatives had failed.R66 was observed lying in his bed with 1/3 rails in the raised position in the middle of each side of his bed on 11/30/25 at 10:30 AM, on 12/01/25 at 5:30 PM, on 12/02/25 at 8:44 AM, 9:02 AM, 11:09 AM, and 5:02 PM.During an observation and interview on 12/02/25 at 8:46 AM, R66's bed rails were observed along with Licensed Practical Nurse (LPN1). LPN1 confirmed 1/3 rails were raised bilaterally in the middle of the resident's bed and stated the rails were generally in that position on the resident's bed.During an observation and interview on 12/02/25 at 9:03 AM, R66's bed rails were observed along with Unit Manager (UM1). UM1 confirmed the rails were in the raised position in the middle of both sides of the resident's bed and stated the rails were raised because that was the way the resident wanted them to be. She stated R66 was able to use the rails as grab bars to move about in his bed.During an interview with the Director of Nursing (DON) on 12/03/25 at 11:00 AM, she confirmed that each resident was expected to have a thorough assessment for the use of bed rails prior to rails being applied to a bed and confirmed her expectation was for the facility policy to be followed regarding the implementation of bed rails.Review of the facility's policy titled, Proper Use of Bed Rails, revised 03/01/25, provided by the facility, revealed Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails . Policy Explanation and Compliance Guidelines: Resident Assessment . 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs . Appropriate Alternatives 9. The facility will attempt to use appropriate alternatives prior to installing or using bed rails Alternatives include but are not limited to: a. Roll guards b. Foam bumpers c. Lowering the bed . 10. Alternatives that are attempted should be appropriate for the resident, safe and address the medical conditions, symptoms or behavioral patterns for which a bed rail was considered . Ongoing monitoring and Supervision . 16. Responsibilities of going monitoring and supervision . d. the Maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails.

Based on observation, interview, and facility policy review, the facility failed to ensure overflow medications were secured for one of two medication supply rooms on the south hall. This failure placed 30 residents' medications at risk of diversion. Findings include:An observation on 11/30/25 from 9:30 to 9:40 am, revealed the medication supply room door was held open with a cardboard box placed between the door and door frame behind the nurses' station on the south hall. During this time, three facility staff members walked past the nurses' station while it was unattended, and the door was open.An observation and interview on 11/30/25 at 9:52 am, with Unit Manager (UM) 2 revealed the medication supply room contained 30 residents' overflow medications (medications that would not fit in the medication cart) stacked on the shelves and two packages of expired medications that needed to be returned to the pharmacy were lying on the floor. UM 2 stated there were no scheduled medications in the room and that two nurses had a key to the room which was in their medication carts. UM 2 stated the door should be closed and always locked so that residents and staff would not have access to the residents' medications and supplies.During an interview on 11/30/25 at 10:15 am, the Director of Nursing (DON) stated the medication supply room door should be closed and always locked to prevent staff and residents from removing the residents' medications per the policy.During an interview on 11/30/25 at 12:35 pm, the Maintenance Director stated he was installing a keypad on the medication supply room door because a nurse reported she did not have a key to the medication supply room door. During an interview on 11/30/25 at 5:05 pm, UM 2 stated Licensed Practical Nurse (LPN) 5 left the supply room door propped open because she needed to return to the room to retrieve supplies and did not realize she had a key to the room in the medication cart. An interview was attempted on 11/30/25 at 5:15 pm, 12/02/25 at 9:55 am, and 10:05 am with LPN 5, but the phone call was not returned.Review of the facility's policy titled, Medication Storage, revised 03/01/25, and provided by the facility, revealed Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medications carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments .

Based on review of facility policy, record review, observation and interviews, the facility failed to ensure their infection control program was followed for two of six residents (R) (R69 and R16) reviewed for infection control. Specifically, personal protective equipment (PPE) was not worn for contact isolation. In addition, a foley catheter bag with tubing was touching the floor. These failures created the potential for cross contamination and spread of infection among residents and staff. Findings include:1. Review of R69's admission Record, dated 12/03/25 and found in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included type 2 diabetes and urinary retention. Review of R69's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 11/13/25 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 12 out of 15, which indicated the resident was moderately cognitively impaired. The assessment indicated the resident had an indwelling urinary catheter in place in his bladder.Review of R69's Physician Order Set, dated 12/02/25 and found in the EMR under the Orders tab, revealed no orders related to the use or care of the resident's urinary catheter. Review of a R69's Catheter Care Plan, dated 11/13/25 and found in the EMR under the Care Plan tab, revealed the resident had an indwelling urinary catheter in place and indicated the resident's intake and output was to be monitored and the resident was to be monitored for potential signs and symptoms of Urinary Tract Infection (UTI) and pain and/or discomfort related to the use of the catheter. R69 was observed on 12/01/25 at 11:07 am, 5:01 pm, and 5:30 pm, and on 12/02/25 at 8:42 am, 10:32 am, 11:07 am and 12:05 am. R69's urinary catheter bag and/or tubing was observed to be either lying or dragging in direct contact with the floor during these observations.An observation and interview on 12/02/25 at 12:10 pm revealed R69 was sitting in his wheelchair in the dining room. UM 1 confirmed the resident's catheter drainage bag was in direct contact with the floor at the time of the observation. UM 1 confirmed the resident's catheter bag and tubing should not be in contact with the floor in order to prevent potential infection. During an interview with the Director of Nursing (DON) on 12/03/25 at 11:00 am, she confirmed her expectation was urinary catheter drainage bags and tubing were to be kept off the floor at all times to prevent potential infection. 2. Review of R16's admission Record, and found in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included infection and Inflammation Reaction Due to Other Internal Joint Prosthesis and idiopathic Necrosis of the Right Femur.Review of R16's admission MDS Assessment, with an ARD of 10/30/25 and found in the EMR under the MDS tab, revealed a BIMS assessment score of 15 out of 15, which indicated the resident was cognitively intact. Review of R16's Physician Order Set, dated 12/02/25 and found in the EMR under the Orders tab, revealed an order, with an original order date of 11/02/25, for R16 to be maintained on Contact Isolation Precautions due to an active infection of her total hip prosthesis. The order indicated R16 was receiving Meropenem Intravenous (IV) Solution (an antibiotic medication) 500 milligrams (MG) per day and Micafungin Sodium IV Solution 50 MG (an antimicrobial medication) per day via her IV to treat the infection to her hip prosthesis. Review of R16's Infection Care Plan, dated 10/30/25 and found in the EMR under the Care Plan tab, revealed the resident was receiving intravenous antibiotics related to a current infection of her right total hip prosthesis. The care plan indicated the resident was to be maintained in contact isolation related to the active infection. On 11/30/25 from 10:38 am until 10:50 am Housekeeper (HK) 1was observed cleaning R16's room. A sign was posted prominently on R16's door indicating the resident was on Contact Isolation Precautions and indicating gloves and a gown were to be worn by anyone entering the resident's room. HK 1 swept and mopped the resident's floor, cleaned the surfaces in the resident's bathroom and cleaned the resident's bed frame and overbed table, coming into direct contact with multiple items consistently used by R16 in her room. HK1 did not apply the required PPE (a gown) while cleaning the resident's room and was observed wearing the same pair of gloves throughout the cleaning process while entering and exiting the resident's room to obtain supplies from her housekeeping cart as well as after she finished cleaning the resident's room and headed down the hallway to clean another resident's roomHK1 was not able to be interviewed related to her observed failure to follow the facility's Infection Control/Contact Isolation procedures. On 12/01/25 at 1:35 pm, Physical Therapy Aide (PTA 1) was observed providing therapy services to R16 in the therapy gym. PTA 1 did not wear a gown or gloves while providing services to R16 and did not appropriately sanitize the equipment used by R16 during therapy after services were provided.During an interview with PTA 1 and the Therapy Director on 12/01/25 at 2:35 pm, PTA 1 confirmed he had not worn gloves or a gown while providing treatment to R16 and confirmed the equipment used during R16's treatment had not been appropriately sanitized after her services were provided. He stated he was not aware that R16 was on contact isolation precautions. The Therapy Director stated her expectation was that appropriate PPE (a gown and gloves) should have been worn by PTA 1 while he was providing treatment to R16, and the equipment should have been sanitized after use to treat R16 to prevent potential spread of infection. During an interview with the DON on 12/01/25 at 3:13 pm, she stated her expectation was all staff working directly with R16, or entering R16's room for any reason, were to wear a gown and gloves per the facility's infection control procedures.Review of the facility's Infection Prevention and Control Program Policy updated on 02/01/25 revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines; and All staff are responsible for following all policies and procedures related to the program; and Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC (Center for Disease Control) guidelines.The facility's policies and procedures related to urinary catheter maintenance and infection control were requested by the survey team on 12/02/25 at 2:00 pm and again on 12/02/25 at 5:00 pm, however the policies were not received prior to survey exit on 12/03/25 at 2:30 pm.

Based on record review interviews and policy review, the facility failed to ensure antibiotics were used in accordance with current evidence-based antibiotic use indications for one of six residents (R) R27 reviewed for antibiotic stewardship. The failure had the potential to increase the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use.Findings include:Review of the Census tab, located in the electronic medical record (EMR) revealed R27 was originally admitted to the facility on [DATE].A review of R27's medical diagnoses, found under the Med Diag [Diagnosis] tab of the EMR, revealed a diagnosis urinary tract infection (UTI), dated 05/29/25. A review of R27's Physician Orders, under the Orders tab of the EMR, revealed an order for 250 milligrams (MG) of Erythromycin taken every 6 hours for urinary tract infection (UTI), for 28 days starting 11/14/25. A review of the EMR, under the Results tab, revealed the last urine culture was collected 10/14/25 and was Negative. During an interview with the Infection Preventionist (IP) on 12/01/25 at 3:27 pm, she stated that R27 made complaints of pain in his lower abdomen and with the resident's history of UTI's and the use of a Foley catheter due to bladder-neck obstruction, the residents' provider decided to place the resident on the antibiotic as prophylaxis. She was asked if the resident had a positive culture to confirm the presence of an infection and she confirmed there was no positive culture.In a follow-up interview with the IP on 12/03/25 at 11:21 am, she confirmed that she was aware that the R27 had not had a positive culture, and after receiving the order for antibiotics, she did not address the Medical Director with any concerns regarding the use of an antibiotic outside of the facility's antibiotic use parameters. A review of the facility's policy titled, Antibiotic Stewardship Program, with an effective date of 03/01/22, revealed the purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The policy also advises that the Medical Director sets the standards for antibiotic prescribing practices as well as oversees adherence to antibiotic prescribing practices and ensures the best practices are followed. The policy also states that the IP is responsible for tracking and monitoring of antibiotic use and adhering to the evidenced-based published criteria during the evaluation and management of treated infections.

Based on staff interviews, record review and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to obtain a consent to become the representative payee (someone who manages the resident's Social Security benefits to make sure the resident's basic needs were met) for one out of 15 sampled residents (R) (R9).Findings include:Review of the facility's policy titled Abuse, Neglect and Exploitation with a revision date of 7/1/2024 revealed the policy of this facility is to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.Review of medical records revealed R9 was admitted to the facility with the following but not limited to diagnoses of paraplegic, chronic pain syndrome, opioid dependence, osteoarthritis, insomnia, and urine retention.Review of R9's Annual Minimum Data Set (MDS) dated [DATE], Quarterly MDS dated [DATE], and Quarterly MDS dated [DATE], revealed for Section C (Cognitive Patterns) a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact.Review of the Medical Source Opinion of Patient's Capability to Manage Benefits form (Form SSA-787 Social Security Administration (SSA)), indicated the facility was applying for representative payee to manage the resident's SSA benefits. The form was completed and signed by a physician on 2/19/2025 who indicated the resident did not have a general understanding of his or her finances, did not have sufficient ability to handle a checking/savings account, and did not have sufficient ability to pay bills in a timely manner. It also indicated the resident could not successfully manage or direct the management of funds to meet basic needs (e.g. food, clothing, shelter). Further documentation on the form noted that the resident was a long-term care resident at [Name of Facility] due to being a paraplegic.During an interview with the Administrator on 7/28/2025 at 2:45 pm, she stated the resident did not pay his bill while he was a resident. The facility set up a payment plan for the resident on 11/1/2024 to make payments each month but he never made a payment. She also stated the facility did not issue a 30-day discharge notice due to nonpayment. She stated she was not the Administrator during that time, but they probably applied to be the Representative payee because the resident was not paying his bill. The Administrator did state the resident was alert and oriented and there was nothing to indicate otherwise.The Administrator provided a copy of a form titled [Name of facility] Payment Agreement Form signed by the resident on 11/1/2024 agreeing to pay an outstanding balance of $5,512.00 in monthly payments of $200.00 per month beginning on 12/3/2024.Review of the Resident Statement Landscape form revealed the facility received the resident's SSA deposit on 6/3/2025. The amount deposited was $718.00. The resident's care cost payment was $648.00 with $70.00 applied to his account.The resident discharged home on 7/1/2025 and on 7/3/2025, the $718.00 deposit to the facility was rejected. Therefore, the facility only received one payment on 6/3/2025.During an interview with the Business Office Manager (BOM) on 8/4/2025 at 3:10 pm, she stated that she started as the BOM on 3/17/2025 and was not involved in the application for representative payee for this resident. She stated apparently a regional person came in the facility to address the overage of one million dollars owed to the facility from several residents, most of which were Medicaid pending approval. Residents who owed money were placed on a payment plan. The regional person applied for representative payee for two other residents. However, consent was given for those two residents. The BOM did confirm that R9 was alert and oriented.

Based on record review, staff and resident interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to implement the protection of resident and reporting/response components of their abuse policy when one resident (R) (R1) alleged R2 struck him five times on his left side. The total sample was 15. Findings include:Review of the facility's policy titled Abuse, Neglect and Exploitation, with a revision date of 7/1/2024 revealed component VI. Protection of Resident noted the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to : Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. Providing emotional support and counseling to the resident during and after the investigation, as needed. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Component VII Reporting/Response noted the facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. Review of medical records revealed that R1 was admitted to the facility with the following diagnoses but not limited to: morbid obesity, nontraumatic intracerebral hemorrhage, absence of right leg above knee, congestive heart failure and gout.Review of R1's Quarterly Minimum Data Set (MDS) dated [DATE], revealed Section C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact.During an interview with R1 on 7/22/2025 at 11:45 am, he revealed that on 5/5/2025 around 2:00 am, the resident (R2) across the hall came into his room and woke him up by sitting on the foot of his bed. He asked R2 What are you doing? and told him You got to go. He stated R2 got up and punched him in the chest a couple of times. He started hollering for help and five to ten minutes later a Certified Nursing Assistant (CNA) came in and took R2 back to his room. He stated he was emotionally upset, had flashbacks and did not feel safe in the facility. He stated nobody ever came to talk with him afterwards to ask him what happened or how he felt.Review of the nurses note dated 5/2/2025 at 4:20 am revealed, R1 reported being hit five times by an unwelcomed resident on left side while lying in bed. Both nurses reported to resident room and asked what side the incident happened. The resident stated, I was hit five times on left side. Both nurses assessed resident, no injuries, marks, bruises, cuts or scratched were visible at time of assessment.Review of the Nurse Practitioner (NP) Progress Note dated 5/5/2025 revealed the resident (R1) reported to her that another resident came into his room and was hitting him with his fists in the chest. He reported that he was scared to go to sleep last night because he was not sure if the other resident would come back. The NP further noted that she explained to him that what happened to him was not ok and would be handled by Administrator.Review of the NP progress note dated 5/7/2025 revealed that the resident (R1) reported that he does not feel safe here since being assaulted by another resident. It was reported that the resident had scissors under his pillow and would not give them to the staff last night. When NP saw the resident there was nothing on his bed except a sheet. The resident said he would protect himself at all cost.Further review of medical records revealed, although R1 had reported to the NP he did not feel safe in the facility, there was no documentation the NP had reported these findings to the staff or requested for the resident to be evaluated by the Social Worker for a psychological evaluation.During an interview with the Social Worker on 7/22/2025 at 2:57 pm, she stated that they usually discuss any allegations of abuse in the morning meetings and she would usually follow up with the residents after the allegation for several weeks just to observe for any behaviors and refer them to CHE Behavioral Health if needed. She confirmed she did not follow up with R1 after his allegation of abuse on 5/4/2025. She also stated that no one reported to her of the resident having scissors under his pillow because he was scared.

Based on staff interviews, record review and review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure that an allegation of abuse was reported to law enforcement for one out of 15 sampled residents (R) (R1).Findings include:Review of the facility's policy titled Abuse, Neglect and Exploitation, with a revision date of 7/1/2024 under Component VII - Reporting/Response revealed, the facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. Review of medical records revealed, R1 was admitted to the facility with the following diagnoses that included but not limited to: morbid obesity, nontraumatic intracerebral hemorrhage, absence of right leg above knee, congestive heart failure and gout.Review of R1's Quarterly Minimum Data Set (MDS) dated [DATE], revealed Section C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact.During an interview with R1 on 7/22/2025 at 11:45 am, he revealed that on 5/5/2025 around 2:00 am, the resident (R2) across the hall came into his room and woke him up by sitting on the foot of his bed. He asked R2 What are you doing? and told him You got to go. He stated R2 got up and punched him in the chest a couple of times. He started hollering for help and five to ten minutes later a Certified Nursing Assistant (CNA) came in and took R2 back to his room. He stated he was emotionally upset, had flashbacks and did not feel safe in the facility. He stated nobody ever came to talk with him afterwards to ask him what happened or how he felt.Review of the nurses note dated 5/2/2025 at 4:20 am revealed, R1 reported being hit five times by an unwelcomed resident on left side while lying in bed. Both nurses reported to resident room and asked what side the incident happened. The resident stated, I was hit five times on left side. Both nurses assessed resident, no injuries, marks, bruises, cuts or scratched were visible at time of assessment.Review of the Facility Incident Report Form dated 5/4/2025 revealed the facility reported an allegation of resident-to-resident abuse that had occurred on May 4, 2025, at approximately 2:50 am. The report revealed that R2 was disoriented and wandered into R1's room. R1 stated that R2 struck him on his left side before exiting the room. R2 stated he did not hit or strike R1 and thought he was in his own room. The report indicated that the Administrator and the Responsible Party were notified but it did not indicate that the police was notified.During an interview with the Administrator on 7/23/2025 at 12:40 pm, she stated she was not the Administrator at that time but stated in this case she would have definitely called the Sheriff department.Refer to F607

Based on resident and staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to revise the care plan for one out of 15 sampled residents (R) (R1). Specifically, the facility failed to address R1's psychological needs related to an allegation of physical abuse.Findings include:Review of the facility's policy titled Comprehensive Care Plans with a revision date of 3/1/2025 revealed, 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 timeframes to meet a resident's medical, nursing, and mental and psychological needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Under the section titled Policy Explanation and Compliance Guidelines noted 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 medical records revealed that R1 was admitted to the facility with the following diagnoses but not limited to: morbid obesity, nontraumatic intracerebral hemorrhage, absence of right leg above knee, congestive heart failure and gout.Review of R1's Quarterly Minimum Data Set (MDS) dated [DATE], revealed Section C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact.During an interview with R1 on 7/22/2025 at 11:45 am, he revealed that on 5/5/2025 around 2:00 am, the resident (R2) across the hall came into his room and woke him up by sitting on the foot of his bed. He asked R2 What are you doing? and told him You got to go. He stated R2 got up and punched him in the chest a couple of times. He started hollering for help and five to ten minutes later a Certified Nursing Assistant (CNA) came in and took R2 back to his room. He stated he was emotionally upset, had flashbacks and did not feel safe in the facility. He stated nobody ever came to talk with him afterwards to ask him what happened or how he felt.Review of the Nurse Practitioner (NP) Progress Note dated 5/5/2025 revealed the resident (R1) reported to her that another resident came into his room and was hitting him with his fists in the chest. He reported that he was scared to go to sleep last night because he was not sure if the other resident would come back. The NP further noted that she explained to him that what happened to him was not ok and would be handled by Administrator.Review of the NP progress note dated 5/7/2025 revealed that the resident (R1) reported that he does not feel safe here since being assaulted by another resident. It was reported that the resident had scissors under his pillow and would not give them to the staff last night. When NP saw the resident there was nothing on his bed except a sheet. The resident said he would protect himself at all cost.Review of R1's care plan revealed a focus area of the resident having a behavior problem by choosing to keep medications at bedside and will refuse his medications at times. Further review of R1's care plan revealed, there was no evidence that the facility had assessed the resident's psychosocial needs after the allegation of physical abuse on 5/4/2025. Therefore, the care plan was not revised to reflect the resident's fear of being in the facility and having flashbacks of the alleged incident.Refer to F607 and F745.

Based on resident and staff interviews, record review, and review of the Social Worker job description, the facility failed to assess the psychosocial status and provide medically related social services to one out of 15 sampled residents (R) (R1) after an allegation of physical abuse.Findings include:Review of the Social Worker job description revealed the Administrative Functions was to ensure that each resident receives necessary behavioral health care and services to obtain and maintain the highest practical physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.Review of medical records revealed that R1 was admitted to the facility with the following diagnoses but not limited to: morbid obesity, nontraumatic intracerebral hemorrhage, absence of right leg above knee, congestive heart failure and gout.Review of R1's Quarterly Minimum Data Set (MDS) dated [DATE], revealed Section C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact.During an interview with R1 on 7/22/2025 at 11:45 am, he revealed that on 5/5/2025 around 2:00 am, the resident (R2) across the hall came into his room and woke him up by sitting on the foot of his bed. He asked R2 What are you doing? and told him You got to go. He stated R2 got up and punched him in the chest a couple of times. He started hollering for help and five to ten minutes later a Certified Nursing Assistant (CNA) came in and took R2 back to his room. He stated he was emotionally upset, had flashbacks and did not feel safe in the facility. He stated nobody ever came to talk with him afterwards to ask him what happened or how he felt.Review of the Nurse Practitioner (NP) Progress Note dated 5/5/2025 revealed the resident (R1) reported to her that another resident came into his room and was hitting him with his fists in the chest. He reported that he was scared to go to sleep last night because he was not sure if the other resident would come back. The NP further noted that she explained to him that what happened to him was not ok and would be handled by Administrator.Review of the NP progress note dated 5/7/2025 revealed that the resident (R1) reported that he does not feel safe here since being assaulted by another resident. It was reported that the resident had scissors under his pillow and would not give them to the staff last night. When NP saw the resident there was nothing on his bed except a sheet. The resident said he would protect himself at all cost.Further review of medical records revealed, although R1 had reported to the NP he did not feel safe in the facility, there was no documentation the NP had reported these findings to the staff or requested for the resident to be evaluated by the Social Worker for a psychological evaluation.During an interview with the Social Worker on 7/22/2025 at 2:57 pm, she stated that they usually discuss any allegations of abuse in the morning meetings and she would usually follow up with the residents after the allegation for several weeks just to observe for any behaviors and refer them to CHE Behavioral Health if needed. She confirmed she did not follow up with R1 after his allegation of abuse on 5/4/2025. She also stated that no one reported to her of the resident having scissors under his pillow because he was scared. During an interview with the Administrator on 7/22/25 at 4:20 pm, she confirmed that the Social Worker should have followed up with the resident after the allegation of abuse. She revealed that she would expect the Social Worker to follow up with residents to monitor for behaviors and to refer them to CHE Behavioral Health if needed.

Based on observations, medical records, and staff interviews, the facility failed to implement the care plan related to wound treatment for two of three sampled residents (R1 and R3) who had stage IV wounds. Harm was determined to have occurred on 3/5/2025 when R1 and R3 experienced pain that was not addressed during wound care treatment. Findings included: 1. A review of the electronic medical record (EMR) revealed R1 was admitted to the facility with the following diagnoses including but not limited to type 2 diabetes mellitus, chronic gout, metabolic encephalopathy, pressure ulcer, hypertensive heart disease, dementia, pain, and glaucoma. A review of the care plan dated 1/21/2025 revealed that R1 had a stage 4 pressure wound to her coccyx with the following interventions/tasks: conduct weekly skin inspections and treatments as ordered. Further, R1 had a pain care plan dated 1/21/2025 which revealed that R1 has chronic pain related to her disease process. The interventions included monitoring and documenting the probable cause of each pain episode, removing and limiting causes of pain where possible, and administering medications per orders. During an observation on 3/5/2025 at 10:39 pm, Licensed Practical Nurse (LPN) CC and LPN DD were observed providing wound care for R1. During this observation, R1 was moving her body away from the nurses' hands that were touching the wound. The resident was moaning and verbalizing, Oh, oh. However, during wound care, LPN CC and LPN DD did not acknowledge R1's pain and LPN CC continued to complete the dressing change. During an interview on 3/11/2025 at 2:11 pm, LPN DD revealed that when a resident has pain, the staff are supposed to stop and administer pain medication. During an interview on 3/11/2025 at 2:17 pm, LPN CC confirmed that she was a wound care nurse. She revealed that she should have stopped the treatment when R1 expressed pain and asked R1 if she had anything for the pain. 2. A review of the admission record revealed R3 was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease, type 2 diabetes mellitus, cirrhosis of the liver, emphysema, atherosclerotic heart disease of native coronary, hypertensive heart disease, and fibromyalgia. A review of the care plan dated 11/27/2024 revealed that R3 had acute/chronic pain related to depression, postoperative discomfort, and wounds. The intervention/task was to administer analgesia as per orders; to give half an hour before treatment or care; anticipate her need for pain relief; and respond immediately to any complaint of pain. A review of the EMR revealed that R3 did not have an order for pain medication until she was enrolled in hospice services on 3/5/2025 after her wound treatment. During an observation on 3/5/2025 at 11:04 am, LPN CC removed the dressing from the coccyx area of R3. As the dressing was being removed, R3 was moaning and grimacing, and LPN DD continued to peel the dressing from the resident's lower buttock. The resident was swarming in bed, trying to move away from the removal of the dressings. The resident started complaining about her face on the bed rail and LPN DD told the resident that they (LPN CC and LPN DD) were just about done. During an interview on 3/12/2025 at 3:24 pm, the MDS Registered Nurse (RN) FF revealed that staff are supposed to follow the pain management care plan and that she did not know why it was not being followed. Cross Reference F697

Based on observations, record review, staff interviews, and a review of the facility policy titled Administering Pain Management, the facility failed to ensure that two of three sampled residents (R) (R1 and R3) were free from pain during wound care treatment. Harm was determined to have occurred on 3/5/2025 when R1 and R3 experienced pain that was not addressed during wound care treatment. Findings included: A review of the undated policy titled Administering Pain Management, it was documented that the pain management program was based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. It was noted that Pain Management was defined as the process of alleviating the resident's pain based on his/her clinical condition and established treatment goals and that Pain Management was a multidisciplinary care process that included the following: assessing the potential for pain; recognizing the presence of pain; identifying the characteristics of pain; and addressing the underlying causes of the pain. 1. A review of the electronic medical record (EMR) revealed that R1 was admitted to the facility with diagnoses of type 2 diabetes mellitus, chronic gout, metabolic encephalopathy, pressure ulcer, hypertensive heart disease, dementia, pain, and glaucoma. During an observation on 3/5/2025 at 10:39 am, R1 was lying in bed on an airflow mattress with bilateral assistive rails in the upper position and had a wedge and a pillow for positioning. Wound Nurse/Licensed Practical Nurse (LPN) CC was being assisted by LPN DD and Certified Nurse Certified (CNA) SS to provide the resident with wound care treatment. LPN CC washed her hands, and CNA SS removed the resident brief and provided perineal care. The wound bed was 80% yellowish slough and 20% reddish granulation. LPN CC cleaned the wound with wound cleanser, and while cleaning the wound, R1 was observed voicing, Ouch, ouch, ouch. That hurts. LPN CC continued to obtain wound measurements of 8.5L x 3.1W x 4.7D. LPN CC began checking for undermining using her finger and again the resident began saying, Oh, oh and tried moving away from LPN CC's hand. LPN DD told R1 to take a deep breath and that it was almost over. LPN CC continued applying the Dakin solution on a kerlix and packing the Dakin-moistened kerlix into the wound bed. LPN CC then placed an adhesive border dressing over the moistened kerlix. R1 continued squirming on the bed throughout the dressing change (moving away from the nurse's hands). Further observation revealed a sign on R1's door documenting that enhanced barrier precautions were in place. LPN CC, LPN DD, and CNA SS were not wearing a gown as they performed wound care and/or perineal care. A review of the Order Summary Report dated 3/5/2025 revealed R1 had an order for Tylenol 325 milligrams (mg) tablet, to administer two tablets orally every six hours as needed for pain related to pressure ulcer of the sacral region with an order and start date of 3/4/2025. A review of the Medication Administration Record (MAR) dated 3/1/2025 through 3/31/2025 revealed no evidence that Tylenol was administered. 2. A review of the EMR revealed that R3 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, cirrhosis of the liver, emphysema, atherosclerotic heart disease of native coronary, hypertensive heart disease, and fibromyalgia. During an observation on 3/5/2025 at 11:04 am, an enhanced barrier precaution sign was posted on R3's door. The resident was observed lying on an airflow mattress with bilateral quarter-side rails in the up position. R1's designated Power of Attorney (POA) was also in the room. LPN CC and LPN DD entered the room and neither nurse was wearing a protective gown. The nurses repositioned the resident turning her to face the door and R3's face was pressing against the quarter side rail. LPN CC removed the dressing from R3's coccyx area and as the dressing was being removed the resident was moaning and grimacing in pain. The resident wound bed was observed with red granulation. The nurse cleaned the wound bed with wound cleaner; obtained measurements 4.0L x 31W; and LPN DD began peeling an adhesive dressing from the right lower buttock. As she was peeling the dressing from the resident skin, the resident began squirming in bed, trying to move away from the removal of the dressing. LPN DD stated that the wound was not open yesterday and that she would call hospice to inform them of the opening of the lower right buttock wound. LPN CC measured the lower right buttock wound and obtained measurements (7.3L x 2.1). The upper part of the wound was red, and the lower half of the wound was dark red. The resident started complaining about her face being pressed against the bed rail, and LPN DD told the resident that they were just about done. The POA, who was standing at the head of the bed, put her hand between the rail and the resident's face. LPN CC began to skin-prep the outer skin surrounding the wound bed, placed calcium alginate on the wound bed, placed a 4x4 gauze over the wound, and covered the area with an adhesive dressing. A review of the order summary report dated 3/5/2025 revealed a wound order to clean R3's coccyx with normal saline, skin prep, alginate calcium, and dressing with border gauze once a day (every Tuesday, Thursday, and Saturday.) There was an order for pain medication of hydrocodone-acetaminophen tablet 10-300 mg that was discontinued on 11/6/2024; Tramadol 50 mg that was discontinued on 9/21/2023, and hydromorphone HCL tablet 4 mg that was discontinued on 10/21/02021. There was no active order for pain medication until R3 was admitted to hospice care on 3/5/2025 later in the afternoon after the wound care treatment. During an interview on 3/5/2025 at 11:33 am, R3 confirmed that she was uncomfortable and that the wound treatment hurt. During an interview on 3/11/2025 at 12:55 pm, the Nurse Practitioner (NP) revealed that staff should be educated on pre-medication and the stages of wounds and that she will follow up on residents with wounds for pain management. During an interview on 3/11/2025 at 2:11 pm, LPN DD revealed that when a resident has pain during wound care treatment, the staff are supposed to stop the treatment and administer pain medication; call the NP for an order for pain medication and send the order to the pharmacy; or if the physician sends a prescription in, the pharmacy will allow nurses to get the pain medication from the pixel as soon as the doctor signs the prescription. During an interview on 3/11/2025 at 2:17 pm, LPN CC revealed that she should have stopped and asked R1 if she needed anything for pain. LPN CC confirmed that she had not assessed R1 or R3 for pain. LPN CC stated that she was focused on the wound care treatment and that is why she did not administer pain medication to R1 or get an order for pain medication for R3. During an interview on 3/12/2025 at 1:26 pm, the Director of Nursing (DON) revealed that the staff should have assessed the residents for pain and determined the cause of the pain. Cross Reference F 656

Based on observations, record review, staff interviews, and a review of the facility policy titled Infection Prevention and Control Program, the facility failed to ensure that the staff wore the appropriate personal protective equipment (PPE) while providing care for three of three sampled residents (R) (R1, R2, and R3) during wound care and perineal care. Findings included: A review of the Infection Prevention and Control Program dated 5/23/23 and last revised on 3/1/2024, revealed that it is standard precaution that all staff shall use PPE according to established facility policy governing the use of PPE. A review of the Enhanced Barrier Precautions (EBP)sign noted that doctors and staff must wear gloves and a gown for high-contact resident care activities such as dressing, bathing/showering, transferring, changing lines, providing hygiene, changing briefs, assisting with toileting, device care or use of a central line, urinary catheter, feeding tube, tracheostomy, wound care, and any skin opening requiring a dressing. It was further noted that staff are not to wear the same gown and gloves for the care of more than one person. 1. A review of the electronic medical record (EMR) revealed that R1 was admitted to the facility with diagnoses of type 2 diabetes mellitus, chronic gout, metabolic encephalopathy, pressure ulcer, hypertensive heart disease, dementia, pain, and glaucoma. During an observation on 3/5/2025 at 10:39 am, there was a sign on the outside of R1's door that read, Enhanced Barrier Precautions. R1 had a bowel movement and Certified Nurse Aide (CNA) SS performed perineal care. R1 had a stage IV coccyx pressure ulcer. Licensed Practical Nurse (LPN) CC and LPN DD provided wound care. CNA SS, LPN CC, and LPN DD did not wear a protective gown during the observations. During an observation on 3/11/2025 at 11:24 am, CNA GG was assisting CNA HH in providing perineal care to R1. During the observation, CNA HH and CNA GG were not wearing protective gowns. While CNA HH and CNA GG were providing perineal care, LPN CC came into the room and replaced the soiled dressing. LPN CC was not wearing a protective gown. During an interview on 3/11/2025 at 3:21 pm, CNA HH revealed she didn't have a gown because she didn't read the sign on the door and had not seen any PPE by the door. During an interview on 3/11/2025 at 12:47 pm, CNA GG revealed that she should have put on the protective gown but that she didn't think about it. 2. A review of the ERM revealed that R2 was admitted to the facility with diagnoses of type 2 diabetes mellitus, hypertension, pressure ulcer of sacral stage 4, and pleural effusion. It was revealed in the EMR that R2 was on EBP. During an observation on 3/5/2025 at 2:01 pm, LPN CC was providing wound care to R2 and was not wearing a protective gown. During an interview on 3/11/2025 at 2:17 pm, LPN CC revealed that she did not know why she didn't put on a gown. 3. A review of the EMR revealed that R3 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, cirrhosis of the liver, emphysema, atherosclerotic heart disease of native coronary, hypertensive heart disease, and fibromyalgia. During an observation on 3/5/2025 at 11:04 am, there was an EBP sign on the door. The Wound Care Nurse/LPN CC was being assisted by LPN DD. They were providing wound care treatment to R3. Neither LPN CC nor LPN DD were wearing protective gowns during the observation of the wound care treatment. A review of the Order Summary Report dated 3/5/2025 revealed an order date and start date for Enhanced Barrier Precautions: Resident is placed on this precaution due to having a colostomy and a wound. The use of PPE when providing care in high-contact resident care activities where gowns and gloves are appropriate, two times a day. During an interview on 3/11/2025 at 2:11 pm, LPN DD revealed that she had no answer for why she didn't put on the protective gown and stated that she just forgot. During an interview on 3/11/2025 at 2:17 pm, LPN CC revealed she didn't know why she didn't put on a protective gown. During an observation on 3/3/2025 at 11:29 am, observed a staff (identified as AA) with a cart loaded with boxes of gloves. She went into the residents' room and brought out partially empty glove boxes to her cart took an open box of gloves on the cart took gloves out with her bare hand and stuffed gloves into the box brought from the residents. If the resident had an empty box, she would replace it with a full box. She continued to go into each resident's room either stuffing gloves with her bare hand into partially empty boxes or placing a box of gloves in the room in the absence of a box of gloves in the room. AA was observed going into each resident's room in the halls and annexes. During an interview on 3/12/2025 at 1:55 pm, Infection Control Preventionist/Registered Nurse (RN) QQ stated that they had one box containing 50 gowns in the outside shed. During an observation on 3/12/2025 at 1:58 pm, two boxes of 50 protective gowns were observed in the medication room. During an interview on 3/11/2025 at 3:38 pm, Central Supply/Medical Record AA revealed that if the glove boxes have four or five gloves, she will replace the entire box with a new box of gloves. If the box was half full and two boxes were the same size, she would take one box out and put the half-full box in another room. If the gloves box is less than half full, she would put the gloves from the box on the cart and put the gloves in the box that came from the room. She stated that she was not wearing gloves when transferring gloves into another glove box. She confirmed that the resident rooms had hand sanitizer, but she didn't use it. She continued to state that she normally does the glove boxes twice a week unless they (the staff) use a lot of gloves. She stated that she would order some, keep a few supplies in the medication room, and keep some in the shed. She had two or three cases of gown and had recently ordered two more cases. During an interview on 3/12/2025 at 2:47 pm, the Administrator revealed that the staff will be retrained on the use of PPE and keeping a clean cart.

Based on record review and staff interviews, the facility failed to develop care plan interventions to address the transfer needs of one resident (R) (R1) who required the use of a mechanical swing lift during transfers from a sample of 11 residents. This failure resulted in actual harm on 6/13/2024 when R1 slid down in the sling of a stand lift causing a chest wall hematoma with subsequent anemia requiring a blood transfusion. Findings include: R1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: intracranial injury, schizophrenia bipolar type, mood disorder, anxiety disorder, and morbid obesity. A review of the resident's annual Minimum Data Set (MDS) with an assessment reference date of 3/25/2024 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident was severely cognitively impaired, had fluctuating inattention, had impairments on both sides of the lower extremities, and was dependent on staff for chair/bed-to-chair transfer. Review of the care plan dated 3/1/2023 indicated the resident needed extensive to total assistance but the care plan did not specify that the resident required a mechanical swing lift for transfers. A review of the facility's investigation completed on 6/21/2024 revealed that on 6/16/2024 the Administrator was notified that the resident had bruising to the right breast with edema and bruising to the abdomen related to the stand lift sling pinching her during a transfer earlier that day. During a follow up body audit on 6/17/2024, the Director of Nursing (DON) notified the Administrator of worsening bruising and edema to the right breast, abdomen and chest wall. According to the 6/17/2024 Situation, Background, Assessment, Recommendation (SBAR) form, the resident was assessed by the Nurse Practitioner and gave an order to send the resident to the hospital for uncontrolled pain and bruising to the right side of the chest and abdomen. On 6/18/2024 the DON interviewed three certified nursing assistants (CNA) (CNA AA, CNA BB, and CNA CC) who were involved with the stand lift transfer. It was determined that during a transfer on 6/13/2024, as the CNA's began to lift the resident the sling belt slipped due to the resident being unable to bear any weight. According to the facility investigation, because the resident is obese with a weight of 342 pounds, the slip in the sling caused it to apply pressure to her right breast, chest wall, right shoulder, and right arm causing the bruising. The investigation revealed three CNA's had received stand lift training competencies prior to incident but failed to act appropriately when the resident slipped in the sling by continuing to transfer the resident. All three CNA's were terminated on 6/17/2024. During an interview with the DON on 6/26/2024 at 1:45 pm, she stated that through their investigation, it was determined that the incident happened on 6/13/2024 on the evening shift when three CNA's used the stand lift instead of the mechanical swing lift to transfer the resident. She stated the staff should have used the mechanical swing lift since the resident was not able to bear 50% of her weight while standing. She confirmed the care plan that was in place at the time of the incident did not specify that the resident required a mechanical swing lift for transfers. Review of the PIP form indicated a start date of 6/21/2024 for safe transfer technique using the mechanical swing lift and stand lift and revealed the following actions: 1. Re-education of CNA's regarding proper use of the stand/hoyer lift following the current plan of care which included education for the correct use of the mechanical swing lift and stand lift and what to do if the resident begins falling or slipping provided by the DON and the Director of Therapy starting on 6/18/2024 and is ongoing. The re-education included return demonstration. 2. All residents were assessed by therapy on 6/18/2024 for correct transfer types which included lift status with care plan revisions made as indicated. 3. Review of Active/Historical Risk Reports showing no injuries caused by the mechanical swing lift or stand lift. 4. The DON or Unit Manager to conduct twice per week transfer competencies for four weeks, then monthly for three months. 5. Quality Assurance and Performance Improvement (QAPI) meeting held on 6/25/2024 regarding risk review lift competencies. The DON to report to QAPI monthly effectiveness of plan and any revisions with the plan to achieve outcome of safe transfers. A review of the education provided to nurses and CNA's revealed 38 of 43 nursing staff had received re-education regarding the proper use of the stand lift and mechanical swing lift following the current care plan. A review of the therapy re-evaluation of transfer/lift status, random review of care plans for transfers, and observation of resident transfers revealed the facility's plan of correction was implemented with no additional deficient practice identified. Cross refer F689

Based on record review, staff interviews, and review of policy titled Lifting Machine, Using a Mechanical and Accidents and Incidents-Investigating and Reporting, the facility failed to transfer a resident with the correct transfer lift for one of 11 sampled residents (R) (R1). This failure resulted in actual harm on 6/13/2024 when R1 slid down in the sling of a stand lift causing a chest wall hematoma with subsequent anemia requiring a blood transfusion. Findings include: Review of the facility policy titled Lifting Machine, Using a Mechanical with a revision date of July 2017 noted the purpose of the procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. The policy noted the following Steps in the Procedure: 1. Before using a lifting device, assess the resident's current condition, including: a. Physical: (1) Can the resident assist with transfer? (2) Is the resident's weight and medical condition appropriate for the use of a lift? b. Cognitive/Emotional: (1) Can the resident understand and follow instructions? (2) Does the resident express fear or appear anxious about the use of a lift? (3) Is the resident agitated, resistant, or combative? Review of the facility policy titled Accidents and Incidents-Investigating and Reporting with a revision date of July 2017 had the following policy statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. R1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: intracranial injury, schizophrenia bipolar type, mood disorder, anxiety disorder, and morbid obesity. A review of the resident's annual Minimum Data Set (MDS) with an assessment reference date of 3/25/2024 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident was severely cognitively impaired, had fluctuating inattention, had impairments on both sides of the lower extremities, and was dependent on staff for chair/bed-to-chair transfer. Review of the manufacturer's instructions for the standing lift indicated the stand lift is a mobile raising aid intended to be used on a horizontal surface for raising to a standing position and short transfer of residents (e.g. raising from bed and transit to wheelchair, or from wheelchair to toilet) in hospitals, nursing homes or other health care facilities where the resident has been clinically assessed to correspond to the following categories; Category C - Sits in a wheelchair - Is able to partially bear weight on at least one leg - Has some trunk stability - Dependent on carer in most situations - Physically demanding for carer - Stimulation of remaining abilities is important The safety instructions instructed that before attempting to use the stand lift, a full clinical assessment of the resident his/her condition, and suitability must be carried out by a qualified person. A review of the facility's investigation completed on 6/21/2024 revealed that on 6/16/2024 the Administrator was notified that the resident had bruising to the right breast with edema and bruising to the abdomen related to the stand lift sling pinching her during a transfer earlier that day. During a follow up body audit on 6/17/2024, the Director of Nursing (DON) notified the Administrator of worsening bruising and edema to the right breast, abdomen and chest wall. According to the 6/17/2024 Situation, Background, Assessment, Recommendation (SBAR) form, the resident was assessed by the Nurse Practitioner and given an order to send the resident to the hospital for uncontrolled pain and bruising to the right side of the chest and abdomen. On 6/18/2024 the DON interviewed three certified nursing assistants (CNA) (CNA AA, CNA BB and CNA CC) who were involved with the stand lift transfer. It was determined that during a transfer on 6/13/2024, as the CNA's began to lift the resident and the sling belt slipped due to the resident being unable to bear any weight. According to the facility investigation, because the resident is obese with a weight of 342 pounds, the slip in the sling caused it to apply pressure to her right breast, chest wall, right shoulder, and right arm causing the bruising. The investigation revealed three CNA's had received stand lift training competencies prior to incident but failed to act appropriately when the resident slipped in the sling by continuing to transfer the resident. All three CNA's were terminated on 6/17/2024. Review of documentation from local hospital indicated R1 admitted to the hospital on 6/17/2024 due to bruising and swelling of right arm, shoulder, and abdomen. R1 was noted to have chest wall hematoma with subsequent anemia requiring the resident to receive a blood transfusion. During an interview with the DON on 6/26/2024 at 1:45 pm, she stated that through their investigation, it was determined that the incident happened on 6/13/2024 on the evening shift when three CNA's used the stand lift to transfer the resident. She stated the staff should have used a mechanical swing lift since the resident was not able to bear 50% of her weight while standing. She stated she had the CNA's come to the facility to demonstrate what happened on 6/13/2024. CNA BB did not show up but CNA's AA and CC both returned to demonstrate how the resident was transferred. CNA AA explained that the resident slipped in the sling and was in a hang glider position with her arms raised. When CNA AA put the sling on the DON for demonstration, the sling was placed on the DON wrong causing the sling to be up over her chest and put her in the hang glider position with her arms raised. CNA CC stated the resident slipped while in the sling. She stated when CNA CC put the sling on she put the sling on upside down. Both CNA's stated they should not have proceeded with the transfer once the resident slipped but they went ahead and transferred the resident to the bed. They also could not explain to the DON why they used the stand lift to transfer the resident. The DON stated the staff know if a resident can't bear 50% of their weight then the stand lift should not be used. She confirmed the care plan that was in place at the time of the incident did not specify that the resident required a mechanical swing lift for transfers. During an interview with the Administrator on 6/25/2024 at 3:15 pm, she stated the three CNA's never reported the incident that occurred on 6/13/2024. Once the bruising was identified on 6/16/2024 they immediately started an investigation and placed in a Project Improvement Plan (PIP). Review of the PIP form indicated a start date of 6/21/2024 for safe transfer technique using the mechanical swing lift and stand lift and revealed the following actions were initiated: 1. Re-education of CNA's regarding proper use of the stand lift and mechanical swing lift following the current plan of care which included education on the correct use of the mechanical swing lift and stand lift and what to do if the resident begins falling or slipping provided by the DON and the Director of Therapy starting on 6/18/2024. The re-education included return demonstration. 2. All residents were assessed by therapy on 6/18/2024 for correct transfer types which included lift status with care plan revisions made as indicated. 3. Review of active/historical risk reports showing no injuries caused by mechanical swing or stand lift. 4. The DON or Unit Manager to conduct twice per week transfer competencies for four weeks, then monthly for three months. 5. Quality Assurance and Performance Improvement (QAPI) meeting held on 6/25/2024 regarding risk review lift competencies. The DON to report to QAPI monthly effectiveness of plan and any revisions with the plan to achieve outcome of safe transfers. A review of the education provided to nurses and CNA's revealed 38 of 43 nursing staff had received re-education regarding the proper use of the stand/Hoyer lift following the current care plan. A review of the therapy re-evaluation of transfer/lift status, random review of care plans for transfers, and observation of resident transfers revealed the facility's plan of correction was implemented with no additional deficient practice identified.

Based on observations, staff interview, and review of the facility policy titled Wound Treatment Management, the facility failed to timely initiate wound treatment for one resident (R#4) and failed to ensure one resident (R#5) continued to receive wound treatment for two of four residents sampled. Actual harm was identified on 3/1/23 for R#4 when pressure ulcers to the left and right buttocks were noted to have slough after being untreated since 2/24/23. Findings include: Review of the facility policy Wound Treatment Management (dated 12/1/22) revealed the following: Policy - To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 1. Review of the Admission Record revealed R#4 was admitted to the facility on [DATE] with a readmit on 9/9/20 with the following diagnoses that include but not limited to paraplegia, neuromuscular dysfunction of bladder, major depression disorder, gastro-esophageal reflux disease and general anxiety disorder. During perineal care observation on 3/1/23 at 11:09 a.m. Certified Nurse Aide (CNA) DD removed feces from the resident buttocks. There was moderated skin breakdown surrounding bilateral buttocks wounds. The wound on the right buttock was 100% yellow slough and the left buttock had yellow slough with the surrounding skin macerated. During an observation on 3/1/23 at 11:40 a.m. Licensed Practical Nurse (LPN) GG (wound nurse) cleaned the wound on the sacral area with wound cleanser; applied skin prep to sacral intact skin, packed in a small opening calcium alginate and applied an adhesive dressing to the sacral wound. LPN GG measurements to the right buttock was 7.5 centimeters (cm) x 5.4 cm. The wound has yellow slough. The surrounding skin was macerated. The left buttock measurements were 9.5 cm x 8.0 cm x 0.1 cm. The wound has yellow slough. Review of the Order Summary Report revealed resident has an order to apply skin protection to left lateral foot every day shift with an order date 2/24/23 and start date 2/25/23. An order to apply skin protection to right later foot every day shift with an order date 2/24/23 and start 2/25/23. Physician Orders for wound care to the right and the left buttocks were entered after the above wound care observation, on 3/1/23, to clean with wound cleanser; pat dry; wipe periwound with skin protection; apply calcium alginate with silver; and cover with dry dressing every day shift Monday and Thursday. The sacral wound has an order date of 2/14/23 and a start date of 2/20/23 to clean sacral wound with wound cleanser, pat day, wipe periwound with skin protection, apply anasept gel, cover with Prisma, cover with dressing every shift Monday. Dressings to be change once weekly. May change dressing if soiled, dislodged, or missing. Review of NSG: WEEKLY SKIN CHECK dated 2/1/23, 2/7/23, 2/14/23, and 2/21/23 revealed no evidence that the left buttocks, right buttocks, and blisters on the bottom of both feet were documented. Review of the Treatment Administration Record (TAR) dated 2/1/23 through 2/28/23 revealed one time treatment on 2/24/23 to evaluate blisters on bottoms of both feet and breakdown on both buttocks. There was no evidence that the right buttock and left buttocks had treatment orders initiated for the breakdown until 3/1/23. Review of the WC: Weekly Wound Evaluation with an effective date of 2/24/23 only identified the sacrum as an identified wound. Review of Progress Notes dated 1/30/23 through 2/23/23 revealed a PAR NOTE dated 2/23/23 that the resident has a sacral wound and is being seen by (name) wound physician for treatment. There were no other wounds noted. During an observation and interview on 3/1/23 at 11:40 a.m. LPN GG (wound nurse) commented that R#4 did not have any wounds on his buttocks when she started working at the facility three weeks ago. She further expressed that on her second week R#4 had a reddish buttock and she used a barrier cream to treat the area. LPN GG confirmed that the sacral dressing was last done on 2/28/23 and the buttocks seemed worse today than it did on yesterday. There was no treatment done to either buttocks on yesterday when treatment was done to the sacrum. An interview on 3/2/23 at 3:47 p.m. LPN GG (wound nurse) revealed again that she began working in the facility 3 weeks ago and R#4 did not have any wounds on either buttock. It was reported that there was a sacral stage IV wound, and R#4 goes to a wound Physician on Mondays, but he did not go to the appointment this past Monday. She again stated that the first week she started working, R#4 only had the healing stage IV to the sacrum but during her second week she noticed his buttocks was red and she began using a barrier cream on it. LPN GG reported that on 2/28/23 R#4 only had treatment completed to the sacral wound. She acknowledged that on 3/1/23 R#4's buttock was noted with slough. She reported that weekend treatments are to be done by the charge nurse when she takes a day off. LPN GG reported that she did not know how to use the software to add additional wounds to the Weekly Wound Evaluation report. During an interview on 3/6/23 at 2:37 p.m. Registered Nurse (RN) AA revealed that the last time she did his dressing change was in January, he only had a sacral wound. There was nothing on his feet or buttocks. During an interview on 3/9/23 at 3:35 p.m. the Director of Nursing (DON) revealed that when a pressure ulcer is identified the treatment nurse is to do weekly skin assessment, meet with wound care doctors on Tuesdays, and follow any recommendations. DON further reported that if the treatment nurse identified blisters and buttocks breakdown on 2/24/23 she should have obtained orders and initiated wound care treatment. 2. Review of the admission record revealed R#5 was admitted to the facility on [DATE] with a readmit on 10/12/22 with the following diagnoses that include but not limited to cerebrovascular, hypertensive heart disease, bipolar disorder, hypothyroidism, gastro-esophageal reflux disease, anxiety disorder, seizures, syncope and collapse, and pressure ulcer of sacral. During an observation on 3/2/23 at 1:31 p.m., LPN GG (wound nurse) was being assist by LPN HH (unit manager), and CNA II. Resident is on an air flow bed. She has bilateral legs contraction, and a left arm splint. The right shoulder upper bony area has a red area. She has a sacral wound that is 95% red granulation with tunneling at 12 O'clock, and 5% yellow slough with the surrounding skin is dark brown. LPN GG cleaned the wound with wound cleanser. The wound measurement was 7.0 cm x 4.6 cm x 1.6 cm. She put honey on a Telfa pad and dry dressing. Skin prep was applied to the outer perimeter intact skin. Resident is constantly hollering but saying she is okay. Review of the Order Summary Report revealed resident had an order to clean sacral wound with wound cleanser, blot dry, apply honey Telfa and cover dry dressing every day shift every Tuesday and Friday with an order start date of 3/1/23. There also was an as needed (PRN) order with a start and order date of 3/1/23 for the same treatment. Review of the TAR dated 2/1/23 through 2/28/23 revealed the sacral wound order to cleanse with wound cleanser; blot dry; apply Honey Telfa; and cover dry dressing every day shift every Monday, Wednesday and Friday with a start date 12/5/22 and discontinued on 2/22/23. There was no evidence that wound care was completed on 2/1/23, 2/3/23, or 2/6/23. Review of the weekly skin check dated 2/3/23 revealed no new skin issues and the sacral pressure ulcer treatment was ongoing. The weekly skin check dated 2/20/23 revealed the sacrum wound was seen by the wound physician. Review of the (name) wound consult report dated 2/21/23 revealed a sacral stage IV pressure wound full thickness. The treatment was Dakin solution apply three times a week for 17 days. Leptospermum honey apply three times a week for 17 days. There was no evidence of the sacral wound care after 2/22/23 until a new order was written on 3/1/23. During an interview on 3/2/23 at 3:47 p.m. LPN GG revealed that she thinks the resident was admitted with the wound on admission. There was no explanation why the sacral wound order was discontinued on 2/22/23. LPN GG expressed difficulty in navigating the system for entering wound data.

Based on observations, record review, staff interviews and review of the facility policy titled, Change in Resident's Condition the facility failed to promptly notify the physician of the identification of wounds and the lack of wound care treatments for one of 13 (R# 22) residents with pressure ulcers. On September 17, 2020, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the Immediate Jeopardy on September 17, 2020 at 10:41 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 7/30/2020 and was removed on 9/22/2020. The Immediate Jeopardy is outlined as follows: Resident #22 (R#22) was admitted to the nursing facility on 7/23/2020, at which time a skin assessment was completed that documented that R#22 had a reddened area to his sacrum. There were not any other weekly Skin Head to Toe assessments for R#22 from 7/23/2020 until 8/24/2020 at which time R#22 was documented as having a Stage III pressure ulcer to the sacrum. On 9/2/2020, R#22 was sent to a local acute care hospital. The hospital's History and Physical note dated 9/2/2020, documented that R#22 was admitted with a large area of Stage IV pressure ulcer with a very foul odor. A wound culture was obtained on 9/2/2020 and the wound was found to be positive for Escherichia coli (E. coli). The History and Physical included an Assessment/Plan that documented: A Physician had been consulted to determine if R#22 needed a wound debridement or if he needed a wound debridement with diverting [MEDICAL CONDITION]. Review of the hospital's Discharge summary dated 9/10/2020, documented that after R#22's surgery for [REDACTED]. Due to his large size and severe debility and Stage IV pressure ulcer R#22 was discharged to a Long-Term Care Acute hospital. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 CFR 483.10 Notify of Changes, F580; 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656; CFR 483.25 Treatment/Services to Prevent/Heal Pressure Ulcers, F686; CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, F686. A Credible Allegation of Compliance (Removal Plan) was received. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 9/22/2020. The facility continued management level staff oversight of wound care and wound care treatments. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing pressure ulcers and wound care. After the Credible Allegation of Compliance (Removal Plan) was received, in-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure staff demonstrated knowledge of the facility' Policies and Procedures related to pressure ulcers and providing wound care. Findings include: Record review of the policy titled, Change in Resident's Condition Documentation Guidelines revealed: Notification of the resident's responsible party, including date and time of changes in the resident's medical/mental condition and/or Status. Policy Interpretation: The Licensed Nurse or other, will notify the resident's Attending Physician or on-call Physician when there has been a significant change in the resident's physical/emotional/mental condition. Record review of the facility Face sheet revealed R#22 was admitted on [DATE] with the following diagnoses, that included but were not limited to [MEDICAL CONDITION] severe, hypertension, obstructive sleep apnea, and [MEDICAL CONDITION]. Record review of the Progress Notes dated 7/28/2020 through 9/2/2020 revealed R#22 had an area which appeared to be worsening and the circumference was becoming larger. It was also noted R#22 may need a referral to wound care specialist for [MEDICATION NAME]. An entry dated 8/28/2020 documented that R#22 currently had a Stage III pressure ulcer to the sacrum. Record review revealed that there was not any evidence of documentation that the Physician was notified. Record review of an Acute Care Regional Medical Center face sheet revealed an admitted [DATE]. The History and Physical documentation dated 9/2/2020 revealed the resident was admitted for a sacral decubitus ulcer stage IV. An interview on 9/10/2020 at 10:32 a.m. with the Medical Director revealed the skin assessment should be done on the initial admission, weekly, and upon hospital return. An interview on 9/16/2020 at 9:24 a.m. with LPN YY revealed on 8/21/2020 she stated the wound appeared to have gotten worse and needed to be debrided. She did not know who the treatment nurse was and she did not take measurements. An interview on 10/19/2020 at 11:11 a.m. with the Director of Nursing (DON) revealed the original treatment nurse unexpectantly resigned on 8/5/2019. Upon resigning, the nurse left no contact information and was unable to be contacted for an interview via the information the facility had on file for the former employee. However, the DON went on to reveal this nurse was responsible for the weekly head to toe and weekly pressure ulcer assessments. The former employee was also responsible for contacting the Medical Director. The DON revealed it was not known why the former treatment nurse did not contact the Medical Director. Interview on 10/22/2020 at 1:48 p.m. with the Medical Director revealed that residents skin assessments should be done weekly and in accordance with the wound protocol. The Medical Director stated she was not aware the head-to-toe assessments were not being done and that head to toe assessments should have been done. Cross refer to F686 The facility implemented the following actions to remove the Immediate Jeopardy: 1. District Clinical Director completed education on the Change in Resident Condition Policy to Administrator, Director of Nursing, and Assistant Director of Nursing, Staff Development Coordinator and MDS/Care Plan Coordinator on 9/17/2020, no revisions were made in the Change in Condition Policy. Nursing Leadership team and Staff Development Coordinator initiated education on The Changes in Resident Condition Policy on 9/17/2020. 2. As of 9/17/2020 each resident with wounds was assessed and proper documentation of wound treatment in place and Medical Director notified. 3. An Ad Hoc QAPI Meeting was completed on 9/17/2020 to review Change in Resident Condition and timely notification of residents' physician. Staff attending the Ad Hoc QAPI was Director of Nursing, Assistant Director of Nursing, Staff Development, Social Services Director, Rehab Program Manager, Wound Care Nurse, MDS/Care Plan Coordinator, Activity Director and Restorative Aide. 4. On 9/17/2020 Administrator, District Director of Clinical Services, Director of Nursing, Assistant Director of Nursing and Staff Development reviewed facility policy Changes in Resident Condition Policy and no changes were made. Identification of other residents having the potential to be affected: All residents have the potential to be affected. Resident #22 no longer resides at the facility. Actions to Prevent Occurrence/Recurrence The following actions were taken to ensure occurrence or reoccurrence of process/system failure 1.On 9/17/2020 Medical Director was contacted and advised on deficiency. 2. District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician to Administrator, Director of Nursing, Assistant Director of Nursing and Staff Development Coordinator on 9/17/2020. Nursing Leadership team and Staff Development Coordinator initiated education on Changes in Resident Condition Policy which includes timely notification of the physician on 9/17/2020. 3. On 9/17/2020 Staff Development Coordinator initiated education for Licensed Nurses, on Changes in Condition Policy which includes timely notification of the physician and when there is a change in resident's physical or mental status, if attending physician cannot be reached, the physician on call and/or facility Medical Director should be contacted and clear documentation should be in resident's progress note. As of 9/18/2020, 10 out of 10 Registered Nurses, 11 out of 11 Licensed Practical Nurses, 1 out of 1 MDS/Care Plan Coordinator were educated regarding Change in Condition Policy which includes timely notification of the physician when there is a change in resident's physical or mental status. If attending physician cannot be reached, the physician on call and/or facility Medical Director should be contacted and clear documentation should be in resident progress note. This is 92% of the License Nursing Staff that were educated. The remaining 8% Licensed Nursing Staff who were unavailable for training due to being on leave or off duty will receive this in-service training upon their return to work. The Licensed Nursing Staff including Agency staff will not be allowed to begin providing direct care to residents without completion of this in-service training. 4. As of 9/21/2020, 25 out of 27 Certified Nursing Assistants were educated on recognizing and reporting changes in the resident's physical condition and understanding skin breakdown. As of 9/21/2020, 25 out of 27 Certified Nursing Assistants were given tests on Recognizing and reporting of changes in the resident's physical conditions, reporting changes to Charge Nurse and pressure ulcer prevention. The process is as follows: the Certified Nursing Assistant will alert the Charge Nurse if there is any change of resident condition. The Charge Nurse will notify the physician of change if physician not available, Medical Director will be notified. This is 92% of the Certified Nursing Assistants that were educated. The remaining 8% who were unavailable for training due to being on leave or off duty will receive this in-service training upon their return to work. These unlicensed Nursing Staff including Agency staff will not be allowed to begin providing direct care to residents without completion of this in-service training. 5. As of 9/18/2020 thirty two residents with wounds were assessed and proper documentation of wound treatment in place which includes site, stage, size, depth, odor, drainage, description, type of dressing, treatment, stage of healing, presence of pain and preventative equipment . On 9/18/2020 District Clinical Director, Administrator and Director of Nursing reviewed wound report which included site, stage, size, depth, odor, drainage, description, type of dressing, treatment, stage of healing, presence of pain and preventative equipment with Medical Director. Director of Nursing or Assistant Director of Nursing and District Director of Clinical Services completed Weekly Wound Check Audit Tool which includes completed head to toe skin check assessments, pressure ulcer and non-pressure ulcer skin assessments, and care plan updates on 9/18/2020. Three residents were noted to have new areas of skin breakdown. Physician was notified, treatment orders implemented, care plans updated, family notified and documented on Pressure Ulcer User Define Assessment. Visual skin checks will be completed weekly by Director of Nursing or Assistant Director of Nursing, Wound Nurse and will be documented on Skin Head to Toe User Define Assessment. Director of Nursing or Assistant Director of Nursing, Wound Nurse will notify physician of any changes in resident's skin assessment. 6. District Director of Clinical Services will complete 3-5 wound assessment compliance rounds using the Compliance Round Form once a week which includes site, stage, size, depth, odor, drainage, description, treatment, stage of healing, and preventative equipment on residents, type of dressing, presence of pain identified with wounds on the Weekly Wound Report. 7. All corrective actions were completed by 9/21/2020. 8. The Immediacy of the IJ was removed on 9/22/2020. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. A record review of the sign-in sheet dated 9/17/2020 revealed the District Clinical Director completed education on the Change in Resident Condition Policy to Administrator, Director of Nursing, and Assistant Director of Nursing, Staff Development Coordinator and MDS/Care Plan Coordinator on 9/17/2020. An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the Social Service Director on 9/24/2020 at 10:29 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the Rehab Program Manager on 9/24/2020 at 10:38 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the Wound Care Nurse on 9/24/2020 at 10:45 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the MDS/ Care Plan Coordinator on 9/24/2020 at 10:52 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the Activity Director on 9/24/2020 at 10:59 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the Restorative Aide Nurse on 9/24/2020 at 11:09 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. 2. Record review of document dated 9/14/2020 revealed facility had a total census of 86 of 86 residents included in building wide skin sweep 9/14/2020 (4 skin assessments completed), 9/15/2020 (4 skin assessments completed), 9/16/2020 (54 skin assessments completed) and 9/17/2020 (24 skin assessments completed) to identify skin issues in the facility. Record review of document dated 9/14/2020 revealed four skin assessments were completed. Record review of document dated 9/15/2020 revealed four skin assessments were completed. Record review of document dated 9/16/2020 revealed fifty-four skin assessments were completed. Record review of document dated 9/17/2020 revealed twenty-four skin assessments were completed. 3. Review of the sign-in sheet revealed an Ad Hoc QAPI Meeting was completed on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Svcs to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). Staff attending the Ad Hoc QAPI was Director of Nursing, Assistant Director of Nursing, Staff Development, Social Services Director, Rehab Program Manager, Wound Care Nurse, MDS/Care Plan Coordinator, Activity Director and Restorative Aide. The Ad Hoc QAPI Committee completed a root cause analysis which concluded that nursing staff had deficient knowledge of Skin. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Social Service Director on 9/24/2020 at 10:29 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Rehab Program Manager on 9/24/2020 at 10:38 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Wound Care Nurse on 9/24/2020 at 10:45 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the MDS/ Care Plan Coordinator on 9/24/2020 at 10:52 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Activity Director on 9/24/2020 at 10:59 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Restorative Aide Nurse on 9/24/2020 at 11:09 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). 4. An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed she along with the District Director of Clinical Services, Director of Nursing, Assistant Director of Nursing and Staff Development reviewed facility policy Changes in Resident Condition Policy and no changes were made. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed she along with the Administrator, District Director of Clinical Services, Assistant Director of Nursing and Staff Development reviewed facility policy Changes in Resident Condition Policy and no changes were made. An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed she along with the District Director of Clinical Services, Administrator, Director of Nursing, Director of Nursing and Staff Development reviewed facility policy Changes in Resident Condition Policy and no changes were made. An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed she along with the District Director of Clinical Services, Administrator, Director of Nursing, and the Assistant Director of Nursing reviewed facility policy Changes in Resident Condition Policy and no changes were made. Identification of other residents having the potential to be affected: All residents have the potential to be affected. Resident #22 no longer resides at the facility. Actions to Prevent Occurrence/Recurrence The following actions were taken to ensure occurrence or reoccurrence of process/system failure 1. Phone interview with Medical Director on 9/17/2020 at 2:47 p.m. revealed Administrator did contact Medical Director and advised on deficiency. 2. Record Review of the sign-in sheet revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed the District Clinical Director completed education on The Changes in Resident Condition Policy and timely notification of the physician. 3. Record review dated 9/17/2020 revealed documentation of an in-service facilitated by the District Clinical Director on Change in Resident Condition Policy to the facility's Administrator, Director of Nursing, and Assistant Director of Nursing, Staff Development Coordinator, MDS Care Plan Coordinator and at least 92% of the facility's Registered Nurses, License Practical Nurses and Certified Nursing Assistants on 9/17/2020. Record Review dated 9/17/2020 10 out of 10 Registered Nurses, 11 out of 11 Licensed Practical Nurses, 1 out of 1 MDS/Care Plan Coordinator were educated regarding Change in Condition Policy which includes timely notification of the physician when there is a change in resident's physical or mental status. If attending physician cannot be reached, the physician on call and/or facility Medical Director should be contacted, and clear documentation should be in resident progress note. Interviews with staff members revealed 10 out of 10 Registered Nurses, 11 out of 11 Licensed Practical Nurses, 1 out of 1 MDS/Care Plan Coordinator were educated regarding Change in Condition Policy which includes timely notification of the physician when there is a change in resident's physical or mental status. If attending physician cannot be reached, the physician on call and/or facility Medical Director should be contacted, and clear documentation should be in resident progress note. 4. Record review dated 9/17/2020 revealed 25 out of 27 Certified Nursing Assistants were educated on recognizing and reporting changes in the resident's physical condition and understanding skin breakdown. Phone interview with staff members on 9/23/2020 at 1:45 p.m. revealed 25 out of 27 Certified Nursing Assistants were educated on recognizing and reporting changes in the resident's physical condition and understanding skin breakdown. Multidisciplinary staff members were interviewed. All staff stated they had attended educational in-services related to the Center's policy and procedure for Recognizing and Reporting Changes In the Resident's Physical Condition, Understanding Skin Breakdown, Skin Management, Physician Notification and Care Plan development and revision related to pressure ulcer treatment. These educational sessions occurred on 9/17/2020. Staff interviewed were able to discuss wound care in-depth to include the following topics: identification, site, size, depth, odor, drainage, description, type of dressing, stage of healing, presence of pain, preventative equipment, treatment, assessment, staging of pressure ulcers, during admission, readmission and weekly until healing. Further interview revealed staff members would always document their findings and immediately report any degradant findings to the physician. Continued interview revealed each staff member knew the importance of following the Care Plan and that it should always be current and adhered to. The following staff members were interviewed on 9/21/2020: at 1:45 p.m., with CNA AA, at 1:49 p.m., with CNA FF, at 1:53p.m., with RN HH, at 1:55 p.m. with RN BB, at 1:58 p.m. with CNA GGG, at 2:25 p.m. with CNA DD, at 2:37 p.m. with Health Information Coordinator HHH, Interview at 3:15 p.m., with CNA III, at 3:25 p.m., with CNA DDD, at 3:31 p.m., with CNA EE, at 3:37 p.m., with CNA EEE, at 3:48 p.m. with CNA FFF, at 3:53 p.m. with CNA CC, at 4:03 p.m. with CNA II, at 4:09 p.m. with RN JJ, at 4:26 p.m. with CNA MM, at 4:31 p.m. with CNA NN, at 4:36 p.m. with Admission/ Care OO The following staff members were interviewed on 9/22/2020: at 10:07 a.m. LPN PP, at 10:12 a.m. LPN QQ, at 10:18 a.m. RN RR, at 10:23 a.m. LPN SS, at 10:29 a.m. LPN TT, at 10:36 a.m. LPN UU, at 10:41 a.m. LPN VV, at 10:46 a.m. Pharmacist WW, at 10:51 a.m. Pharmacist XX, at 10:57 a.m. LPM YY, at 11:03 a.m. RN/ MDS ZZ The following staff members were interviewed on 9/23/2020: at 3:59 p.m. with RN GG, at 1:52 p.m. with CNA JJJ, at 1:54 p.m. with RN KKK, at 1:57 p.m. with RN LLL, at 1:59 p.m. with CNA LL, at 2:01 p.m. with CNA MMM, at 2:03 p.m. with Floor Tech NNN, at 2:10 p.m. with LPN VVV, at 2:35 p.m. with RN PPP, at 2:42 p.m. with RN RR, at 2:59 p.m. with LPN UU, at 3:02 p.m. with LPN VV, at 3:36 p.m. with LPN QQ, at 3:44 p.m. with LPN QQQ, at 3:46 p.m. with RN RRR, at 3:48 with LPN SSS, at 3:50 p.m. with LPN TTT, at 3:52 p.m. with LPN UUU, at 3:53 p.m. with DON, at 4:08 p.m. with LPN WWW, at 4:55 p.m. with CNA XXX, at 5:05 p.m. with LPN YYY The following staff member was interviewed on 9/24/2020: at 9:16 a.m. RN KK 5. Record Review revealed on 9/18/2020 thirty two residents with wounds were assessed and proper documentation of wound treatment in place which includes site, stage, size, depth, odor, drainage, description, type of dressing, treatment, stage of healing, presence of pain and preventative equipment. Skin assessments were completed weekly which included proper documentation. 6. An interview with Clinical Director on 9/17/2020 at 11:31 a.m. revealed the District Director of Clinical Services will complete 3-5 wound assessment compliance rounds using the Compliance Round Form once a week which includes site, stage, size, depth, odor, drainage, description, treatment, stage of healing, and preventative equipment on residents, type of dressing, presence of pain identified with wounds on the Weekly Wound Report. 7. Based on record reviews and interviews, all corrective actions were completed by 9/21/2020. 8. The Immediacy of the IJ was removed on 9/22/2020.

Based on record review, interviews, and review of the facility policy titled, Comprehensive Care Plan the facility failed to implement comprehensive care plans for six of 22 residents (R) (R#6, R#7, R#19, R#20, R#21, R#22) related to the identification and treatment of [REDACTED]. On September 17, 2020, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the Immediate Jeopardy on September 17, 2020 at 10:41 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 7/30/2020 and was removed on 9/22/2020. The Immediate Jeopardy is outlined as follows: Resident #22 (R#22) was admitted to the nursing facility on 7/23/2020, at which time a skin assessment was completed that documented that R#22 had a reddened area to his sacrum. There were not any other weekly Skin Head to Toe assessments for R#22 from 7/23/2020 until 8/24/2020 at which time R#22 was documented as having a Stage III pressure ulcer to the sacrum. On 9/2/2020, R#22 was sent to a local acute care hospital. The hospital's History and Physical note dated 9/2/2020, documented that R#22 was admitted with a large area of Stage IV pressure ulcer with a very foul odor. A wound culture was obtained on 9/2/2020 and the wound was found to be positive for Escherichia coli (E. coli). The History and Physical included an Assessment/Plan that documented: A Physician had been consulted to determine if R#22 needed a wound debridement or if he needed a wound debridement with diverting [MEDICAL CONDITION]. Review of the hospital's Discharge summary dated 9/10/2020, documented that after R#22's surgery for [REDACTED]. Due to his large size and severe debility and Stage IV pressure ulcer R#22 was discharged to a Long-Term Care Acute hospital. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 CFR 483.10 Notify of Changes, F580; 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656; CFR 483.25 Treatment/Services to Prevent/Heal Pressure Ulcers, F686; CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, F686. A Credible Allegation of Compliance (Removal Plan) was received. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 9/22/2020. The facility continued management level staff oversight of wound care and wound care treatments. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing pressure ulcers and wound care. After the Credible Allegation of Compliance (Removal Plan) was received, in-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure staff demonstrated knowledge of the facility' Policies and Procedures related to pressure ulcers and providing wound care. Findings include: Review of Policy Comprehensive Care Plan (Revision date; November 2017) revealed the following: The facility will develop a comprehensive person-centered care plan that identifies each resident's medical, nursing, mental, and psychosocial needs within 7 days after completion of the comprehensive assessment. The care plan is developed with the resident or the resident's representative and reflects the resident's goal, wishes and preferences. The plan includes measurable objectives and timetables agreed to by the resident to meet such objectives. Fundamental Information Minimum Requirements of the Comprehensive Care Plan. The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The plan must address the resident's individual need, strength and preferences. Services provided must meet current professional standards of quality and be provided by qualified persons. 1.Review of the Admission Record revealed R#22 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] Section C - Cognitive Patterns, Brief Interview Mental Status (BIMS) revealed a score of 15 indicating intact cognition. Section G - Functional Status G0100 - Activity of Daily Living (ADL) Assist revealed R#22 required assistance with bed mobility and transfer. and G0400 noted no upper or lower extremity impairment. Section M - Skin Condition M300 revealed no pressure ulcers. Other Conditions noted that R#22 had a skin tear and moisture associated skin damage (MASD). Review of the care plan dated 8/18/2020 related to risk for pressure ulcer and MASD to the sacrum revealed that R#22 was at risk for the development of pressure ulcers related to impaired mobility. The care plan for MASD revealed MASD was present on admission. An update on 8/24/2020 revealed R#22 had a stage III pressure ulcer to sacrum. Interventions dated 8/18/2020 were to administer treatment as ordered, to complete a full body check weekly, and to provide incontinence care after each incontinence episode. On 8/25/2020 an intervention was added to the care plan to refer to wound care notes for weekly updates. Review of the July 2020 Treatment Administration Record (TAR) revealed R#22 had a Physician's Order to apply [MEDICATION NAME] 2% powder to MASD to buttock. There was no indication that the treatment was applied on 7/31/2020. Review of the August TAR revealed a treatment order to clean stage III pressure ulcer to sacrum (named) wound cleanser spray daily was dated 8/24/2020. There was no indication that the stage III pressure ulcer was cleaned with (named) wound cleanser spray on 8/29/2020. A treatment order to clean MASD bilateral upper buttocks to open areas of non-necrotic tissue every day shift every other day with antimicrobial skin and wound cleanser spray was dated 8/5/2020. There was no indication the MASD on upper bilateral buttocks was cleaned as ordered on [DATE], 8/16/2020, 8/20/2020, 8/22/2020, and 8/24/2020. Review of the Admission Skin-Head to Toe Skin Check dated 7/23/2020 revealed that R#22 had no identified pressure ulcer on admission. A weekly Skin- Head to Toe Skin Check dated 8/23/2020 revealed no pressure ulcers. The sacral area was noted as red. There was no indication that licensed nursing staff completed weekly Skin- Head to Toe Skin Checks on 7/30/2020, 8/6/2020, 8/13/2020, and 8/30/2020. 2. Review of the Admission Record revealed Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] Section C - Cognitive Patterns, BIMS revealed a score of 14 indicating intact cognition. Section G - Functional Status G0100 - Activity of Daily Living (ADL) Assist revealed R#6 required assist with bed mobility and transfer. G0400 noted no upper or lower extremity impairment. Section M - Skin Condition M300 revealed no pressure ulcers. Review of the care plan for deep tissue injury (DTI) (no date) revealed R#6 had a left heel DTI. The interventions were to administer treatments as ordered and observe for effectiveness, complete a full body check weekly and document, float heels while in bed, and refer to wound care notes for weekly update. Review of the July 2020 TAR for R#6 revealed that R#6 did not have wounds or wound treatments. Review of the August 2020 TAR revealed a treatment order dated 8/25/2020 to apply skin prep to DTI left heel daily, and float heel while in bed one time a day. Review of the Admission Skin- Head to Toe Skin Checks dated 7/24/2020 revealed R#6 was admitted with intact skin. The weekly Skin - Head to Toe Skin Checks dated 8/23/2020 also revealed the resident's skin was intact. There was no indication that licensed nursing staff performed weekly Skin - Head to Toe Skin Checks on 7/31/2020, 8/7/2020, 8/14/2020, 8/21/2020 and 8/28/2020 to identify possible skin breakdown timely as care planned. There was no indication on Skin- Head to Toe Skin Checks of when R#6 began to develop eschar to the left heel DTI that was observed on 8/25/2020. 3. Review of the Admission Record revealed R#7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] Section C - Cognitive Patterns, Brief Interview Mental Status (BIMS) revealed no score (resident did not complete the test). Section G - Functional Status G0100 - Activity of Daily Living (ADL) Assist revealed R#7 required extensive assist with bed mobility and transfer and G0400 noted one side upper and lower extremity impairment. Section M - Skin Condition M300 revealed one pressure ulcer stage III present upon admission. Review of the care plan (no date) for pressure ulcers revealed that R#7 was admitted with a stage III pressure ulcer to the sacrum. The Interventions/Tasks were to administer treatment as ordered, complete a full body check weekly and document. Additional interventions included refer to wound care notes for weekly updates. Review of the July 2020 TAR revealed a treatment to clean stage III pressure ulcer with (named) wound cleanser spray to sacrum every day shift. There was no indication that licensed nursing staff provided cleaning of the stage III pressure wound as ordered on [DATE], 7/3/2020, 7/17/2020, and 7/21/2020. Review of the August 2020 TAR revealed no indication that licensed nursing staff provided wound cleaning as ordered on [DATE], 8/15/2020, 8/16/2020, 8/17/2020, 8/19/2020, 8/20/2020, 8/21/2020, 8/22/2020, 8/23/2020, and 8/29/2020. 4. Review of the Admission Record revealed Resident #19 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE], Section C - Cognitive Patterns, BIMS revealed a score of 99 indicating R#19 was not able to complete the BIMS assessment. Section G - Functional Status G0100 - Activity of Daily Living (ADL) Assist revealed required extensive assist with bed mobility and transfer did not occur. The G0400 noted no upper extremity impairment and both sides of lower extremity impairment. Section M - Skin Condition M300 revealed one stage IV pressure ulcer present on admission. Review of the pressure ulcer care plan dated 4/1/2020 revealed that R#19 had a stage IV sacrum pressure ulcer. The Interventions/Tasks were to administer treatments as ordered and observe for effectiveness; and to complete weekly skin checks per facility protocol. Review of the Medication Review Report (Physician's Orders) for R#19 revealed the following treatment orders: Treatment order dated 4/1/2020 revealed an order for [REDACTED]. Treatment order dated 4/6/2020 revealed an order to cleanse stage 4 pressure ulcer to sacrum with (named) antimicrobial spray, apply (named) [MEDICATION NAME] ointment to tan/yellow necrotic tissue, pack wound with Dakin's solutions saturated gauze, cover with (named) foam dressing. Apply barrier skin solution to peri wound, every day shift for stage 4 pressure ulcer. This order was discontinued on 5/3/2020. Treatment order dated 5/3/2020 revealed an order to cleanse stage 4 pressure ulcer to sacrum with (named) spray, pack wound with Dakin solution saturated gauze, cover with (named) foam dressing. Apply skin barrier solution to peri wound every day shift for stage 4 pressure ulcer of sacrum. This order was discontinued on 5/6/2020. Treatment order dated 5/6/2020 revealed an order to cleanse stage 4 pressure ulcer to sacrum with (named) antimicrobial spray. Apply (named) skin barrier solution to peri wound every day shift for stage 4 pressure ulcer of sacrum. This order was discontinued on 7/8/2020. Treatment order dated 7/9/2020 revealed an order to cleanse stage 4 pressure ulcer to sacrum with (named) antimicrobial spray, apply (named) gel to left side of wound (normal granulation tissue) and apply [MEDICATION NAME] to right side of wound bed (hypergranulation tissue) then apply 4 x 4 gauze to wound bed and cover with (named) foam dressing. Apply (named) skin barrier to peri wound, every day shift. This order was discontinued on 7/12/2020 Treatment order dated 7/12/2020 revealed an order to cleanse stage 4 pressure ulcers to sacrum with (named) antimicrobial spray, apply (named) gel to wound bed, 4x4 gauze and cover with (named) foam dressing. Apply skin barrier solution to peri wound every day shift. This order was discontinued on 8/12/2020. Treatment order dated 8/12/2020 revealed an order to cleanse healing stage 4 pressure ulcer with (named) antimicrobial spray, blot dry, apply calcium alginate, moistened with (named) gel, cover with (named) foam dressing every 3 days and PRN if soiled or loosened, one time a day every 3 days. Review of the April 2020 TAR revealed wound treatments were provided as ordered. Review of the May 2020 TAR revealed no indication that the stage IV sacrum wound care treatments were completed on 5/18/2020, 5/25/2020 and 5/27/2020. Review of the June 2020 TAR revealed no indication that the sacrum stage IV pressure wound treatments were completed on 6/2/2020, 6/3/2020, 6/4/2020, 6/6/2020, 6/11/2020, 6/16/2020, 6/17/2020, 6/18/2020, 6/20/2020, 6/24/2020, 6/25/2020, 6/26/2020, 6/27/2020, 6/28/2020 and 6/30/2020. Review of the July 2020 TAR revealed no indication that the sacrum stage IV pressure wound treatments were completed on 7/2/2020, 7/3/2020, 7/17/2020, 7/18/2020 and 7/31/2020. Review of the August 2020 TAR revealed no indication of application of preventive cream on 8/5/2020, 8/10/2020, 8/13/2020, 8/14/2020 and 8/18/2020 for the evening shift. Review of the weekly Skin-Head to Toe Skin Checks revealed no evidence of (Weekly) Skin Head to Toe Skin Checks assessments for April 2020. Further review revealed there was only one (Weekly) Skin Head to Toe Skin Checks in May and that was dated 5/15/2020. There were no weekly Skin- Head to Toe Skin Checks for the month of June 2020 or July 2020. In August 2020, there were two (Weekly) Skin- Head to Toe Skin Checks dated 8/22/2020 and 8/29/2020. 5. Review of the Admission Record revealed R#20 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] Section C - Cognitive Patterns, Brief Interview Mental Status (BIMS) revealed a score of 0 indicating severe cognitive impairment. Section G - Functional Status G0100 - Activity of Daily Living (ADL) Assist revealed R#20 required extensive assist with bed mobility and transfer did not occur. and G0400 noted no upper extremity impairment and one side lower extremity impairment. Section M - Skin Condition M300 revealed no pressure ulcers. Review of the risk for pressure ulcer care plan with no date revealed R#20 was at risk for the development of pressure ulcers related to impaired mobility. An entry dated 7/20/2020 revealed a description of a quarter size discoloration to right side of sacrum. On 7/22/2020 the care plan was updated to include a stage II pressure ulcer to sacrum. The Interventions/Tasks for the stage II pressure ulcer were to administer treatments as ordered, complete a full body check weekly and document findings. Additional interventions included to observe/document/report as needed any changes in skin status. Review of the May 2020 TAR dated 5/1/2020 through 5/31/2020 revealed an order to apply skin protectant paste to buttocks every shift dated 5/1/2020. There was no indication that skin protectant paste was applied on 5/1/2020, 5/4/2020, 5/5/2020, 5/8/20, 5/9/2020, 5/10/2020, 5/11/2020, 5/12//2020, 5/16/2020, 5/23/2020, 5/25/2020, 5/26/2020, 5/27/2020, 5/28/2020, 5/29/2020, 5/30/2020 and 5/31/2020 for the evening shift and on 5/1/2020, 5/25/2020 for the morning shift. Review of the June 2020 TAR revealed no evidence that skin protectant paste was applied on 6/1/2020, 6/2/2020, 6/3/2020, 6/4/2020, 6/5/2020, 6/6/2020, 6/7/2020, 6/8/2020, 6/11/2020, 6/13/2020, 6/15/2020, 6/17/2020, 6/18/2020, 6/19/2020, 6/20/2020, 6/21/2020, 6/22/2020, 6/24/2020, 6/25/2020, 6/26/2020, 6/28/2020, 6/29/2020 and 6/30/2020. Review of the July 2020 TAR revealed no indication that the sacrum wound treatment to cleanse with (named) spray, then pat dry, apply heavy coating of skin barrier solution and cover with (named) foam dressing every day shift was completed on 7/31/2020. There was no indication that skin protective paste was applied on 7/3/2020, 7/4/2020, 7/5/2020, 7/8/2020, 7/9/2020. 7/13/2020, 7/14/2020, 7/17/2020, 7/18/2020, 7/19/2020, and 7/21/2020. Review of the August 2020 TAR revealed no indication that the sacrum wound treatment (to cleanse with (named) antimicrobial spray, then pat dry, apply heavy coating of skin barrier solution and cover with (named) foam dressing every day shift ) was completed on 8/10/2020, 8/14/2020, 8/15/2020, 8/16/2020, 8/17/2020, 8/18/2020, 8/19/2020, 8/22/2020, 8/23/2020, 8/24/2020, and 8/27/2020. Review of the May 2020, June 2020, July 2020, and August 2020 Medication Administration Record [REDACTED]. There was no indication that the weekly skin checks were provided from May 1, 2020 through August 31, 2020. The clinical record for R#20 only included three completed weekly Skin- Head to Toe Skin Checks dated 7/29/2020, 8/5/2020, and 8/12/2020. 6. Review of the Admission Record revealed Resident #21 [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] Section C - Cognitive Patterns, Brief Interview Mental Status (BIMS) revealed a score of 4, indicating severe cognitive impairment. Section G - Functional Status G0100 - Activity of Daily Living (ADL) Assist revealed R#21 required extensive assist with bed mobility and transfer and G0400 noted one side upper extremity impairment and no lower extremity impairment. Section M - Skin Condition M300 revealed one stage II pressure ulcer. Review of the undated care plan for risk for pressure ulcers revealed an entry dated 5/23/2020 that R#21 had a stage II pressure ulcer to the sacrum. The Interventions/Tasks were to administer treatment as ordered, and complete a full body check weekly and document. Additional interventions included notify the resident/family/caregivers of any new areas of skin breakdown. Review of the Medication Review Report (Physician's Orders) for R#21 revealed the following treatment orders: Treatment order dated 5/26/2020 Cleanse sacral wound with antimicrobial spray, pat dry, apply foam dressing daily on day shift and prn soiled or loosened. This order was discontinued on the same day, and the new order is listed below. A subsequent treatment order was dated 5/26/2020 to cleanse sacral wound with antimicrobial spray, pat dry, apply antimicrobial gel on a folded 4X4, apply barrier solution to peri wound and apply foam dressing daily on day shift and prn soiled or loosened. protective barrier solution to bilateral heels every Tuesday and Friday was ordered on [DATE]. Review of the May 2020 TAR revealed there was no indication that either of the sacrum wound treatments were completed on 5/27/2020. Review of the June 2020 TAR revealed no indication that the stage II sacrum pressure ulcer treatments were completed on 6/3/202, 6/4/2020, 6/10/2020, 6/11/2020, 6/17/2020, 6/18/2020, 6/20/2020, 6/21/2020, 6/22/2020, 6/23/2020, 6/24/2020, 6/26/2020, 6/27/2020, 6/29/2020, and 6/30/2020. The June 2020 TAR had no indication that any licensed nursing staff applied protective barrier solution to bilateral heels on 6/26/2020. Review of the July 2020 TAR revealed no indication that the sacrum pressure ulcer treatments were completed for 7/13/2020, 7/17/2020, 7/18/2020, 7/19/2020 and 7/31/2020. Review of the August 2020 TAR dated 8/1/2020 through 8/31/2020 revealed no indication that licensed nursing staff completed sacrum wound treatments on 8/14/2020, 8/16/2020, 8/18/2020, and 8/26/2020. Review of the July and August 2020 MAR for the weekly Skin- Head to Toe Skin Checks revealed no indication that skin assessments were completed on 7/4/2020, 8/1/2020, and 8/15/2020. An interview on 10/21/2020 at 12:04 p.m. The DON revealed that all nursing and nursing team are responsible for following the care plans to provide preventative treatments, wound care and skin assessments. The DON confirmed that the staff should have followed the care plans. An interview on 10/21/2020 at 12:41 p.m. RN LLL revealed that the care plans have interventions on how to take care of the residents and should be followed. An interview on 10/21/2020 at 2:40 p.m. RN GG revealed that the care plans are to let staff know how to take of a resident and nurses are to follow the interventions. An interview on 10/20/2020 at 3:31 p.m. The Administrator confirmed that the nursing staff and any person that provides direct care to the residents were to follow the care plan. The Administrator acknowledged that the staff should have followed the interventions put in place for the residents. Refer to F 686 The facility implemented the following actions to remove the Immediate Jeopardy: 1. District Clinical Director completed education on Comprehensive Care Plan Policy to Administrator, Director of Nursing, and Assistant Director of Nursing, Staff Development Coordinator and Care Plan Coordinator on 9/17/2020. Nursing Leadership team and Staff Development Coordinator initiated education on Comprehensive Care Plan Policy, including guidelines, on updating and following Care Plan interventions which include risk factors, refusal of care and hydration. 2. Thirty-two residents with wounds, care plans were reviewed, and updated to be reflective of patient wound status. Interventions, which comprised of staging, risk factors, preventative care, refusal of care, pain and hydration, were included in the care plans. 3. Administrator held Ad Hoc QAPI Meeting on 9/17/2020 to review F656 (Development/Implement Comprehensive Care Plan) and following the care plan relating to completing weekly skin assessments. Staff attending the AdHoc QAPI was Director of Nursing, Assistant Director of Nursing, Staff Development, Social Services Director, Rehab Program Manager, Wound Care Nurse, Activity Director and Restorative Aide. 4.On 9/17/2020 Administrator, District Director of Clinical Services, Director of Nursing, Assistant Director of Nursing and Staff Development reviewed facility policy Comprehensive Care Plan Policy and no changes were made. Identification of other residents having the potential to be affected. The following actions were taken to ensure occurrence or reoccurrence of process/system failure. Actions to Prevent Occurrence/Reoccurrence 1.On 9/17/2020 Medical Director contacted and advised on deficiency. 2.District Clinical Director completed education on Comprehensive Care Plan Policy to Administrator, Director of Nursing, and Assistant Director of Nursing, Staff Development Coordinator and MDS/Care Plan Coordinator on 9/17/2020. Nursing Leadership team and Staff Development Coordinator initiated education on Comprehensive Care Plan Policy, including guidelines, on updating and following Care Plan interventions. Staff Development Coordinator initiated education for Licensed Nurses, on Comprehensive Care Plan Policy, including guidelines, on updating and following Care Plan interventions. As of 9/18/2020, 10 out of 10 Registered Nurses, 11 out of 11 Licensed Practical Nurses, 1 out of 1 MDS/Care Coordinator were educated on Comprehensive Care Plan Policy, including guidelines, on updating and following Care Plan interventions. This is 92% of License Nursing Licensed Nursing Staff have been educated. The remaining 8% Licensed Nursing Staff who were unavailable for training due to be on leave or off duty will receive this in-service training upon their return to work. These Licensed Nursing Staff including Agency staff will not be allowed to begin providing direct care to residents without completion of this in-service training. 3. Thirty-two residents with wounds, care plans were reviewed, and updated to be reflective of patient wound status. Interventions, which comprised of staging, risk factors, preventative care, refusal of care, pain and hydration, were included in the care plans. 4.Thirty two residents with skin alterations were evaluated, updates made to plan of care and interventions in place which comprised of site, stage, size, depth, odor, drainage, description, treatment, stage of healing, preventive equipment, risk factors, preventative care, refusal of care, pain and hydration were included in the care plans. 5.The care plans for all residents with wounds will be reviewed weekly in Risk Meeting. 6.District Director of Clinical Services will complete compliance rounds using the Compliance Round Form once a week on 3-5 residents which includes site, stage, size, depth, odor, drainage, description, type of dressing, treatment, stage of healing, present of pain and preventative equipment on residents identified with wounds on the Weekly Wound Report. 7.All corrective actions were completed on 9/21/2020. 8.The Immediacy of the IJ was removed on 9/22/2020. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Review of records reveals in-service sign-in sheets 9/17/2020 revealed the Clinical Director completed education on Comprehensive Care Plan Policy to Administrator, Director of Nursing, Assistant Director of Nursing and Staff Development Coordinator. An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed she attended an in-service on the topic of Comprehensive Care Plan Policy. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed she attended an in-service on the topic of Comprehensive Care Plan Policy. An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed she attended an in-service on the topic of Comprehensive Care Plan Policy. An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed she attended an in-service on the topic of Comprehensive Care Plan Policy. An interview with the Rehab Program Manager on 9/24/2020 at 10:38 a.m. revealed she attended an in-service on the topic of Comprehensive Care Plan Policy. An interview with the Wound Care Nurse on 9/24/2020 at 10:45 a.m. revealed she attended an in-service on the topic of Comprehensive Care Plan Policy. An interview with the MDS/ Care Plan Coordinator on 9/24/2020 at 10:52 a.m. revealed she attended an in-service on the topic of Comprehensive Care Plan Policy. An interview with the Activity Director on 9/24/2020 at 10:59 a.m. revealed she attended an in-service on the topic of Comprehensive Care Plan Policy. An interview with the Restorative Aide Nurse on 9/24/2020 at 11:09 a.m. revealed she attended an in-service on the topic of Comprehensive Care Plan Policy. 2. An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed Thirty-two residents with wounds, care plans were reviewed, and updated to be reflective of patient wound status. Interventions, which comprised of staging, risk factors, preventative care, refusal of care, pain and hydration, were included in the care plans. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed Thirty-two residents with wounds, care plans were reviewed, and updated to be reflective of patient wound status. Interventions, which comprised of staging, risk factors, preventative care, refusal of care, pain and hydration, were included in the care plans. An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed Thirty-two residents with wounds, care plans were reviewed, and updated to be reflective of patient wound status. Interventions, which comprised of staging, risk factors, preventative care, refusal of care, pain and hydration, were included in the care plans. An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed Thirty-two residents with wounds, care plans were reviewed, and updated to be reflective of patient wound status. Interventions, which comprised of staging, risk factors, preventative care, refusal of care, pain and hydration, were included in the care plans. Record review revealed care plan were reviewed and updated to reflect wound status and included interventions to stage, risk factors, prevenentive care, pain, and hydration. 3. Review of the sign-in sheet revealed Administrator held Ad Hoc QAPI Meeting on 9/17/2020 to review F656 (Development/Implement Comprehensive Care Plan) and following the care plan relating to completing weekly skin assessments. Staff attending the AdHoc QAPI was Director of Nursing, Assistant Director of Nursing, Staff Development, Social Services Director, Rehab Program Manager, Wound Care Nurse, MDS/Care Plan Coordinator, Activity Director and Restorative Aide. The AdHoc QAPI Committee completed a root cause analysis which concluded that nursing staff had deficient knowledge of Skin. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F656 (Development/Implement Comprehensive Care Plan) and following the care plan relating to completing weekly skin assessments. An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F656 (Development/Implement Comprehensive Care Plan) and following the care plan relating to completing weekly skin assessments. An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F656 (Development/Implement Comprehensive Care Plan) and following the care plan relating to completing weekly skin assessments. An interview with the Social Service Director on 9/24/2020 at 10:29 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F656 (Development/Implement Comprehensive Care Plan) and following the care plan relating to completing weekly skin assessments. An interview with the Rehab Program Manager on 9/24/2020 at 10:38 a.m. revealed she attended an Ad Hoc QAPI Meeting o (TRUNCATED)

Based on record review, review of the facility policy titled, Skin Management System and staff interview, the facility failed to ensure that weekly skin assessments were completed, failed to identify skin breakdown, failed to consistently provide Physician ordered treatment for [REDACTED].#22) of 22 sampled residents. In addition, the facility failed to consistently provide weekly skin assessments, consistently assess the status of pressure ulcers and provide treatments in accordance with Physician's orders for five additional residents (R#6, R#7, R#19, R#20, R#21) of 22 sampled residents. On September 17, 2020, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the Immediate Jeopardy on September 17, 2020 at 10:41 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 7/30/2020 and was removed on 9/22/2020. The Immediate Jeopardy is outlined as follows: Resident #22 (R#22) was admitted to the nursing facility on 7/23/2020, at which time a skin assessment was completed that documented that R#22 had a reddened area to his sacrum. There were not any other weekly Skin Head to Toe assessments for R#22 from 7/23/2020 until 8/24/2020 at which time R#22 was documented as having a Stage III pressure ulcer to the sacrum. On 9/2/2020, R#22 was sent to a local acute care hospital. The hospital's History and Physical note dated 9/2/2020, documented that R#22 was admitted with a large area of Stage IV pressure ulcer with a very foul odor. A wound culture was obtained on 9/2/2020 and the wound was found to be positive for Escherichia coli (E. coli). The History and Physical included an Assessment/Plan that documented: A Physician had been consulted to determine if R#22 needed a wound debridement or if he needed a wound debridement with diverting [MEDICAL CONDITION]. Review of the hospital's Discharge summary dated 9/10/2020, documented that after R#22's surgery for [REDACTED]. Due to his large size and severe debility and Stage IV pressure ulcer R#22 was discharged to a Long-Term Care Acute hospital. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 CFR 483.10 Notify of Changes, F580; 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656; CFR 483.25 Treatment/Services to Prevent/Heal Pressure Ulcers, F686; CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, F686. A Credible Allegation of Compliance (Removal Plan) was received. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 9/22/2020. The facility continued management level staff oversight of wound care and wound care treatments. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing pressure ulcers and wound care. After the Credible Allegation of Compliance (Removal Plan) was received, in-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure staff demonstrated knowledge of the facility' Policies and Procedures related to pressure ulcers and providing wound care. Findings include: Review of Policy titled Skin Management System (revision date July 2017) as follows: PRACTICE GUIDELINES: 1. Upon admission or readmission, residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition and completing the Braden Scale for Predicting Pressure Sore Risk User Defined Assessment (UDA) in conjunction with the Nursing Admission Data Collection Set (UDA). 7. If a new pressure ulcer is identified, either upon admission, readmission, or during the resident's stay, the wound is assessed and documented on the Weekly Pressure Ulcer Record (UDA). 8. The licensed nurse will document daily monitoring of pressure ulcers on the Treatment Administration Record (TAR). 9. ONGOING SKIN ASSESSMENTS: 1. A Weekly Skin Check will be completed in the resident's record using the Head to Toe Skin Check (UDA). 2. An SBAR Communication Form and Progress Note (UDA) is completed and a new physician's order is obtained for new incidence of compromised skin integrity. 3. The nurse will initiate treatments, interventions, care plan, and the appropriate skin documentation records in a timely manner according to Practice Guidelines. 4. Pressure Ulcers are measured and staged in accordance with the Practice Guidelines. 1. Review of the closed record for R#22 revealed transfer to Emergency Department (ED) for wound evaluation on 9/2/2020. No observation of the wound was made by the surveyor due to the transfer. Review of the Admission Record revealed R#22 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] Section C - Cognitive Patterns, Brief Interview Mental Status (BIMS) revealed a score of 15, indicating that R#22 was cognitively intact. Section G - Functional Status G0100 - Activity of Daily Living (ADL) Assist revealed the resident required assist with bed mobility and transfer and G0400 noted no upper or lower extremity impairment. Section M - Skin Condition M300 revealed no pressure ulcers. It was noted under other condition that R#22 had a skin tear and moisture associated skin damage (MASD). Review of the Braden Scale for Predicting Pressure Sore Risk dated 7/30/2020 revealed a score of 16 indicating he was at risk. A 2nd Braden Scale for Predicting Pressure Sore Risk form dated 8/6/2020 revealed a score of 18 indicating at risk. A third Braden Scale for Predicting Pressure Sore Risk form dated 8/27/2020 revealed a score of 14 indicating moderate risk. (At risk 15-18, Moderate Risk 13 - 14, High Risk - 10 - 12, Very High Risk - 9 or below). Review of the Medication Review Report (Physician's Orders) revealed the following treatment orders: Apply [MEDICATION NAME] 2% powder to MASD to buttocks and abdominal folds daily and as needed (PRN) every day shift for redness and irritation related to [MEDICAL CONDITION], start date 7/31/2020. Clean bilateral lower legs with antimicrobial spray and pat dry, cover any open areas with calcium alginate, paint remaining areas with scales with [MEDICATION NAME], then wrap with kerlix daily and PRN if soiled or loosened, every day shift related to [MEDICAL CONDITION], start date 7/31/2020. Cleanse MASD to bilateral upper buttocks with antimicrobial spray, then pat dry, apply honey alginate to open areas of non-necrotic tissue, apply skin barrier solution to skin around open areas and cover with foam dressing every day shift every other day, dated 8/5/2020. Cleanse stage III pressure ulcer with antimicrobial spray, blot dry, apply medical grade honey [MEDICATION NAME] agent, cover with foam dressing daily and PRN if soiled or loosened one time a day. This order was dated 8/24/2020 and was the first day of treatment of [REDACTED]. Review of the facility Admission Data Collection dated 7/23/2020 revealed the following: Section 7. Physical Examination: Skin Integrity A. Skin Conditions 1. Is the skin intact was marked no; 2. Does the resident have a pressure ulcer was marked yes; 3. Does the resident have non-pressure areas/other skin condition was not marked yes or no. 4. If answer to #2 or #3 was yes, indicated type, location, size, etc., revealed the right buttock has redness, left thigh (rear) has bruising and the sacrum has redness. There were no pressure ulcers listed on the Admission Data Collection form. Review of the Progress Notes (nursing notes) for R#22 dated 7/28/2020 through 9/2/2020 revealed a nursing entry dated 8/21/2020 that indicated the sacral wound area was cleaned and redressed. The area appeared to be worsening and circumference becoming larger. The Progress Note indicated there was a possible need for a wound care consult for the removal of necrotic (dead) tissue. A second nursing entry related to the sacral wound dated 8/28/2020 revealed that R#22 had a stage III to sacrum that was being followed by wound care. A nursing entry dated 9/2/2020 revealed R#22 was transferred to the hospital for debridement of his sacral wound. However, there was no evidence that R#22 received an evaluation, treatment or Physician Orders from a wound care center specialist until 9/2/2020 when R#22 was sent to the hospital for surgical wound debridement of necrotic tissue. There was no evidence of additional Progress Notes that reflected any other skin impairment. Review of the facility Weekly Pressure Ulcer Log dated 8/25/2020 revealed R#22 had a facility acquired stage III pressure ulcer to the sacrum identified on 8/24/2020. This was the first documented indication of an alteration in skin integrity for R#22 on the Weekly Pressure Ulcer Log The measurements, dated 8/25/2020, were 10 cm x 8 cm x 5 cm. The sacral pressure ulcer stage III was described as having moderate odor, yellow drainage, 100% yellow slough and not improving. The Weekly Pressure Ulcer Log dated 9/2/2020 revealed R#22 had a facility acquired stage IV pressure ulcer to the sacrum. The report measurements were 10 cm x 8 cm x 6 cm. The sacral pressure ulcer stage IV was described as having moderate odor, yellow drainage, 100% yellow slough and deterioration of the wound. Review of the July 2020 TAR revealed no evidence that the treatment to apply [MEDICATION NAME] 2% powder to MASD on buttocks and abdominal folds was completed on 7/31/2020. Review of the August 2020 TAR revealed no evidence that treatment to the stage III pressure ulcer to sacrum was completed on 8/29/2020. There was no evidence that the treatment order dated 8/5/2020 to cleanse MASD to bilateral upper buttocks with antimicrobial spray, then pat dry, apply honey alginate to open areas of non-necrotic tissue, apply skin barrier solution to skin around open areas and cover with foam dressing every day shift every other day was completed on 8/14/2020, 8/16/2020, 8/20/2020, 8/22/2020, and 8/24/2020. Review of the admission Skin- Head to Toe Skin Check dated 7/23/2020 and the weekly Skin- Head to Toe Skin Check dated 8/23/2020 revealed that R#22's skin integrity assessments noted other existing issues. There was no pressure ulcer identified. There was no evidence licensed nursing staff completed a weekly Skin- Head to Toe Skin Check on 7/30/2020, 8/6/2020, 8/13/2020, and 8/30/2020. Review of the facility Weekly Skin Observations 7A-7P, 7P-7A schedule by room numbers revealed that R#22 was to have his weekly skin check every Monday on 7A-7P shift. Review of the Skin Weekly Pressure Ulcer Record dated 7/30/2020 revealed that R#22's MASD to his bilateral upper buttocks had worsened and noted that current treatment with [MEDICATION NAME] powder was ineffective. The MASD was characterized by severe excoriation and erosion. The erosion was described as partial thickness penetrating into the dermis. The wound bed was described as pink [MEDICATION NAME] tissue, red granulation tissue and 30% yellow/tan slough. Physician treatment orders were to start applications of medical grade honey-based gel sheet, honey alginate and foam dressing, no frequency was included with the order on this Skin Weekly Pressure Ulcer Record. Review of Skin-Weekly Pressure Ulcer Record dated 8/24/2020 revealed that R#22 had a new facility acquired stage III pressure ulcer to the sacrum. The measurements were 10 cm x 8 cm x 5 cm. The stage III pressure ulcer to sacrum was described as 100% yellow slough with yellow drainage. There was undermining at 11 o'clock position measured as 5 cm. A wound care appointment was made for telemedicine on 9/1/2020. The Skin - Weekly Pressure Ulcer Record dated 8/27/2020 revealed that R#22 had a new facility acquired stage IV pressure ulcer to the sacrum. The measurements were 10 cm x 8.5 cm x 6. The wound was described as necrotic tissue with moderate to heavy yellow drainage, 100% yellow slough. It was also noted that a consult was requested for a wound care Physician. There was no evidence that the Physician or the resident were informed of the stage IV pressure wound. The notification section of the form revealed that the Physician had been notified of the stage III pressure ulcer on 8/24/2020 and not notified of the stage IV pressure ulcer on 8/27/2020. Review of the admission Nutrition Data Collection dated 7/29/2020 revealed redness to right buttock and sacrum. No pressure ulcers were listed. Review of the Medication Administration Record (MAR) for July and August 2020 revealed there was no evidence documented on the MAR for the weekly skin checks. Review of the laboratory results for R#22, dated 7/24/2020, revealed the following: Glucose 101 mg/dl (70-105 mg/dl reference range), [MEDICATION NAME] 2.4 g/dl (3.5 -5.7 reference range), Total Protein 4.5 g/dl (6.2 - 8.2), HgbA1c 4.8 (nondiabetic <5.7, pre-diabetic 5.7 - 6.4, diabetic >/= 6.5). Review of the Progress Note Details dated 9/2/2020 revealed that Wound Care Physician MMM saw R#22 via telemedicine on 9/2/2020 for the first time. Physician MMM sent R#22 to the ED for admission for Operating Room (OR) debridement and intravenous (IV) antibiotics on 9/2/2020. The wound had been present greater than one month. Physician MMM described that R#22's sacral wound was located midline sacrum. The measurements were 10 cm x 8 cm x 5 cm. Muscle and fat layer s were exposed. There was a large amount of serosanguineous drainage noted and foul odor after cleaning. There was no granulation (healing tissue) within the wound bed. There was a large (67-100%) amount of necrotic (dead) tissue within the wound bed including adherent slough and necrosis of the muscle. The wound status was documented as caused by pressure injury. Review of the Order Summary Report revealed a Physician's telephone order dated 9/2/2020 to send R#22 to ED for evaluation and treatment. Review of an acute care hospital History and Physical dated 9/2/2020 documented R#22 was admitted for a sacral decubitus ulcer stage IV. The sacrum wound was noted to be a large area of stage IV decubitus, very foul odor from wound, some surrounding [DIAGNOSES REDACTED] and had poor granulation tissue. The consultant had questioned whether R#22 needed debridement versus debridement with diverting [MEDICAL CONDITION]. The acute care hospital Discharge Documentation dated 9/10/2020 revealed resident (R#22) was sent from the nursing home with a large stage IV decubitus on sacrum for wound debridement and care. Resident was taken to the Operating Room (OR) by the surgery team and surgical debridement was done. He developed some [MEDICAL CONDITION] following surgery and had to be intubated and went to Intensive Care Unit (ICU). Due to his obesity and large size of the wound, the resident needed a longer-term care and aggressive treatment for [REDACTED]. Review of the hospital sacrum decubitus wound culture dated 9/2/2020 documented that the wound culture from R#22's stage IV pressure ulcer was infected with Escherichia coli (E. coli). During an interview on 9/16/2020 at 9:24 a.m. Licensed Practical Nurse (LPN) YY revealed she saw R#22's sacral wound on 8/21/2020 and described the wound as dead skin in the middle which had pulled away from the edges. The wound was not black but had a yellowish color. She stated the wound looked like it had gotten worse and needed to be debrided. LPN YY revealed she did not know who the treatment nurse was and didn't take measurements. During an interview on 9/22/2020 at 2:20 p.m. Certified Nurse Aide (CNA) AAA revealed that when R#22 arrived at the facility he required total care, and later was able to reposition and turn himself. He was very cooperative and was not on a turn schedule. CNA AAA revealed she was assigned to his care the last 14 days he was in the facility. She described his sacrum as being red, and about 5 or 6 days later, the skin started to open. CNA AAA revealed the opening had an awful smell and a yellow substance was falling off the wound into the diaper. She stated that she reported her findings to the treatment nurse on the day it opened and the next day there was a dressing covering the wound. During an interview on 9/23/2020 at 2:26 p.m. Wound Care Physician MMM revealed that the initial visit should be in person for residents who require his services and are referred to him. Physician MMM revealed he would then follow with telemedicine based on the individual. Physician MMM was not available for additional interviews after 9/23/2020. 2. Review of the Admission Record revealed Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] Section C - Cognitive Patterns, Brief Interview Mental Status (BIMS) revealed a score of 14 indicating R#6's cognition was intact. Section G - Functional Status G0100 - Activity of Daily Living (ADL) Assist revealed required assist with bed mobility and transfer and G0400 noted no upper or lower extremity impairment. Section M - Skin Condition M300 revealed no pressure ulcers. Review of the hospital discharge summary dated 7/23/2020 revealed R#6 was discharged to the nursing home for rehabilitation without any skin issues identified. Review of the skin and wound Progress Notes dated 8/25/2020 revealed a new DTI to left heel measuring 3.0 cm x 2.0 cm. The Progress Notes revealed a new treatment order to apply skin barrier solution daily and to float heels while in bed. The Progress Notes (nursing note) dated 7/25/2020 through 8/25/2020 did not reveal any other skin issues. Review of the facility schedule for Weekly Skin Observations 7A -7P 7P-7A revealed R#6's room number was scheduled for skin assessments every Monday 7P-7A shift. During an observation 8/26/2020 at 10:43 a.m. with Registered Nurse (RN) KK, interim treatment nurse, and with R#6's permission. Measurements by RN KK were observed and were 4.0 cm x 3.3 cm. and the surrounding skin was described by RN KK as boggy. The right heel skin was intact, however, on the right ankle was an open area. The measurements by RN KK were 1.7 cm x 0.5 cm. During the measurement, RN KK stated that right ankle pressure ulcer was a stage II wound and had not been identified previously. Review of the Braden Scale for Predicting Pressure Sore Risks dated 8/22/2020 (Admission) revealed a score of 17 indicating at risk (Scoring - At Risk 15-18, Moderate Risk 13-14, High Risk 10-12, Very High Risk 9 or below). Review of the MAR for July and August 2020 revealed no evidence that the weekly skin assessment was on the MAR. Review of a subsequent August 2020 MAR revealed that the weekly skin checks were added on 8/26/2020 for every Thursday every shift. On 8/27/2020, R#6 was noted to have a weekly skin check documented on the MAR. Review of the July 2020 TAR revealed no evidence of any pressure wound treatments. Review of the August 2020 TAR revealed a treatment order dated 8/25/2020 to apply skin barrier solution to a deep tissue injury (DTI) to the left heel daily, and float heels while in bed. There was no evidence that on 8/29/2020 that skin barrier solution was applied to the left heel. Review of the admission Skin- Head to Toe Skin Checks dated 7/24/2020 revealed intact skin and no other skin issues were identified. The weekly Skin - Head to Toe Skin Checks dated 8/23/2020 revealed intact skin and no other skin issues identified. There was no evidence for weekly Skin - Head to Toe Skin Checks for 7/30/2020, 8/6/2020, 8/13/2020, 8/20/2020. A review of the admission Nutrition Registered Dietician (RD) assessment dated [DATE] revealed no skin issues and no nutritional recommendations. During an interview on 8/31/2020 at 2:26 p.m. CNA MM revealed that she was assigned to provide care for R#6 when she worked. She denied seeing any open areas on R#6. CNA MM revealed that she did recall seeing a scar on his right ankle during a bed bath. During an interview on 8/31/2020 at 2:38 p.m. RN KK interim treatment nurse revealed that R#6's pressure wounds were facility acquired wounds. She explained that the former treatment nurse resigned. RN KK continued to explain that she had recently returned from leave and was unofficially assigned to the treatment nurse position. 3. Review of the Admission Record revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] Section C - Cognitive Patterns, BIMS revealed no score (resident did not complete the assessment). Section G - Functional Status G0100 - Activity of Daily Living (ADL) Assist revealed R#7 required extensive assist with bed mobility and transfer and G0400 noted one side upper and lower extremity impairment. Section M - Skin Condition M300 revealed one pressure ulcer stage III present upon admission. Review of the Admission Data form dated 6/27/2020 revealed R#7 was admitted with a stage III pressure ulcer to sacrum with no measurements or description on the form. Review of admission Braden Scale for Predicating Pressure Sore, dated 6/26/2020, revealed a score of 13 indicating moderate risk (Scoring - At Risk 15 -18, Moderate Risk 13-14, High Risk 10-12, Very High Risk 9 or below) Review of the Order Summary Report (Physician Orders) revealed there were no wound treatment orders dated on admission on 6/26/2020. On 6/31/2020 Physicians Orders for wound treatment included the following: Clean stage III pressure ulcer with antimicrobial spray, pat dry, apply calcium alginate and cover with foam dressing daily and as needed if soiled or loosened every day shift. On 7/8/2020 a new order was received for wound care as follows: Clean sacral pressure wound with antimicrobial spray, pat dry, apply medical honey based gel and cover with foam dressing every other day on day shift and prn if soiled or loosened. On 7/21/2020 a new order was received as follows: Clean the stage III pressure ulcer with antimicrobial spray, pat dry, apply [MEDICATION NAME] ointment and cover with name foam dressing daily and as needed (PRN) if soiled or loosened. The [MEDICATION NAME] ointment 250 unit/gm order was ordered to apply to sacral wound topically every day shift for stage III sacral ulcer. During an observation on 8/26/2020 at 10:30 a.m. with RN KK, of R#7's sacral wound, with his permission, RN KK measured the wound and revealed the measurements were 2.3 cm x 2.2 cm x 1.5 cm. Review of the July 2020 TAR revealed no evidence that the stage III pressure ulcer to sacrum treatments were completed for 7/2/2020, 7/3/2020, 7/17/2020, and 7/21/2020. Review of the August 2020 TAR revealed no evidence that treatments to the sacral stage III pressure wound were completed on 8/9/2020, 8/15/2020, 8/16/2020, 8/17/2020 8/18/2020, 8/19/2020, 8/20/2020, 8/21/2020, 8/22/2020, 8/23/2020, and 8/29/2020. Review of the Skin- Weekly Pressure Ulcer Record dated 7/31/2020, revealed no measurements for the sacral pressure wound. The description of the site listed a stage III pressure ulcer without any details. The wound bed description noted that the sacral wound did not have drainage or odor and was improving. The weekly Skin -Weekly Pressure Ulcer Record dated 8/24/2020 revealed the sacral wound had 60% yellow slough with 40% red granulation and the measurements were 2 cm x 2 cm x 0.3 cm with a small amount of drainage and mild odor. There was no evidence that weekly Skin - Weekly Pressure Ulcer Records were completed on 7/1/2020, 7/8/2020, 7/15/2020, 7/22/2020, 8/5/2020, 8/12/2020, and 8/19/2020. Review of the Weekly Pressure Ulcer Log report revealed as follows: 7/1/2020 no measurements were obtained for the stage III pressure ulcer to the sacrum. 7/8/2020- no report 7/15/2020 sacral wound measurements were 2.5 cm x 2.4 cm x 0.3 cm and had a mild odor, pinkish granulation with 40% yellow slough. 7/22/2020 sacral wound measurements are 2.5 cm x 2.4 cm x 0.3 cm with red granulation, 75% yellow slough, and slightly worsened. 7/29/2020 sacral wound measured 2.7 cm x 3.2 cm x 0.3 cm with 65% yellow slough. 8/5/2020 sacral wound measurements 2 cm x 2.5 cm x 0.3 cm was improving. 8/12/2020 no report 8/19/2020 no report 8/25/2020 sacral wound measurements were 2 cm x 2.5 cm x 0.3 cm with 60% yellow slough. 9/2/2020 sacral wound measurements were 3 cm x 2 cm x 0.2 cm with 60% yellow slough and worsening of the wound. There was no evidence that the Weekly Pressure Ulcer Log was completed and measurements were obtained for 7/8/2020, 8/12/2020, and 8/19/2020. Review of the above Weekly Pressure Ulcer Log measurements revealed that R#7 had a decline in his sacral wound. Review of the Progress Notes (Skin/Wound Note) dated 6/29/2020 revealed a sacral wound measurement of 2 cm x 2 cm x 0.2 cm. The Progress Notes (Skin/Wound Note) dated 7/14/2020, revealed a sacral wound measurements of 2.0 cm x 2.0 cm x 0.6 cm. There was no evidence of progress notes (Skin/Wound or Nursing Notes) for the sacral wound documentation for 7/8/2020, 7/15/2020, 7/22/2020, 7/29/2020, 8/5/2020, 8/12/2020, 8/19/2020, 8/25/2020 and 9/2/2020. During an interview on 9/9/2020 at 3:19 p.m. RN KK, interim treatment nurse, revealed that R#7 was admitted to the facility with a stage III sacral pressure ulcer. The previous treatment nurse was unavailable for interviews. 4. Review of the Admission Record revealed Resident #19 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] Section C - Cognitive Patterns, Brief Interview Mental Status (BIMS) revealed a score of 99 indicating unable to answer one or more assessment questions. R#19 had a BIMS score of 10 on the previous Quarterly MDS dated [DATE], indicating a decline in cognition. The 9/4/2020 MDS Section G - Functional Status G0100 - Activity of Daily Living (ADL) Assist revealed R#7 required extensive assist with bed mobility and transfer did not occur. The G0400 noted no upper extremity and both side lower extremity impairment. Section M - Skin Condition M300 revealed one stage IV pressure ulcer. An observation was conducted on 8/31/2020 at 11:11 a.m. with RN KK and LPN BB assisting with wound care. The measurements provided by RN KK were 4.0 cm x 2.3 cm. Review of the Braden Scale for Predicting Pressure Sore Risk dated 8/16/2020 revealed a score of 13 indicating Moderate Risk (Scoring - At risk 15-18 Moderate Risk 13-14, High Risk 10-12, Very High Risk 9 or below) Review of the Medication Review Report (Physician's Orders) revealed treatment orders as follows: Dakins Solution 0.125% apply to sacral topically one time a day, dated 4/1/2020. This order was discontinued 5/6/2020. Cleanse stage IV pressure ulcer to sacrum with (named) antimicrobial spray, pack wound with Dakin's saturated gauze, cover with (named) foam dressing. Apply skin barrier solution to peri wound every day shift, dated 5/6/2020. This order was discontinued on 7/8/2020. Cleanse stage 4 pressure ulcer to sacrum with (named) antimicrobial spray, apply (named) antimicrobial gel to left side of wound (normal granulation tissue) and apply [MEDICATION NAME] to right side of wound bed (hyper granulation tissue) than apply 4x4 gauze to wound bed and cover with (named) foam dressing. Apply skin barrier solution to peri wound every day shift, dated 7/9/2020. This order was discontinued on 7/12/2020. Cleanse stage 4 pressure ulcer to sacrum with (named) antimicrobial spray, apply (named) antimicrobial gel to wound bed, 4x4 gauze and cover with (named) foam dressing. Apply skin barrier solution to peri wound every day shift for stage 4 pressure ulcer of sacrum, dated 7/12/2020. This order was discontinued on 8/12/2020. Clean healing stage IV pressure ulcer to sacrum with antimicrobial spray. blot dry, apply calcium alginate moisten with antimicrobial gel, cover with foam dressing every 3 days and PRN if soiled or loosened one time a day, dated 8/13/2020. Review of the May 2020 TAR revealed no evidence that the stage IV pressure ulcer treatment to the sacrum was completed on 5/18/2020, 5/25/2020 and 5/27/2020. Review of the June 2020 TAR revealed no evidence that the stage IV pressure ulcer treatment to the sacrum was completed on 6/2/2020, 6/3/2020, 6/4/2020, 6/6/2020, 6/11/2020, 6/16/2020. 6/17/2020, 6/18/2020, 6/24, 6/25, 6/26, 6/27, 6/28 and 6/30/2020. Review of the July 2020 TAR revealed no evidence that the stage IV pressure ulcer treatment to the sacrum was completed on 7/2/2020/ 7/3/2020, 7/17/2020, 7/18/2020, 7/31/2020. Review of the August 2020 TAR revealed no evidence that the stage IV pressure ulcer treatment to the sacrum was completed on 8/5/2020, and 8/10/2020. There was no evidence that the weekly Skin - Head to Toe Skin Checks and the Skin - Weekly Pressure Ulcer Record for 5/20/2020 through 8/21/2020 2020 were completed. Review of the facility Weekly Pressure Ulcer Log report dated revealed no evidence for weekly measurements to the sacrum pressure ulcer for 7/1/2020, 7/8/2020, 8/12/2020, and 8/19/2020. Review of the hospital Discharge Summary dated 3/16/2020 revealed R#19 had a stage IV sacrum decubitus. There were no other pressure ulcers identified upon discharge from the hospital. The wound care nurse employed at the time of R#19's admission was unavailable for interviews. 5. Review of the Admission Record revealed Resident #20 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change MDS dated [DATE] Section C - Cognitive Patterns, Brief Interview Mental Status (BIMS) revealed a score of 0. Section G - Functional Status G0100 - Activity of Daily Living (ADL) Assist revealed R#20 required extensive assist with bed mobility and transfer did not occur. and G0400 noted no upper impairment and one side lower extremity impairment. Section M - Skin Condition M300 revealed no pressure ulcers. Review of the weekly Skin-Head to Toe Skin Check revealed as follows: 7/29/2020 existing bruises and existing skin tears. The description of skin issues revealed existing bruises to right and left upper extremities and anterior neck. The description also included a skin tear to back of left hand. 8/5/2020 skin integrity had existing bruises, existing skin tears and existing abrasions. It was noted that R#20 had bruising to bilateral upper extremities. The description o (TRUNCATED)

Based on record review, staff interviews, and review of the Administrator and Director of Nursing job descriptions, administration failed to ensure adequate management and monitoring of services to prevent and treat pressure ulcers and failed to ensure that care planned interventions were followed. The facility census was 84. On September 17, 2020, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the Immediate Jeopardy on September 17, 2020 at 10:41 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 7/30/2020 and was removed on 9/22/2020. The Immediate Jeopardy is outlined as follows: Resident #22 (R#22) was admitted to the nursing facility on 7/23/2020, at which time a skin assessment was completed that documented that R#22 had a reddened area to his sacrum. There were not any other weekly Skin Head to Toe assessments for R#22 from 7/23/2020 until 8/24/2020 at which time R#22 was documented as having a Stage III pressure ulcer to the sacrum. On 9/2/2020, R#22 was sent to a local acute care hospital. The hospital's History and Physical note dated 9/2/2020, documented that R#22 was admitted with a large area of Stage IV pressure ulcer with a very foul odor. A wound culture was obtained on 9/2/2020 and the wound was found to be positive for Escherichia coli (E. coli). The History and Physical included an Assessment/Plan that documented: A Physician had been consulted to determine if R#22 needed a wound debridement or if he needed a wound debridement with diverting [MEDICAL CONDITION]. Review of the hospital's Discharge summary dated 9/10/2020, documented that after R#22's surgery for [REDACTED]. Due to his large size and severe debility and Stage IV pressure ulcer R#22 was discharged to a Long-Term Care Acute hospital. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 CFR 483.10 Notify of Changes, F580; 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656; CFR 483.25 Treatment/Services to Prevent/Heal Pressure Ulcers, F686; CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, F686. A Credible Allegation of Compliance (Removal Plan) was received. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 9/22/2020. The facility continued management level staff oversight of wound care and wound care treatments. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing pressure ulcers and wound care. After the Credible Allegation of Compliance (Removal Plan) was received, in-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure staff demonstrated knowledge of the facility' Policies and Procedures related to pressure ulcers and providing wound care. Findings include: Review of the job description titled, Administrator revealed: Summary - responsible for the overall management of a facility, plans, develops, directs, monitors, and supports all operational, administrative, clinical . programs and services. Functions - directs and coordinates all functions of the facility. Responsibility - is responsible for efficient execution of the programs and services with highest possible standards. Ensures the quality and appropriateness of resident/ patient care meets or exceeds company and regulatory standards. A review of the job description titled, Director of Nursing job revealed that the primary purpose of the job position is to plan, organize, develop and direct the day to day functions of the Nursing Service Department to ensure that the highest degree of quality of care is maintained at all times. However, facility administrative and nursing administrative staff failed to provide effective supervision of licensed nursing staff and failed to adequately manage and monitor services to prevent and treat pressure ulcers for R#22. 1. Administration failed to promptly notify the physician of the identification of wounds, the lack of wound care, and the deterioration of a wound for R#22. Cross refer F580 2. Administration failed to ensure that the care plans were being followed failed to follow the care plan to complete weekly Skin Head to Toe assessments and weekly Skin Weekly Pressure Ulcer Records and failed to administer treatment for [REDACTED]. 3. Administration failed to ensure that weekly Skin Head to Toe assessments and weekly Skin Weekly Pressure Ulcer Records were completed consistently; failed to identify breakdown timely, failed to consistently assess and provide treatment for [REDACTED].#22) who required inpatient hospital care for an infected Stage IV pressure ulcer. In addition, the facility failed to consistently complete weekly Skin Head to Toe assessments and weekly Skin Weekly Pressure Ulcer Records consistently for five of 13 residents (R#6, R#7, R#20, R#21, R#22) with pressure ulcers. Cross refer F686 4. Administration failed to have an effective Quality Assurance process that identified concerns related to the care and management of residents with pressure ulcers that required wound care. Cross refer F867 During an interview on 9/17/2020 at 9:34 a.m. with the Administrator revealed she was informed on 8/12/2020 there was a problem with wound care and the LPN treatment nurse left. The Administrator revealed she became aware of R#22 having a bad wound a couple of days before 9/2/2020. The Administrator confirmed the facility did fail to ensure adequate monitoring of services to prevent and treat pressure ulcers. The facility implemented the following actions to remove the Immediate Jeopardy: 1. As of 9/18/2020 District Clinical Director completed education on adequate monitoring of services to prevent and treat pressure ulcers to Administrator, Director of Nursing, Assistant Director of Nursing and Staff Development Coordinator. 2. Total census of 86 of 86 resident were included in facility wide skin assessment sweep 9/14/2020 (4 skin assessments completed), 9/15/2020 (4 skin assessments completed), 9/16/2020 (54 skin assessments completed) and 9/17/2020 (24 skin assessments completed) to identify skin issues in the facility. 3. On 9/17/2020 Administrator ensured each skin concern was reported to Medical Director and interventions are in place. 4. On 9/17/2020 Administrator and Director of Nursing reviewed head to toe skin assessments with District Clinical Director. Three residents were noted to have new areas of skin breakdown. Physician was notified, treatment orders implemented, care plans updated, family notified and documented on Pressure Ulcer User Define Assessment. 5. On 9/17/2020 Administrator and Director of Nursing notified Medical Director and Wound Care Physician on the status of wounds in the facility which included 32 out of 32 current wounds in the facility and the Immediate Jeopardy Citations. 6. An Ad Hoc QAPI Meeting was completed on 9/17/2020 to review F835 (Administration) and adequate monitoring of services to prevent and treat pressure ulcers. Staff attending the AdHoc QAPI was Director of Nursing, Assistant Director of Nursing, Staff Development, Social Services Director, Rehab Program Manager, Wound Care Nurse, Activity Director and Restorative Aide. Identification of other residents having the potential to be affected: All residents have the potential to be affected. Resident #22 no longer resides at the facility. Actions to Prevent Occurrence/ Recurrence 1. On 9/17/2020 Medical Director contacted and advised on deficiency. 2. On 9/18/2020 District Clinical Director completed education on adequate monitoring of services to prevent and treat pressure ulcers to Administrator, Director of Nursing, Assistant Director of Nursing and Staff Development Coordinator. 3. On 9/18/2020 District Clinical Director educated the Administrator and Director of Nursing regarding the regulatory guidelines of F835. On 9/18/2020 the Vice President of Operations reviewed the Licensed Nursing Home Administrator job description to include ensuring the facility is safe and in accordance with company policy and regulatory guidelines. 4. Administrator will attend Clinical Morning meetings at least three times weekly. 5. Administrator will attend weekly Risk Meetings weekly for four weeks and bi-monthly thereafter. 6. Administrator will review with Director of Nursing and District Director of Clinical Services in- house wound status weekly which includes new areas of skin breakdown, physician notification, treatment orders implemented, care plans updated, family notification and review of wound documentation to ensure all wounds are assessed and documented thoroughly. 7. All corrective actions were completed on 9/21/2020. 8. The Immediacy of the IJ was removed on 9/22/2020. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Review of records reveals in-service sign-in sheets 9/18/2020 revealed the Clinical Director completed education on adequate monitoring of services to prevent and treat pressure ulcers to Administrator, Director of Nursing, Assistant Director of Nursing and Staff Development Coordinator. An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed she attended an in-service on the topic of adequate monitoring of services to prevent and treat pressure ulcers. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed she attended an in-service on the topic of adequate monitoring of services to prevent and treat pressure ulcers. An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed she attended an in-service on the topic of adequate monitoring of services to prevent and treat pressure ulcers. An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed she attended an in-service on the topic of adequate monitoring of services to prevent and treat pressure ulcers . 2. Record review of document dated 9/14/2020 revealed four skin assessments were completed. Record review of document dated 9/15/2020 revealed four skin assessments were completed. Record review of document dated 9/16/2020 revealed fifty-four skin assessments were completed. Record review of document dated 9/17/2020 revealed twenty-four skin assessments were completed. 3. Phone interview with Medical Director on 9/17/2020 at 2:47 p.m. revealed Administrator did report skin concerns to Medical Director's office and interventions were in place. 4. On 9/17/2020 Administrator and Director of Nursing reviewed head to toe skin assessments with District Clinical Director. Three residents were noted to have new areas of skin breakdown. Physician was notified, treatment orders implemented, care plans updated, family notified and documented on Pressure Ulcer User Define Assessment. 5. Interview with Medical Director on 9/17/2020 at 2:47 p.m. revealed Administrator and Director of Nursing notified Medical Director and Wound Care Physician on the status of wounds in the facility. Three residents were noted to have new areas of skin breakdown. Physician was notified, treatment orders implemented, care plans updated, family notified and documented on User Define Assessment. 6. Review of the sign-in sheet revealed an Ad Hoc QAPI Meeting was completed on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Svcs to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). Staff attending the AdHoc QAPI was Director of Nursing, Assistant Director of Nursing, Staff Development, Social Services Director, Rehab Program Manager, Wound Care Nurse, MDS/Care Plan Coordinator, Activity Director and Restorative Aide. The AdHoc QAPI Committee completed a root cause analysis which concluded that nursing staff had deficient knowledge of Skin. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Social Service Director on 9/24/2020 at 10:29 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Rehab Program Manager on 9/24/2020 at 10:38 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Wound Care Nurse on 9/24/2020 at 10:45 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the MDS/ Care Plan Coordinator on 9/24/2020 at 10:52 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Activity Director on 9/24/2020 at 10:59 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Restorative Aide Nurse on 9/24/2020 at 11:09 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). Identification of other residents having the potential to be affected: All residents have the potential to be affected. Resident #22 no longer resides at the facility. Actions to Prevent Occurrence/ Recurrence 1. Phone interview with Medical Director on 9/17/2020 at 2:47 p.m. revealed Administrator did contact Medical Director and advised on deficiency. 2. Record review of document dated 9/17/2020 revealed District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. 3. Record review of document dated 9/18/2020 revealed District Clinical Director educated the Administrator and Director of Nursing regarding the regulatory guidelines of F867 (QAPI/QAA Improvement Activities.) An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed the District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed the District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. 4. An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed the District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. 5. An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed the District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. 6. An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed the District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. 7. Based on record reviews and staff interviews, all corrective actions were completed on 9/21/2020. 8. The Immediacy of the IJ was removed on 9/22/2020.

Based on clinical record review, staff interviews, and review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program the facility failed to ensure that there was a Quality Assurance and Performance Improvement (QAPI) process in place that identified concerns related to the care and management of residents with pressure ulcers including failed to ensure that weekly skin assessments were completed and failed to ensure timely identification and treatment of [REDACTED]. On September 17, 2020, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the Immediate Jeopardy on September 17, 2020 at 10:41 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 7/30/2020 and was removed on 9/22/2020. The Immediate Jeopardy is outlined as follows: Resident #22 (R#22) was admitted to the nursing facility on 7/23/2020, at which time a skin assessment was completed that documented that R#22 had a reddened area to his sacrum. There were not any other weekly Skin Head to Toe assessments for R#22 from 7/23/2020 until 8/24/2020 at which time R#22 was documented as having a Stage III pressure ulcer to the sacrum. On 9/2/2020, R#22 was sent to a local acute care hospital. The hospital's History and Physical note dated 9/2/2020, documented that R#22 was admitted with a large area of Stage IV pressure ulcer with a very foul odor. A wound culture was obtained on 9/2/2020 and the wound was found to be positive for Escherichia coli (E. coli). The History and Physical included an Assessment/Plan that documented: A Physician had been consulted to determine if R#22 needed a wound debridement or if he needed a wound debridement with diverting [MEDICAL CONDITION]. Review of the hospital's Discharge summary dated 9/10/2020, documented that after R#22's surgery for [REDACTED]. Due to his large size and severe debility and Stage IV pressure ulcer R#22 was discharged to a Long-Term Care Acute hospital. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 CFR 483.10 Notify of Changes, F580; 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656; CFR 483.25 Treatment/Services to Prevent/Heal Pressure Ulcers, F686; CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, F686. A Credible Allegation of Compliance (Removal Plan) was received. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 9/22/2020. The facility continued management level staff oversight of wound care and wound care treatments. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing pressure ulcers and wound care. After the Credible Allegation of Compliance (Removal Plan) was received, in-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure staff demonstrated knowledge of the facility' Policies and Procedures related to pressure ulcers and providing wound care. Findings include: Review of the policy titled, SUBJECT: Quality Assurance Performance Improvement documents the following: It is the policy of the facility to develop a QAPI plan in accordance with Federal Guidelines to describe how the facility will address clinical care, resident quality of life and residents' choice and is based on the scope and complexity of services defined by the Facility Assessment. Procedure 2. The plan describes the process for identifying and correcting quality deficiencies and contains the necessary components such as: a. tracking and measure performance: b. establishing goals and thresholds for performance measurement; c. Identifying and prioritizing quality deficiencies; d. Systematically analyzing underlying causes of systemic quality deficiencies; Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. Review of the Facility Assessment Tool revealed the following documentation: Our QAPI plan addresses: Clinical Care, Quality of Life and Resident. Data Sources revealed that pressure ulcers and wounds data analysis frequency is weekly. The Staff meetings, occurrence reporting, QAPI Meeting is noted to include residents, families, staff, QAPI Committee. During a subsequent interview and review of the QAPI Meeting Minutes on 10/19/2020 at 2:09 p.m. with the Administrator revealed the Administrator failed to monitor their system for any goals or interventions to address skin assessments and wound care. Further review of the minutes revealed that there was no specific information about the incident involving R#22. Review of the meeting minutes document titled, QAPI Committee Agenda/Notes dated 8/12/2020 revealed that there was no specific information about the incident. The QA meeting held on 8/28/2020, R#22 was not discussed because she was not aware that his wound had deteriorated. The Administrator stated she was not aware that the weekly head to toe assessments were not being completed but that they should have been completed. The facility has a skin management protocol which should have been followed. Further interview with the Administrator revealed There was a lack of consecutive weekly Head-to-Toe assessments. The Administrator stated again that she was not aware that the Head-to-Toe and weekly pressure ulcer checks were being completed. She recognized that the MD was notified after it was brought to her attention. The Administrator revealed R#22 was not discussed in the QA meeting on 8/28/2020 because she was not aware that his wound had deteriorated, and the physician had not been notified of the stage IV sacral wound. When asked why she was not told, the Administrator said, she was not told. The Administrator revealed that the QAPI meeting on 8/28/2020 was to discuss the PIP already in place and she was not aware of any new issues such as R#22 or wound treatments, insulin, finger stick blood sugars. Interview on 10/22/2020 at 1:48 p.m. with the Medical Director revealed that residents skin assessments should be done weekly and in accordance with the wound protocol. As it relates to the QA meeting held on 8/28/2020, R#22 was not discussed because she was not aware that his wound had deteriorated. The Medical Director stated she was not aware the head-to-toe assessments were not being done and that head to toe assessments should have been done. The facility implemented the following actions to remove the Immediate Jeopardy: 1. As of 9/17/2020 District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. 2. An Ad Hoc QAPI Meeting was completed on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Svcs to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). Staff attending the AdHoc QAPI was Director of Nursing, Assistant Director of Nursing, Staff Development, Social Services Director, Rehab Program Manager, Wound Care Nurse, MDS/Care Plan Coordinator, Activity Director and Restorative Aide. The AdHoc QAPI Committee completed a root cause analysis which concluded that nursing staff had deficient knowledge of Skin. 3. Total census of 86 of 86 residents were included in building wide skin sweep 9/14/2020 (4 skin assessments completed), 9/15/2020 (4 skin assessments completed), 9/16/2020 (54 skin assessments completed) and 9/17/2020 (24 skin assessments completed) to identify skin issues in the facility. 4. On 9/17/2020 Administrator ensured each skin concern was reported to Medical Director and interventions in place. On 9/17/2020 Administrator and Director of Nursing reviewed head to toe skin assessments with District Clinical Director. 5. On 9/17/2020 Administrator and Director of Nursing notified Medical Director and Wound Care Physician on the status of wounds in the facility. Three residents were noted to have new areas of skin breakdown. Physician was notified, treatment orders implemented, care plans updated, family notified and documented on User Define Assessment. 6. On 9/17/2020 Administrator, District Director of Clinical Services, Director of Nursing, Assistant Director of Nursing and Staff Development reviewed facility policy Quality Assurance and Performance Improvement Program and Committee and no changes were made. Identification of other residents having the potential to be affected: All residents have the potential to be affected. Resident #22 no longer resides at the facility. Actions to Prevent Occurrence/ Recurrence The following actions were taken to ensure occurrence or reoccurrence of process/system failure. 1. On 9/17/2020 Administrator contacted Medical Director and advised on deficiency. 2. On 9/17/2020 District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. 3. On 9/18/2020 District Clinical Director educated the Administrator and Director of Nursing regarding the regulatory guidelines of F867 (QAPI/QAA Improvement Activities.) 4. Wound Report, treatment and management of pressure ulcers will be discussed during monthly QAPI meetings. 5. A Performance Improvement Plan has been initiated related to F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Svcs to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). The QAPI Committee will review and monitor ongoing compliance. The District Director of Clinical Services and/or Regional Vice President of Operations will participate monthly in the QAPI Meeting to provide corporate oversight. 6. The items contained in this plan of immediate removal will be reviewed weekly by the QAPI Committee with review of the documentation of audits and monitoring provided by Director of Nursing and Staff Development Coordinator to ensure monitoring and adherence to the above plan. The District Director of Clinical Services and/or Regional Vice President of Operations will participate to provide corporate oversight. These reviews will be documented via the Ad-Hoc QAPI Meeting/ Four Point Plan of Correction Agenda and Summary. 7. All corrective actions were completed on 9/21/2020. 8. The Immediacy of the IJ was removed on 9/22/2020. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Review of in-service sign-in sheets 9/18/2020 revealed the Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed she attended an in-service on the topic of identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed she attended an in-service on the topic of identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed she attended an in-service on the topic of identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed she attended an in-service on the topic of identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. 2. Review of the sign-in sheet revealed an Ad Hoc QAPI Meeting was completed on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Svcs to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). Staff attending the AdHoc QAPI was Director of Nursing, Assistant Director of Nursing, Staff Development, Social Services Director, Rehab Program Manager, Wound Care Nurse, MDS/Care Plan Coordinator, Activity Director and Restorative Aide. The AdHoc QAPI Committee completed a root cause analysis which concluded that nursing staff had deficient knowledge of Skin. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Social Service Director on 9/24/2020 at 10:29 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Rehab Program Manager on 9/24/2020 at 10:38 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Wound Care Nurse on 9/24/2020 at 10:45 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the MDS/ Care Plan Coordinator on 9/24/2020 at 10:52 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Activity Director on 9/24/2020 at 10:59 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). An interview with the Restorative Aide Nurse on 9/24/2020 at 11:09 a.m. revealed she attended an Ad Hoc QAPI Meeting on 9/17/2020 to review F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Services to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). 3. Record review of document dated 9/14/2020 revealed four skin assessments were completed. Record review of document dated 9/15/2020 revealed four skin assessments were completed. Record review of document dated 9/16/2020 revealed fifty-four skin assessments were completed. Record review of document dated 9/17/2020 revealed twenty-four skin assessments were completed. 4. An interview with Clinical Director on 9/17/2020 at 11:31 a.m. revealed Administrator and Director of Nursing reviewed head to toe skin assessments with District Clinical Director. 5. Interview with Medical Director on 9/17/2020 at 2:47 p.m. revealed Administrator and Director of Nursing notified Medical Director and Wound Care Physician on the status of wounds in the facility. Three residents were noted to have new areas of skin breakdown. Physician was notified, treatment orders implemented, care plans updated, family notified and documented on User Define Assessment. 6. Record review of document dated 9/17/2020 revealed Administrator, District Director of Clinical Services, Director of Nursing, Assistant Director of Nursing and Staff Development reviewed facility policy Quality Assurance and Performance Improvement Program and Committee and no changes were made. An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed she reviewed facility policy Quality Assurance and Performance Improvement Program and Committee and no changes were made. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed she reviewed facility policy Quality Assurance and Performance Improvement Program and Committee and no changes were made. An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed she reviewed facility policy Quality Assurance and Performance Improvement Program and Committee and no changes were made. An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed reviewed facility policy Quality Assurance and Performance Improvement Program and Committee and no changes were made. Identification of other residents having the potential to be affected: All residents have the potential to be affected. Resident #22 no longer resides at the facility. Actions to Prevent Occurrence/ Recurrence The following actions were taken to ensure occurrence or reoccurrence of process/system failure. 1. Phone interview with Medical Director on 9/17/2020 at 2:47 p.m. revealed Administrator did contact Medical Director and advised on deficiency. 2. Record review of document dated 9/17/2020 revealed District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. An interview with the Assistant Director of Nursing on 9/24/2020 at 10:17 a.m. revealed District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. An interview with the Staff Development Coordinator on 9/24/2020 at 10:24 a.m. revealed District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. 3. Record review of document dated 9/18/2020 revealed District Clinical Director educated the Administrator and Director of Nursing regarding the regulatory guidelines of F867 (QAPI/QAA Improvement Activities.) An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed the District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed the District Clinical Director completed education on identifying of problems/concerns timely through the QA process to prevent complications related to the treatment of [REDACTED]. 4. An interview with the Director of Nursing on 9/24/2020 at 10:09 a.m. revealed Wound Report, treatment and management of pressure ulcers will be discussed during monthly QAPI meetings. 5. An interview on 9/17/2020 at 11:46 a.m. with the District Clinical Director revealed a Performance Improvement Plan has been initiated related to F580 (Notify of Changes), F656 (Develop/Implement Comprehensive Care Plan), F686 (Treatment/Svcs to Prevent/Heal Pressure Ulcers), F835 (Administration) and F867 (QAPI/QAA Improvement Activities). The QAPI Committee will review and monitor ongoing compliance. The District Director of Clinical Services and/or Regional Vice President of Operations will participate monthly in the QAPI Meeting to provide corporate oversight. 6. An interview with the Administrator on 9/24/2020 at 10:07 a.m. revealed the items contained in this plan of immediate removal will be reviewed weekly by the QAPI Committee with review of the documentation of audits and monitoring provided by Director of Nursing and Staff Development Coordinator to ensure monitoring and adherence to the above plan. The District Director of Clinical Services and/or Regional Vice President of Operations will participate to provide corporate oversight. 7. Based on record reviews and staff interviews, all corrective actions were completed on 9/21/2020. 8. The Immediacy of the IJ was removed on 9/22/2020.

Based on record review, it was determined that the facility had failed to develop a comprehensive care plan that included interventions specific to the assessed assistance needs for bed mobility and toileting for one resident ("Z") from a sample of 35 residents. This failure resulted in harm for resident "Z". Findings include: Resident "Z" was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the 10/12/2010 annual Minimum Data Set (MDS) assessment, licensed staff coded him/her as being non-ambulatory, as requiring extensive assistance of two persons for bed mobility and extensive assistance of one person for toileting. The resident was coded as being occasionally incontinent of bowel and bladder. Resident "Z" had a care plan since 10/13/10 to address his/her physical functioning deficit related to his/her mobility impairment, [MEDICAL CONDITION] and [MEDICAL CONDITION]. There were interventions for staff to provide bed mobility assistance "as appropriate", to monitor and report changes in his/her physical functioning ability, and to provide toileting assistance "as appropriate". However, staff had failed to specify what those "appropriate" assistance interventions were regarding the resident's assessed need for extensive assistance of two staff for bed mobility. According to the 7/23/11 at 0:51 a.m. "Change in Condition Report-Post Fall/Trauma" documentation, the resident was being provided incontinence care by one CNA and slipped/fell out of bed onto his/her stomach. Although staff were aware on 10/13/10 that the resident required extensive assistance of two persons with bed mobility due to his/her [MEDICAL CONDITION] and limited mobility, staff failed to develop a comprehensive care plan with the specific services to be furnished based on the resident's assessed need for two staff to assist him/her with bed mobility. See F323 for additional information regarding resident "Z".

Based on record review, it was determined that the facility failed to revise the care plan to include interventions specific to one resident's ("Z") continued assessed need for the assistance of two persons for bed mobility and toileting from a total sample of 35 residents. This failure resulted in harm for resident "Z". Findings include: Resident "Z" was admitted on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS] arthritis, [MEDICAL CONDITION], sinusitis, [MEDICAL CONDITION] reflux disease, lumbago, [MEDICAL CONDITION], diabetes, hypertension, constipation, [MEDICAL CONDITIONS] and end stage [MEDICAL CONDITION]. According to the 10/12/2010 annual Minimum Data Set (MDS) assessment, licensed staff coded him/her as being non-ambulatory, as requiring extensive assistance of two persons for bed mobility and extensive assistance of one person for toileting. The resident was coded as being occasionally incontinent of bowel and bladder. Resident "Z" had a care plan since 10/13/10 to address his/her physical functioning deficit related to his/her mobility impairment, [MEDICAL CONDITION] and [MEDICAL CONDITION]. There were interventions for staff to provide bed mobility assistance "as appropriate", to monitor and report changes in his/her physical functioning ability, and to provide toileting assistance "as appropriate". However, staff had failed to specify what those "appropriate" assistance interventions were regarding the resident's assessed need for extensive assistance of two staff for bed mobility and one staff for toileting. The resident had an x-ray on 6/9/11 of both of his/her feet that showed an oblique nondisplaced fracture at the base of the distal phalanx of the right great toe superimposed on severe osteopenia and advanced [MEDICAL CONDITION] change about the interphalangeal joints, mid foot and ankle. The resident was hospitalized from [DATE] to 6/13/11. On 6/13/11, staff reviewed the resident's care plan but, did not revise it for specific interventions related to the resident's physical functioning deficit. According to the 6/20/2011 quarterly MDS assessment, licensed staff coded the resident as non-ambulatory and requiring extensive assistance of two persons for bed mobility. The resident was coded as requiring extensive assistance of two persons, instead of one person,. for toileting and as being frequently incontinent of bowel and bladder. Although staff were aware of the 6/9/11 x-ray results and had assessed the resident's need for the extensive assistance of two persons for toileting, staff failed to revise the resident's care plan to reflect the need for two person assistance for bed mobility and toileting. The facility failed to ensure that two persons had assisted resident "Z" on 7/23/11 when he/she fell and sustained a left leg fracture. See F323 for additional information regarding resident "Z".

Based on observation, record review and resident and staff interview, it was determined that the facility failed to ensure that nursing staff provided the necessary assistance for bed mobility and toileting to prevent a fall with resulting leg fracture for one resident ("Z") and failed to appropriately transfer using two person assistance to prevent injury for one resident ("Y") from a total sample of 35 residents. This failure resulted in harm for resident "Z". Findings include: 1. Resident "Z" was admitted on [DATE] with [DIAGNOSES REDACTED]. osteoarthritis, rheumatoid arthritis, [DIAGNOSES REDACTED], sinusitis, gastroesophageal reflux disease, lumbago, osteoporosis, diabetes, hypertension, constipation, chronic obstructive pulmonary disease, anemia and end stage renal disease. According to the 10/12/2010 annual Minimum Data Set (MDS) assessment coding, the resident was coded as non-ambulatory, as requiring extensive assistance of two persons for bed mobility and extensive assistance of one person for toileting. The resident was coded as being occasionally incontinent of bowel and bladder. Resident "Z" had a care plan since 10/13/10 to address his/her physical functioning deficit related to his/her mobility impairment, morbid obesity and cerebral vascular accident. There were Interventions for staff to provide bed mobility assistance "as appropriate", to monitor and report changes in physical functioning ability, and to provide toileting assistance "as appropriate". However, staff had failed to specify what those "appropriate" assistance interventions were regarding the resident's assessed need for extensive assistance of one or two persons for bed mobility and toileting. The resident had an x-ray on 6/9/11 of his/her bilateral feet that showed an oblique nondisplaced fracture at the base of the distal phalanx of the right great toe superimposed on severe osteopenia and advanced degenerative change about the interphalangeal joints, mid foot and ankle. The resident was hospitalized from [DATE] to 6/13/11. On 6/13/11, staff reviewed the resident's care plan but, did not revise the interventions related to the resident's physical functioning deficit. According to the 6/20/2011 quarterly MDS assessment, the resident was coded as continuing to be non-ambulatory and requiring extensive assistance of two persons for bed mobility. In that assessment period, licensed staff coded the resident as requiring extensive assistance of two persons, instead of one person,. for toileting and as being frequently incontinent of bowel and bladder. Although staff were aware of the 6/9/11 x-ray results and had coded the resident on the 6/20/11 MDS assessment as requiring extensive assistance of two persons for toileting, staff failed to revise the resident's care plan to reflect the assessed continued need for two person assistance for bed mobility and the assessed need for two person assistance with toileting. According to the 7/23/11 at 0:51 a.m. "Change in Condition Report-Post Fall/Trauma" form, the resident was being provided incontinence care by one CNA and slipped/fell out of bed onto his/her stomach. The resident complained of left leg pain. The resident was sent to the hospital and an x-ray was done. According to the 7/24/11 hospital "History and Physical" report, the x-ray showed an impacted distal femur fracture and advanced degenerative joint disease. The physician recommended non-operative treatment. Staff revised the resident's care plan on 7/25/11 to include an intervention for two staff persons to assist the resident with incontinence care and activities of daily living. On 8/28/11 at 3:20 p.m., Resident "Z" was observed to be morbidly obese and lying on an extra large pressure relieving mattress.On 8/29/11 at 10:35 a.m. supervisory nursing staff "HH" stated that the resident had fallen on 7/24/11 and had sustained a leg fracture . "HH" stated that the resident was turning in bed during incontinence care and that he/she had slid too far off of the mattress. "HH" stated that the resident never hit the floor but, the weight of his/her leg on top of the other leg caused an osteopenic fracture. On 8/31/11 at 8:30 a.m., resident "Z" was lying in his/her bed. He/she stated that he/she had fallen out of bed about one month ago. He/she stated that one certified nursing assistant (CNA) was providing incontinence care for him/her at that time. The resident stated that when the CNA pushed the resident over onto his/her side, he/she just slipped right out of the bed with his/her whole body falling on the floor. On 8/31/11 at 11:40 a.m., certified nursing assistant "YY" stated that two CNAs were supposed to provide the resident with personal care. "YY" stated that the CNAs were notified of changes to the resident's care plan by the nurse. "YY" stated that the CNAs could also look at the resident's care plan in the resident's chart to see if any changes had been made. On 8/31/11 at 12 noon, supervisory nursing staff "HH" stated that the charge/medication nurse was responsible for ensuring that the residents were provided with appropriate assistance during care. "HH" stated that he/she also randomly entered a resident's room to see if that resident was provided appropriate care. On 8/31/11 at 12:25 p.m., licensed nurse "XX" stated that the charge/medication nurses were responsible for ensuring that the CNAs were providing appropriate care for the residents. However, although staff were aware on 10/13/10 that the resident required extensive assistance of two persons with bed mobility due to his/her morbid obesity and limited mobility, staff failed to develop a comprehensive care plan to address interventions specific to the resident's assessed need for assistance of two persons. Although staff were aware on 6/20/11 that the resident continued to require the assistance of two persons for bed mobility and at that time also required the assistance of two persons for toileting, staff failed to revise the resident's care plan to reflect his/her assessed need for two person assistance with toileting. Although the resident required the assistance of two persons for bed mobility and toileting, supervisory nursing staff failed to ensure that two persons had assisted the resident on 7/23/11. This failure resulted in a fall with left leg fracture for resident "Z". 2. Resident "Y" was admitted on [DATE] with [DIAGNOSES REDACTED].According to the 2/24/11 annual Minimum Data Set (MDS) assessment coding, the resident was non-ambulatory and required extensive assistance of two persons for transfer. The resident had a care plan since 2/25/11 to address his/her physical functioning deficit with an intervention for staff to assist with activities of daily living as needed. On 8/28/11 at 2:13 p.m., the resident stated that sometime in May 2011, a certified nursing assistant transferred him/her from the bed to the wheelchair using a Hoyer lift. The resident stated that his/her foot got caught between the seat and footrest causing a fracture. According to the 5/31/11 at 10:09 p.m. nurses' note, the resident complained of right foot pain. There was no discoloration or bruising. The physician was notified and the resident's foot was x-rayed on 6/1/11 and showed an oblique minimally displaced lateral malleolar fracture superimposed on severe osteopenia and degenerative changes about the interphalangeal joints mid foot and ankle. A second x-ray done later that day showed no fracture. According to the 6/13/11 orthopedic surgeon's note, the resident had a questionable nondisplaced fracture of the right fibula. Staff revised the resident's care plan on 6/1/11 to include a fracture of his/her foot with an intervention for two persons to assist the resident while transferring him/her with the lift at all times. However, on 8/30/11 at 9:20 a.m., CNA "ZZ" transferred the resident with the Hoyer lift from the bed to the wheelchair by herself . The CNA was not assisted by another staff person as planned to prevent potential injury to the resident. On 8/31/11 at 11:40 a.m., CNA "YY" stated that two CNAs were supposed to transfer the resident with the lift. "YY" stated that the CNAs were notified of changes to the resident's care plan by the nurse. "YY" stated that the CNAs could also look at the resident's care plan in the resident's chart to see if any changes had been made. On 8/31/11 at 12 noon, supervisory nursing staff "HH" stated that the charge/medication nurse was responsible for ensuring that the residents were being transferred as care planned. "HH" stated that he/she also randomly entered a resident's room to see if that resident was being transferred as planned. On 8/31/11 at 12:25 p.m., licensed nurse "XX" stated that the charge/medication nurses were responsible for ensuring that the CNAs were transferring the residents as planned. However, supervisory nursing staff had failed to ensure that a CNA had transferred resident "Y" with assistance as planned to prevent potential injury to the resident.