Every finding on record at Hathorne Hill Rehabilitation and Healthcare Center

Based on interviews, observations, and policy review, the facility failed to ensure staff treated one Resident (#140) in a dignified manner during the dining experience out of a total sample of 26 residents. Specifically, for Resident #140 who was dependent on staff for assistance with meals, the facility failed to provide assistance when his/her meal was delivered.Findings include:Review of the facility policy titled Dignity, dated 2/21, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights for example, residents are: provided with a dignified dining experience. Resident #104 was admitted to the facility in February 2021 with diagnoses that included dysphagia, cerebral infarction, and macular degeneration. Review of Resident #104's most recent Minimum Data Set (MDS) assessment, dated 10/23/25, indicated he/she scored a 11 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairments. Further review of the MDS indicated he/she requires partial/moderate assistance from staff for eating. On 12/2/25 at 8:25 A.M., the surveyor observed Resident #140 in bed awake with his/her meal left on their bedside table not set up to consume. No staff were present in the room to assist the Resident. On 12/3/25 from 8:24 A.M. to 8:35 A.M., the surveyor observed Resident #140 in bed awake with his/her meal left on their bedside table not set up to consume. No staff were present in the room to assist the Resident. On 12/4/25 from 8:25 A.M. to 8:30 A.M., the surveyor observed Resident #140 in bed awake with his/her meal set up to consume on their over the bed table. No staff were present in the room to assist the Resident. The Resident was observed to not initiate self-feeding. Review of Resident #104's activity of daily living care plan, dated 8/14/25, indicated he/she requires assist with eating. Review of Resident #104's active CNA (Certified Nurse Aide) Kardex (form indicating the need of the Resident), indicated he/she required assist for eating, if coughing occurs, no food/liquids until coughing resolves. Review of Resident #104's dietary assessment, dated 10/20/25, indicated the Resident required Feeding skills: Set-up help/Extensive Assist/Dependent Assist. During an interview on 12/4/25 at 8:30 A.M., CNA #1 said Resident #140 needs assistance from staff to eat and is not sure who delivered his/her tray but they should have assisted the Resident once it was delivered. During an interview on 12/4/25 at 8:31 A.M., Unit Manager #1 said Resident #140 needs assistance from staff to eat because they are unable to see. Unit Manager #1 said staff should not deliver the tray until they are ready to assist the resident. Unit Manager #1 said she expects staff to follow each resident's plan of care.

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for one Resident (#46) out of a total sample of 26 residents. Specifically, for Resident #46 the facility failed to provide assistance and/or supervision with meals as per the plan of care.Findings include:Review of the facility policy titled Activities of Daily Living (ADLs), dated 4/25, indicated Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. A resident's ability to perform ADLs is measured using clinical tools, including the MDS. Functional decline and improvement are evaluated using the following MDS definitions: Supervision or touching assistance - if the helper provides verbal cues or touching/steadying/contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. Partial/moderate assistance - if the helper does less than half the effort. Substantial/maximal assistance - if the helper does more than half the effort. Resident #46 was admitted to the facility in October 2024 with diagnoses that included dysphagia following cerebral infarction, aphasia, and major depressive disorder. Review of Resident #46's most recent Minimum Data Set (MDS) assessment, dated 11/25/25, indicated he/she scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicating he/she required supervision/touching assistance from staff for eating. On 12/2/25 at 8:24 A.M., the surveyor observed Resident #46 in bed with his/her food tray set up for consumption. Staff were not present in the room or in the hallway. The Resident was not able to be seen from the hallway. The Resident was observed to not initiate self-feeding. On 12/3/25 from 8:21 A.M. to 8:35 A.M., the surveyor observed Resident #46 in bed with his/her food tray set up for consumption. Staff were not present in the room or in the hallway. The Resident was not able to be seen from the hallway. The Resident was observed to not initiate self-feeding and was sleeping at times. On 12/3/25 from 1:12 P.M. to 1:20 P.M., the surveyor observed Resident #46 in his/her wheelchair with their meal tray set-up to consume. The Resident was observed to not initiate self-feeding. On 12/4/25 from 8:27 A.M. to 8:32 A.M., the surveyor observed Resident #46 in bed with his/her food tray set up for consumption. Staff were not present in the room. The Resident was observed to not initiate self-feeding and was not able to be seen from the hallway. Review of Resident #46's activity of daily living care plan, dated 11/2/25, indicated Provide the individualized diet to the resident and assist as per his/her need. Ensure that the proper assistive devices are used for eating and drinking as indicated. Review of Resident #46's nutrition care plan, dated 11/2/25, indicated monitor for signs and symptoms of aspiration. Review of Resident #46's active Certified Nurse Aide (CNA) Kardex (form that indicates the needs of the Resident), indicated he/she requires tube feeding and water flushes. See MD orders for current feeding orders. Review of Resident #46's Nurse Practitioner (NP) progress note, dated 10/27/25, indicated dysphagia: Strict aspiration precautions. Review of Resident #46's dietary assessment, dated 11/24/25, indicated the Resident required Feeding skills: Supervision/Limited Assist/Extensive Assist/Dependent Assist. Review of Resident #46's nursing progress note, dated 12/1/25, indicated the Resident was assisted with meals. Review of Resident #46's Physiatry progress note, dated 12/1/25, indicated diet is dysphagia advanced texture, regular fluids. Requiring assist. Review of Resident #46's active physician orders, indicated Regular diet, Dysphagia Advanced texture, Regular Fluid consistency. During an interview on 12/4/25 at 8:31 A.M., Unit Manager #1 said she expects staff to follow each resident's plan of care. During an interview on 12/4/25 at 8:33 A.M., Nurse #1 said Resident #46 had a recent stroke and needs assistance with meals. Nurse #1 said if the meal is in the Residents room, then a staff member should be with him/her as they are at risk for chocking. During an interview on 12/4/25 at 8:34 A.M., Certified Nurse Aide #2 said Resident #46 should have a staff member with them during meals because they have a hard time feeding themselves. CNA #2 said if a resident is supposed to be supervised or assisted then staff should be with that resident for the duration of their meal at all times.

Based on record review and interview the facility failed to ensure that for two out of five staff records reviewed (Nurse #2 and Additional Staff #2), who did not receive the covid vaccination, signed a statement certifying that they are exempt from vaccination and they received information about the risks and benefits of COVID-19 vaccine.Findings include:Review of Nurse #2's personnel health records indicated a facility document titled Covid-19 Vaccine Consent form had a check mark indicating the declination of the covid vaccine, but the document was not signed by the staff member.Review of Additional Staff #2's personnel health records indicated a facility document titled Covid-19 Vaccine Consent form had a check mark indicating the declination of the covid vaccine, but the document was not signed by the staff member.During an interview on 12/3/25 at 1:30 P.M. the Staff Development Coordinator/Infection Preventionist (SDC/IP) said that the Human Resource (HR) Director is responsible for the hiring process, including maintaining the staff employment records and ensuring documents are signed. During an interview on 12/3/25 at 1:35 P.M., the Human Resource (HR) Director said that the SDC/IP should be ensuring the staff sign the covid consent forms as she is the nurse. The HR director said that the SDC/IP is in charge of the vaccine consents during the hiring process. The HR Director then said that there is no facility policy for what to include in the personnel records or how to maintain them. She then said she has a new hire check off list that she follows but was not able to produce this list for either staff member.

Based on observation, record review, and interview, the facility failed to implement interventions related to pressure ulcer care and prevention for one Resident (#46) out of a total of 23 sampled Residents. Specifically, the facility failed to implement an air mattress as recommended by the Wound Physician for Resident #46 after he/she developed a stage III pressure ulcer at the facility. Findings include: Review of the facility's Pressure Injury Prevention and Management Policy, dated May 2024, indicated: Evidenced based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: Redistribute pressure, minimize exposure to moisture and keep skin clean, provide appropriate, pressure redistributing support surfaces. Resident #46 was admitted to the facility in July 2024 with diagnoses including spinal stenosis and age related osteoporosis. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #46 is severely cognitively impaired evidenced by a score of five out of possible 15 on the Brief Interview for Mental Status exam. Review of Resident #46's clinical record indicted he/she developed a Stage III pressure ulcer on his/her sacrum at the facility. Review of the Wound Physicians note dated 11/18/24 indicated: Resident was seen today as a consultation for evaluation and management of their wound(s). Location Sacrum. Context: Pressure. Sacral area has a full thickness wound with slough and granulation tissue present, consistent with Stage 3 Pressure injury. Patient educated on offloading. Air mattress rec'd (recommended). Will start treatment plan today. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Honey gel to base of the wound. 3. secure with Bordered foam. 4. change Daily, PRN for soiling, saturation, or accidental removal . Wound Recommendations as above. Facility Pressure Ulcer Prevention Protocol, Group 2 support surface - powered pressure reducing air mattress or non-powered advanced pressure reducing mattress. On 12/3/24 at 9:09 A.M., and 12/4/24 at 7:16 A.M., the surveyor observed Resident #46 asleep on a standard mattress and not an air mattress. Review of Resident #46's physicians orders and care plans failed to indicate the use of an air mattress. During an interview on 12/4/24 at 11:47 A.M., Nurse Practitioner (NP) #1 said that he works with the Wound Physician and will review recommendations and either approve them or alter them. NP #1 said that he would agree with the use of an air mattress for Resident #46 and he was not aware that one was not in place. NP #1 said that there was no reason for Resident #46 to not have an air mattress. During an interview on 12/4/24 at 12:37 P.M. Unit Manager #1 said that she rounds with the wound physician and relays the recommendations for treatments. Unit Manager #1 said that when the Wound Physician had recommended the air mattress, one was not available. Unit Manager #1 said when one became available it was forgotten. During an interview on 12/4/24 at approximately 1:30 P.M., the Administrator said she would expect staff to implement interventions as recommended by the Wound Physician.

Based on observation and interview, the facility failed to maintain a sanitary oxygen filter for one Resident (#93) out of a total sample of 23 residents. Findings include: Review of the facility policy titled Oxygen Concentrator, dated 8/1/24, indicates the following: Care of Concentrator: Follow the manufacturer recommendations for the frequency of cleaning filters and servicing the device. Resident #93 was admitted in October 2023 with diagnoses including chronic obstructive pulmonary disorder. Review of the current physician's order indicated Resident #93 requires oxygen delivery continuously. There were no physicians orders related to the monitoring or maintenance of Resident #93's oxygen concentrator filter. During an observation on 12/3/24 at 8:07 A.M., Resident #93's oxygen filter was dirty and caked in dust. During an observation on 12/4/24 at 10:30 A.M., Resident #93's oxygen filter was dirty and caked in dust. During an interview on 12/4/24 at 10:30 A.M., Nurse #1 said she does not know who changes the filters. She said she is only responsible for changing the oxygen tubing weekly. During an interview on 12/4/24 at 1:18 P.M., the Maintenance Director said he checks the oxygen filters monthly and changes them. The Maintenance director said that if a filter is dirty or dusty then it can be changed as needed as well and would expect to be told if a filter needed to be changed. The Maintenance Director said he changed all of the filters on 11/26/24.

Based on record review and interview, the facility failed to follow the dietary plan for one Resident (#44) of 23 sampled residents. Specifically, the facility served Resident #44 fish, which was a documented allergen. Findings include: Resident #44 was admitted to the facility in December 2023 with the following active diagnoses: dementia and chronic pulmonary disorder. Review of Resident #44's Minimum Data Set assessment dated [DATE], indicated he/she required set-up assistance for meals. The Resident had a Brief Interview for Mental Status exam score of 9, signifying moderately impaired cognition. Review of Resident #44's allergens list dated 1/15/18, indicted he/she was allergic to fish containing products. Review of Resident #44's Nurse Practitioner note dated 1/26/24, indicated staff accidentally gave fish (not tuna) for his/her evening meal and reported an allergic reaction. The note indicated he/she experienced a tingling on his/her nose, but no other symptoms. Review of Nurse #3 written statement dated 1/26/24, indicated she served the incorrect meal tray for Resident #44, which included fish. During an interview on 12/4/24 at 2:05 P.M., the Administrator said the incident was reported to the Department of Public Health, immediately investigated, and staff were re-educated on food allergens. The Administrator said the issue was addressed through the facility's quality assurance program. Review of the documentation indicated the incident was reported to the Department of Public Health and an internal investigation completed on 1/26/24. Review of staff re-education for allergens indicated this was completed by 1/29/24. The quality assurance performance improvement plan for food allergies was completed on 2/16/24.

Based on observation, record review, and interview, the facility failed to accurately document the completion of shaving for one Resident (Resident #22) of 23 sampled residents. Findings include: Resident #22 was admitted to the facility in May 2024, and has active diagnoses which include anxiety, depression, and esophageal cancer. Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE], indicated he/she required partial to moderate assistance with personal hygiene (includes shaves). The Resident had a Brief Interview for Mental Status exam score of 14, signifying intact condition. The Resident exhibited verbal and non-verbal behaviors and rejected care approximately 1 to 3 times per week. Review of Resident #22's care plan dated 1/2/24, indicated he/she required set-up and assist of one as needed for personal hygiene. The care plan also indicated he/she required two staff members present for all care related to accusatory statements. The care plan indicated he/she was verbally abusive toward staff and frequently refused care. During an interview on 12/3/24 at 12:45 P.M., Resident #22 said he/she asked nursing staff to shave him/her over the past three weeks, but they had refused. The Resident said he/she needed some help to shave because of upper body muscle weakness. The surveyor observed that Resident #22 had a full mustache and the remainder of his/her face had approximately 1/4 inch long whiskers. On 12/4/24 at approximately 9:00 A.M. and on 12/5/24 at 8:59 A.M., the surveyor observed that Resident #22's face remained unshaven. Resident #22 said staff had not offer to shave him/her. Review of Resident #22's November and December 2024 Tasks document indicated he/she refused personal hygiene assistance only once, on 11/22/24. The Tasks document did not specify if shaving assistance was offered or refused. Review of Resident #22's nurse progress notes did not reference shaving or rejection of personal hygiene assistance. During an interview on 12/5/24 at 10:07 A.M., Unit Manager #2 said she had provided care, including activities of daily living assistance, to Resident #22 since his/her admission. Unit Manager #2 said the Certified Nurse Aide (CNA) who is usually assigned to Resident #22 was not working at this time. Unit Manager #2 said Resident #22 frequently refuses personal hygiene assistance, including shaves, and often tells staff to leave his/her room. Unit Manager #2 reviewed the November and December 2024 Tasks document and said it was inaccurate because staff were not coding that the Resident had refused personal hygiene assistance.

Based on observations, interviews and record review the facility failed to ensure it performed skin checks and wound evaluations, implemented physician orders, updated the physician and plan of care when significant changes occurred, and prevented the deterioration of pressure injuries (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) for five residents (#182, #97, #101, #67, #65) of 11 residents with a pressure ulcer out of a total sample of 44 residents. Specifically: 1. For Resident #182, the facility failed to evaluate a Stage 2 pressure ulcer, complete wound evaluations, notify the physician when the wound deteriorated to a Stage 4 and had signs of infection, or revise the plan of care, which resulted in a significant deterioration to the wound and a 100% increase in wound size. In addition, the facility failed to notify the provider and evaluate a newly developed midspine thoracic wound. 2. For Resident #97, the facility failed to implement physician orders and obtain skin/wound evaluations. 3. For Resident #101, the facility failed to measure a Stage 2 pressure ulcer on admission or obtain physician orders to treat the wound. 4. For Resident #67, the facility failed to review a wound treatment recommendation made by the wound nurse. 5. For Resident #65, the facility failed to perform comprehensive weekly wound assessments, implement interventions to reduce the risk for pressure ulcers and revise the plan of care. Findings include: Review of the facility's policy Skin Integrity and Wound Management dated 2/1/23, indicated: - Complete comprehensive evaluation, and risk evaluation on admission and weekly for the first month. - The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continuously observe and monitor patients for changes and implement revision to the plan of care as needed. - The licensed nurses will document newly identified skin/wound impairments as a change in condition. - Complete wound evaluation with unanticipated decline in wounds. - Document daily monitoring of ulcer including signs of decline in wound status - Notify physician to obtain orders. - Review care plan and revise as needed. 1. Resident #182 was admitted to the facility in November 2023, and had diagnoses which included a Stage 2 pressure ulcer (a break in the top two layers of skin because of pressure), diabetes and congestive heart failure (a heart disease resulting in poor blood circulation). Review of the Minimum Data Set assessment dated [DATE] indicated Resident #182 was admitted to the facility with a Stage 2 pressure ulcer on the coccyx, was at risk for skin breakdown, and had a Brief Interview for Mental Status score of 15 out of a possible 15, indicating intact cognition. Review of the Hospital discharge summary dated 11/2/23, indicated Resident #182 was discharged to the facility with a Stage 2 coccyx wound. Review of the nursing note dated 11/2/23, indicated Resident #182 was admitted with a Stage 2 pressure ulcer located on the coccyx with scattered bruising. His/her skin was warm and dry. The skin on the right and left lower extremity was red. Review of the nursing admission assessment dated [DATE], failed to indicate staff measured or further described Resident #182's Stage 2 coccyx wound. Review of the Nutritional assessment dated [DATE], indicated Resident #182 required additional calories and protein for wound healing. The Dietitian recommended Resident #182 have a new order to liberalize his/her diet to regular and add 4-ounce house shakes three times a day. Review of the medical record failed to show the Nurse Practitioner (NP), or other provider, examined Resident #182's wound on 11/3/23 or reviewed the Dietician's recommendations. Review of the nursing note and Treatment Administration Record (TAR) dated 11/3/23, failed to indicate staff measured or further described Resident #182's Stage 2 coccyx wound. Review of the physician order dated 11/3/23, indicated Resident #182 was to receive silver sulfadiazine cream 1% to be applied to coccyx topically every day shift for ulcer after normal saline wash and cover with foam dressing. Review of the Medication Administration Record (MAR) indicated this treatment was administered on this date. Review of the [NAME] Pressure Ulcer Scale dated 11/3/23, indicated Resident #182 scored 11, signifying he/she was at medium-risk for developing pressure ulcers. Review of the baseline care plan dated 11/3/23, indicated Resident #182 was at risk for skin breakdown related to diagnoses of diabetes and age-related frail skin, and was admitted to the facility with a Stage 2 pressure ulcer located on the coccyx. The baseline care plan was incomplete and failed to include any nursing interventions for wound treatment. Review of the nursing note dated 11/4/23, indicated Resident #182 presented with a pressure area to the coccyx. The note indicated the dressing was changed and the Resident was repositioned. Review of the nursing note and TAR failed to indicate staff obtained wound measurements on this date. Review of the NP note dated 11/4/23, indicated a visit to Resident #182, but there was no reference to his/her coccyx wound or an examination of the wound. Review of the physician orders for Resident #182 dated 11/4/23, indicated: * An as-needed order (PRN): Gently cleanse coccyx wound with vashe wash, allow a vashe soaked gauze to remain in place over the wound for 5 minutes and gently pat dry. Apply sure prep peri wound. Apply cut to fit, moistened hydrofera blue to the wound bed. Cover with a foam dressing as needed for soiling/dislodgement. This order was discontinued the same day, on 11/4/23. A revised physician order for a scheduled treatment dated 11/4/23 and with a start date of 11/6/23, replaced the above PRN order: * Gently cleanse coccyx wound with vashe wash, allow a vashe soaked gauze to remain in place over the wound for 5 minutes and gently pat dry. Apply sure prep peri wound. Apply cut to fit, moistened hydrofera blue to the wound bed. Cover with a foam dressing every day shift every other day for wound care. * Daily weights. Review of the nursing note dated 11/5/23, indicated Resident #182's buttocks were red and an open area on the skin. The nurse applied barrier cream to the skin. The nursing and TAR failed to indicate staff obtained wound measurements on this date. Review of the medical record failed to show the Nurse Practitioner (NP), or another provider, examined or measured Resident #182's wound on 11/5/23. Review of the nursing note dated 11/6/23, indicated Resident #182's buttocks were red and an open area on the skin. The nurse applied barrier cream to the skin. The Resident reported buttocks pain of 6 out of 10 and staff administered an as needed acetaminophen 325 milligrams (mg). The nursing notes and TAR failed to indicate staff obtained wound measurements on this date. Review of the NP note dated 11/6/23, indicated a visit: Decubitus. I could not see [his/her] backside today. [Resident] does have a well-known, well-established decubitus going back several months. Today, [Resident] seemed to believe there was a piece of metal in it. Or maybe [he/she] was in a metal box. [Resident] feels very uncomfortable. Both of [his/her] daughters, and [Resident], were in full agreement to try increased analgesics, beyond just Tylenol. We have agreed upon tramadol (an opioid medication to treat moderate to moderately severe pain) 50 mg every 6 hours as needed for now. This can be titrated up as needed. Review of the medical record failed to show the NP, or another provider, examined or measured Resident #182's wound on 11/6/23. Review of the NP note dated 11/7/23, indicated a visit to Resident #182. The note indicated Resident #182 remained somewhat uncomfortable. Decubitus noted. Continue with regular dressing changes. We will titrate up tramadol 50 mg every 6 to 4 hours, as needed (tramadol is an opioid medication used to relieve moderate to moderately severe pain). Review of the medical record failed to show the NP, or another provider, examined or measured Resident #182's wound on 11/7/23. Review of Resident #182's physician order dated 11/7/23, indicated: * Increase tramadol (pain medication) 50 mg as needed to every 4 hours. Review of the Skin Check assessment, dated 11/8/23, indicated: The following skin injury/wound(s) were previously identified and were evaluated as follows: Rash(s): Description: fungal rash groin Pressure Area(s): Location(s): coccyx wound. Midspine thoracic wound. The Skin Check assessment included the following care plan interventions: * Weekly skin check by licensed nurse. * Weekly wound assessment to include measurements and description of wound status. * Provide wound treatment as ordered. * Pat do not rub skin when drying. * Obtain dietitian consult as needed/ordered. * Provide supplements as ordered. * Provide patient and/or healthcare decision maker education regarding risk factors and interventions. * Provide preventative skin care lotions barrier creams as ordered. * Apply barrier cream with each dressing. * Assist resident with turning and repositioning every 2 hours. * Encourage resident to consume all fluids of choice. * Observe skin for signs and symptoms of skin breakdown. * Evaluate for any localized skin problems. * Observe skin condition daily during ADL care and report abnormalities. * Observe for verbal and non-verbal signs of pain related to wound/Tx. Review of the nursing note dated 11/8/23, indicated Resident #182 had a Stage 4 pressure ulcer on the coccyx, (Stage 4 ulcers are defined as deep wounds that may impact muscle, tendons, ligaments, and bone, which indicates Resident #182's wound deteriorated since admission). Resident #182 presented with some discomfort and was relieved from repositioning and scheduled pain medication. Resident #182's pain level was rated as mild and located on the coccyx. The following skin injury/wound(s) were previously identified and were evaluated as follows: Rash(s): Description: fungal rash groin, pressure area(s): Location(s): coccyx wound, midspine thoracic wound. Review of the nursing note dated 11/8/23 failed to indicate Resident #182's coccyx pressure ulcer and midspine thoracic wound were measured or described further, or that staff notified the physician that the coccyx wound progressed from a Stage 2 to a Stage 4, or the developement of the midspine thoracic wound. The nursing note did not indicate if staff applied a dressing treatment to either wound. Review of the NP note dated 11/8/23 indicated the NP visited Resident #182. The note indicated decubitus and to continue with regular dressing changes. The NP note dated 11/8/23, failed to indicate the coccyx or midspine thoracic wounds were examined or measured. Review of the nursing and provider notes from 11/9/23 indicated Resident #182's wounds were not examined or measured on this date. Review of the Risk Meeting note dated 11/10/23, indicated Resident #182 had an unstageable coccyx wound, no signs of infection, and a treatment was in place. No further notes were included. Review of the nursing note dated 11/10/23, indicated Resident #182 had a Stage 4 coccyx wound, was alert and oriented to self only. Resident #182 was pleasant and cooperative with care and presented with pressure area to coccyx. Staff repositioned the Resident side to side and he/she presented with moderate pain and relieved from repositioning and scheduled acetaminophen. The note did not reference the midspine thoracic wound. Review of the NP note dated 11/10/23, indicated: Decubitus. Continue with regular dressing changes. Review of the nursing and provider notes from 11/10/23 indicated Resident #182's wounds were not examined or measured on this date. Review of the care plan dated 11/11/23 for skin breakdown indicated goals and interventions were added on this date. The goal was for the coccyx wound to remain free of infection for 90 days. Interventions included: * Weekly skin check by licensed nurse * Weekly wound assessment to include measurements and description of wound status. * Provide wound treatment as ordered. * Pat do not rub skin when drying * Obtain dietitian consult as needed/ordered. * Provide supplements as ordered. * Provide patient and/or healthcare decision maker education regarding risk factors and interventions. * Provide preventative skin care lotions barrier creams as ordered. * Apply barrier cream with each dressing. * Assist resident with turning and repositioning every 2 hours. * Encourage resident to consume all fluids of choice. * Observe skin for signs and symptoms of skin breakdown. * Evaluate for any localized skin problems. * Observe skin condition daily during ADL care and report abnormalities. * Observe for verbal and non-verbal signs of pain related to wound/Tx. The updated care plan interventions dated 11/11/23, did not indicate an actual pressure ulcer to the coccyx, the progression of Resident #182's coccyx wound from Stage 2 to Stage 4, or include interventions to manage the deteriorated wound. The care plan did not reference the midspine thoracic wound. Review of the nursing and provider notes from 11/11/23, indicated Resident #182's wounds were not examined or measured on this date. Review of the nursing note dated 11/12/23 indicated Resident #182 had Stage 4 on his/her coccyx and was in moderate pain. According to the Mayo Clinic, complications and outcomes of Stage 4 pressure ulcers include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization . It may develop within the first 2 weeks of pressure ulcer formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). Review of the nursing and provider notes from 11/12/23, failed to indicate staff or providers examined or measured Resident #182's wounds on this date. Review of the NP note dated 11/13/23, indicated a sacral decubitus wound measuring about 3 inches x 1- 1 1/2 inches [7.62 centimeters (cm) x 2.54/3.81 cm equaling approximately 29 square cm]. The bed of the wound is dark necrotic tissue [necrosis is the death of body tissue, often due to illness, infection, or lack of blood flow to the tissue], with a thin ring of yellow slough, and pink granulation. The necrotic center is not entirely dried out, but obviously very thin and, with palpation, is lying directly over the bone. There is no subcutaneous tissue between the necrotic base and [his/her] bone. Still, technically, this is unstageable. There was no significant surrounding erythema or induration consistent with soft tissue infection. The NP note dated 11/13/23 was the first documented NP examination and first measurement of Resident #182's wound since admission on 11/2/23. Review of the NP and nursing notes dated 11/2/23 through 11/13/23, failed to indicate a discussion with the Resident or family members about treatment options for the coccyx wound, including the services of a wound specialist or surgeon, despite the wound's significant deterioration. Review of the NP note dated 11/14/23, indicated very advanced decubitus, very likely stage 4, but technically unstageable. The note indicated there was a likelihood of underlying sacral osteomyelitis and the focus of treatment is transitioning to comfort. The note indicated nursing staff will continue with dressing changes. The note indicated the NP did not believe the coccyx wound was healable. Review of the nursing note dated 11/14/23 indicated Resident #182 had an unstageable deep tissue injury (DTI) to coccyx with slough in center and macerated wound edges. The note indicated the Resident had a thoracic spine pressure area, skin was intact, and staff changed the protective dressing. The note did not indicate staff obtained wound measurements and did not reference the midspine thoracic wound. Review of the physician orders, provider notes and nursing notes indicated that during Resident #182's admission period the facility did not notify a provider that he/she had a midspine thoracic wound, or request an order for a protective dressing, or evaluate and measure this wound. Review of the nursing and provider notes from 11/14/23, failed to indicate staff or providers examined or measured #182's wounds on this date. Review of the NP note dated 11/15/23 indicated Resident #182 exhibited increased pain. Review of the NP note dated 11/16/23 indicated Resident #182 had extremely limited capacity for significant functional recovery, had not been out of bed since admission, and the focus of treatment was shifting to care and comfort. The NP note indicated his/her prognosis is very poor. The plan is for discharge home with hospice, as early as 11/20/2023. Review of the nursing and provider notes from 11/14/23, 11/15/23, 11/16/23 and 11/17/23 failed to indicate staff or providers examined or measured #182's wounds. Review of the nursing note dated 11/18/23, indicated Resident #182 presented with a wound to the coccyx 9 cm x 6.4 cm in total [approximately 58 square cm] 5/4 cm X 4 cm center necrotic area. Necrotic area surrounded by 0.2 cm yellow ring followed by red ring. Moderate purulent drainage noted on dressing. Odor noted. Dressing applied and pressure offloaded. Staff turned the Resident side to side throughout shift. The 11/18/23 nursing note was the first instance of nursing staff documenting measurements of Resident #182's coccyx wound since admission to the facility on [DATE]. The NP's coccyx wound measurement on 11/13/23 of approximately 29 square cm and the nursing staff measurement on 11/18/23 of approximately 58 square centimeters indicated a 100% increase in Resident #182's wound size over five days. Review of Resident #182's physician orders dated 11/19/22, indicated: * Weekly wound evaluations to the back every Wednesday. * Apply protective dressing to reddened/bony area on thoracic spine every day shift. * Weekly wound measurements and temperatures every Wednesday to coccyx. Review of the nursing note dated 11/20/23, indicated Resident #182 was discharged to home on this date. On 11/20/23 at 11:03 A.M., the surveyor observed Resident #182 lying supine in bed. Resident #182 said his/her bottom was painful and the surveyor informed Nurse #1. Resident #182 said he/she did not want the surveyor to observe his/her coccyx wound. During an interview with the Director of Nurses (DON) on 11/16/23 at 1:30 P.M. and 11/20/23 at 10:45 A.M., she said it was her expectation that nurses evaluate wounds and obtain full measurements on admission, weekly and as needed, update the physician when a wound has a significant change, and revise the plan of care, including treatments, to reflect changes to the wound. The DON said she was unable to locate any wound evaluations or measurements in Resident #182's medical record other than the measurements referenced in the 11/13/23 NP note and the 11/18/23 nursing note. During an interview with the Assistant Director of Nurses (ADON) on 11/17/23 at 8:30 A.M., she said staff discussed Resident #182's coccyx wound during the Risk meeting held on 11/10/23. The ADON said there was no discussion of changing the treatment even though the coccyx wound worsened, or of notifying the physician of the change in status. The ADON said both issues should have been addressed in the meeting but were not. The ADON said that if staff had made the provider aware of the worsening wound, then the provider could decide about whether to make a change in treatment. During interviews with Nurse #1 on 11/19/23 at 10:40 A.M. and on 12/5/23 at 9:00 A.M., she said she was Resident #182's primary nurse, but she was not working when Resident #182 was admitted so did not see his/her coccyx wound on 11/2/23. Nurse #1 said the first time she was assigned to Resident #182 was 11/8/23. Nurse #1 said at this time the coccyx wound was a Stage 4. Nurse #1 said the coccyx bone was visible. Nurse #1 said she had been staging wounds for over [AGE] years. Nurse #1 said she reported the wound to the Unit Manager (#1) that day but not to the Nurse Practitioner, or other provider. Nurse #1 said staff nurses are not responsible for measuring wounds or notifying the physician of worsening wounds because this was the responsibility of the Unit Manger. Nurse #1 said the Unit Manager (UM), DON and ADON are responsible for wound management. During an interview with UM #1 on 11/19/23 at 10:50 A.M., she said she was aware of Resident #182's coccyx wound but she was not responsible for evaluating wounds. UM #1 said she had not informed the NP or other provider Resident #182's wound deteriorated to a Stage 4 and was unaware if other staff notified Resident #182's providers that the wound had deteriorated from Stage 2 to Stage 4. During an interview with the DON on 12/4/23 at 10:01 A.M., she said unit managers were responsible for evaluating wounds, including obtaining measurements, and notifying the physician if a wound worsens. The DON said there should be a physician's order to evaluate and measure resident wounds and wound status and a description should be documented on the TAR. The DON said Resident #182's wound status and measurements were not documented in the TAR. The DON said that if wound measurements are not obtained on admission, then staff would be unable to determine if a wound has worsened or improved when examined on a later date. The DON said there was no indication nursing staff reported to a provider the worsening of Resident #182's coccyx wound between 11/2/23 and 11/8/23. The DON said observations should have been reported to the nurse or UM for evaluation. During an interview with the Nurse Practitioner (NP) on 12/5/23 at 9:27 A.M., Resident #182 ' s record was reviewed with the surveyor. The NP said the first time he visually assessed Resident #182's coccyx wound was on 11/13/23 and during that assessment determined it to be unstageable due to dead tissue present. He said he could palpate the bone under the layer of dead tissue present and said the wound was likely present as an unstageable wound for months but could provide no documentation of this. The NP said he was unaware that Resident #182's wound was determined to be a Stage 2 pressure ulcer according to the hospital paperwork and on the facility admission assessment and had progressed to a Stage 4 on 11/8/23 as documented by the nursing staff in the medical record. The NP said he did not recall nursing staff informing him on 11/8/23 that Resident #182's wound had worsened. The NP said he expects nursing staff to inform him if a wound is present on admission and if the wound worsens, but that he does not always examine a wound on admission and relies on the nursing assessments completed by the facility staff. The NP said he likely did not change the wound treatment for Resident #182's wound because of the Resident's age and he felt the wound could not be healed. The Nurse Practitioner further said the wound looked stable despite this being the first time he examined the wound. In addition, the Nurse Practitioner said he could not be sure but thought Resident #182 likely had an infection in the underlying bone. The NP said he did not think any changes in treatment were clinically appropriate and that the family members did not want aggressive interventions at this time. The NP said Resident #182's wound had purulent drainage and odor, and that these may or may not have been signs of wound infection. The NP said he did not recall nursing staff making him aware of the drainage and odor. The NP said Resident #182 exhibited increasing pain in the coccyx area and in response he adjusted his/her pain medications but did not examine the wound at the time the increasing pain was identified. The NP said he did not recall seeing the Dietitian's recommendation dated 11/2/23 for Resident #182 to receive supplements. The NP said supplements probably would not have helped the Resident because his/her wound was very advanced. During an interview with the Physician on 12/5/23 at 1:54 P.M., he said he would normally have examined Resident #182's wound on admission but that he was ill at this time. The Physician said he expected that another provider would have completed the examination in his absence. The Physician said nursing staff should be documenting wound measurements and descriptions beginning on the day of admission and informing providers if a wound is not healing or worsening. The Physician said staff should notify the provider if a wound has purulent drainage and odor because these are signs of infection. The Physician said that if Resident #182's wound was either not improving or worsening, he expected a referral would have been made to a wound specialist or surgeon for further treatment. 2. Resident #97 was admitted to the facility in November 2023, and had diagnoses which included fractures with multiple trauma, kidney disease and diabetes. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #97 was cognitively intact, at risk for skin breakdown, and admitted with an unhealed Stage 2 pressure ulcer. Review of the Nurse Practitioner note dated 11/4/23, indicated Resident #97 had a Stage 2 pressure ulcer located on the right buttock. Review of Resident #97's physician orders indicated: * Comprehensive skin check to be completed by licensed nurse weekly, every day shift every Sunday for skin check, dated 11/5/23. Review of the Skin and Wound assessment dated [DATE], indicated Resident #97 was at medium-risk for the development of pressure ulcers. Review of the care plan for skin breakdown dated 11/12/23, indicated Resident #97 had skin breakdown located on the left side of the back and buttocks. Interventions included: * Provide wound treatment as ordered. * Weekly skin check by licensed nurse. * Weekly wound assessment to include measurements and description of wound status. Review of the nursing progress note dated 11/11/23, failed to indicate a skin check was performed, wound rounds completed, and Resident #97's buttock was evaluated. The note did not indicate wound measurement or other description. Review of the nursing progress note dated 11/12/23, indicated a skin check was performed and Resident #97 had a pressure ulcer on the right buttock. The note did not indicate wound measurement or other description. Review of the Treatment Administration Record on 11/17/23 indicated there were no documented comprehensive skin checks, or skin/wound evaluations completed for Resident #97 during the month of November 2023. Review of the provider notes and nursing notes for the month of November 2023 indicated there were no measurements obtained or documented descriptions of Resident #97's Stage 2 pressure ulcer. During an interview with the Director of Nurses (DON) on 11/17/23 at 8:30 A.M., she said staff should have documented measurements and descriptions of Resident #97's Stage 2 wound, located on the right buttock, on admission and at least weekly. The DON said staff should have followed the physician order and plan of care to document weekly comprehensive skin checks. 3. Resident #101 was admitted to the facility in September 2023, and had diagnoses which included heart disease, diabetes, and dementia. Review of the Admission Nursing Documentation dated 9/29/23, indicated Resident #101 had a Stage 2 pressure ulcer located on the coccyx, and redness to the skin in the area of the coccyx. The Admission Nursing Documentation failed indicate measurements for Resident #101's wound. Review of the [NAME] Pressure Ulcer Scale dated 9/29/23, indicated Resident #101 scored an 8, signifying a very high risk for skin breakdown. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #101 had a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15, signifying severely impaired cognition. The MDS indicated Resident #101 was at risk for skin breakdown. Review of the care plan for skin breakdown dated 10/8/23, indicated Resident #101 was admitted to the facility with a Stage 2 pressure ulcer located on the coccyx. The care plan indicated he/she was at risk for skin breakdown related to advanced age, frail and fragile skin, incontinence, impaired cognition, limited mobility, refusal to aspects of care, poor safety awareness and shear/friction risks. Care plan interventions included, but were not limited to: * Provide wound treatment as ordered. * Weekly skin check by licensed nurse. * Weekly wound assessment to include measurements and description of wound status. * Provide preventative skin care. * Apply barrier cream with each cleansing. The care plan failed to indicate measurements for Resident #101's wound. Review of the Skin Check dated 12/6/23, indicated Resident #101 had a pressure ulcer located on the coccyx. The Skin Check failed to indicate staging or measurements. Interventions to manage the wound included, but were not limited to: * Provide wound treatment as ordered. Review of the Skin Check dated 12/8/23, indicated Resident #101 had a pressure ulcer located on the coccyx. The Skin Check failed to indicate staging or measurements. Interventions to manage the wound included, but were not limited to: * Provide wound treatment as ordered. Review of the Skin and Wound Evaluation dated 12/8/23, indicated Resident #101 had a Stage 2 pressure ulcer located on the coccyx, which measured 3.5 centimeters (cm) x 0.6 cm. The evaluation indicated the wound was covered with a foam dressing, and no secondary dressing, and the wound was stable. Review of Resident #101's physician orders indicated: * House barrier cream to bilateral buttocks and groin area, every shift for protection (dated 11/30/23). Review of Resident #101's physician orders indicated from admission through 12/10/23 there was no order for a dressing to be placed on his/her Stage 2 coccyx wound. Review of the Treatment Administration Record dated December 2023, indicated Resident #101 had no documented dressing treatments through 12/10/23. Review of Resident #101's nursing, nurse practitioner and physician progress notes from his/her admission through 12/10/23 indicated there were no references to nursing staff notifying any providers that he/she had a Stage 2 coccyx wound or a discussion of wound treatment. Review of these notes indicated there was no reference to the NP or Physician examining Resident #101's coccyx wound. Review of the physician orders and nursing progress notes indicated that on 12/11/23 (day of survey) an order was placed for cleansing and a dressing to be applied to Resident #101's Stage 2 coccyx wound. On 12/11/23 at 2:05 P.M., the surveyor observed nursing staff change a foam dressing located on Resident #101's coccyx wound. The wound appeared to have partial-thickness skin loss into but no deeper than the dermis. During [TRUNCATED]

Based on interviews, record review, staff education and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skillsets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to: 1) Ensure the licensed nursing staff were trained and demonstrated competency to identify, assess, evaluate, intervene, and respond to a significant change in condition of a wound, for one Resident (#182), out of a total sample of 44 Residents. Resident #182 was admitted with a Stage 2 pressure ulcer that progressed and deteriorated to a Stage 4 pressure ulcer. Resident #182 developed a pressure ulcer to the midthoracic spine while in the facility. and; 2) Ensure 10 out of 10 staff education records reviewed, education and competencies were completed and documented annually, per Facility Assessment. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies and training in areas as indicated in the facility assessment: Activities of Daily Living: Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment, supporting resident independence in doing as much of these activities by himself/herself. Mobility and fall/fall with injury prevention: Transfers, ambulation, restorative nursing, contracture prevention/care, supporting resident independence in doing as much of these activities by him or herself. Bowel/bladder: Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence, and promote resident dignity. Skin Integrity: Pressure injury prevention and care, skin care, wound care, surgical and other skin wounds. Mental Health and Behavior: Manage the medical conditions and medication related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with things anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, and other psychiatric diagnosis, intellectual or developmental disabilities. Medication: Awareness of any limitations of administering medications, administration of medications that residents need, by route; oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic, etc. Assessment/management of polypharmacy. Pain management: Assessment of pain, pharmacologic and non-pharmacological pain management. Infection Prevention and Control: Identification and containment of infections, prevention of infections. Management of Medical Conditions: Assessment, early in identification of problem/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD), gastroenteritis, infections such as UTI and gastroenteritis, pneumonia, hypothyroidism. Therapy: PT, OT, Speech/Language, Respiratory, Music, Art, management of braces, splints. Other Special Care Needs: Dialysis, hospice, ostomy care, tracheostomy care, ventilator care, bariatric care, palliative care, end of life care. Nutrition: Individualized dietary requirements, liberalized diets, specialized diets, IV nutrition, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions, hypodermoclysis. Provide Person-Centered/Directed Care: Psycho/Social/Spiritual Support: Build relationship with resident /get to know him/her; engage resident in conversation. Find you what resident preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. Record and discuss treatment and care preferences. Support emotional and mental well-being, support helpful coping mechanisms. Support resident having familiar belongings. Provide culturally competent care; learn about resident preferences and practices with regard to culture and religion; stay open to requests and preferences and work to support those as appropriate. Provide or support access to religious preferences, use or encourage prayer as appropriate/ desired by the resident. Provide opportunities for social activities/life enrichment (individual, small group, community). Support community integration if resident desires. Prevent abuse and neglect. Identify hazards and risks for residents. Provide family/representative support. Offer and assist resident and family caregivers (or other proxy as appropriate) to be involved in person-centered care planning and advanced care planning. Review of the Facility Assessment, dated as reviewed with the QAPI committee, in [DATE], indicated the following: Staff Training, education, and competencies: Staff receive training, education and competencies that are necessary to provide the level and types of support and care needed for our patient/resident population. Staff receive a comprehensive orientation program that is designed based on their job title and responsibilities. Additional training is required for specialty areas such as wound care, infection control, IV administration as examples. All staff are required to have an initial 8 hours of training on dementia care principles and four hours annually thereafter. The nurse practice educator is the leader of training and competencies in the center. An annual calendar is created that schedules required training for all staff. Training is conducted online, in the classroom, on the nursing units as appropriate. Clinical staff are CPR certified. Nurses obtain additional certification in areas of specialty required to care for our patient populations ex. IV certification, wound care certification etc. We also use collaboration within the interdisciplinary team for advancement of skills (example: PT Training staff on weight bearing restrictions or use of special equipment). [NAME] Hill also has a full-time Nurse Practitioner who is available for teaching and training staff. [NAME] Hill will also contract vendors or hospitals to provide additional training on new clinical programs. Facility has an extensive library of clinical policies and procedures that are developed through a shared governance model using clinical practice councils. Policies and procedures are based on federal regulations, standards from professional organizations (APIC, CDC, NPUAP, etc.) and professional clinical resources. ([NAME] and other evidence-based resources). An annual review is performed by the Practice Councils and the center Quality Improvement Committee to determine if updates are needed. However, policies and procedures are also updated throughout the year if practice standards change. New policies and procedures are developed as new population trends and needs are identified. Provider recruitment, retention and training is a priority at the Facility: Each regional division is supported by a physician leader and a director of provider relations, who partners with operational leadership to ensure each center is appropriately staffed. Our [NAME] President for Medical Affairs meet with our medical directors regularly, individually and as a group to ensure coordination and collaboration in optimizing the car of our residents. [NAME] Hill collaborates with the Medical Practitioners/NP's regularly to ensure the policies and re-hospitalization s, pressure ulcers, weight loss and falls, to ensure the center has quality outcomes and measures necessary to provide high quality of life and quality of care standards that align with the facility mission and vision of the organization. Quarterly (QAPI) meeting, the medical director meets with the leadership team and consultants (pharmacist, lab/x-ray) to discuss outcomes and develop protocols necessary to achieve optimum clinical outcomes and customer service. The facility physician services provide training to medical practitioners that aligns with the expectations each year. The facility accepts residents with combinations of conditions that require complex care and management. The facility failed to provide training and demonstrated competency with Quality of Life, Quality of Care, Behavioral Health, Pharmacy Services, Food and Nutrition Services, Administration, and Infection Control in the following care areas: ADL Care Provided for Dependent Residents related to showers. Quality of Care related to wound treatment orders. Free of Accident Hazards/Supervision/Devices related to falls with fractures. Bowel/Bladder Incontinence, Catheter, UTI related to incorrect foley catheter size. Pain Management related to physician's order for pain patch. Trauma Informed Care related to PTSD care plan. Bedrails related to use and lack of assessment. Treatment and Services for Mental/Psychosocial Concerns related to use of psychotropic medication. Free from Unnecessary Psychotropic Medication /PRN use related to no stop date. Free from Medication Error Rate of 5% or more related to facility medication error rate of 9%. Residents are free from Significant Medication Errors Label/Store Drugs & Biologicals related to expired medication found in resident room. Resident Allergies, Preferences and Substitutes related to food allergies. Resident Records - Identifiable Information related to inaccurate documentation in medical records. Infection Prevention & Control related to tracking and implementation of contact precautions. 1. Resident #182 was admitted to the facility in [DATE], and had diagnoses which included a Stage 2 pressure ulcer (a break in the top two layers of skin as a result of pressure) and diabetes. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #182 was admitted to the facility with a Stage 2 pressure ulcer on the coccyx, was at risk for skin breakdown, and was cognitively intact. Review of the medical record indicated that Resident #182's Stage 2 pressure ulcer, identified on [DATE] developed into a Stage 4 pressure ulcer on [DATE]. The medical record failed to indicate Resident #182's coccyx pressure ulcer or midthoracic spine wound was evaluated,measured, or that staff notified the physician that the coccyx wound progressed from a Stage 2 pressure ulcer to a Stage 4 pressure ulcer. Further review of Resident #182's medical record indicated Nurse #1 signed off as completing the wound dressing to the Resident coccyx on [DATE], [DATE], [DATE] and [DATE]. There were no evaluations or measurements of the wound indicated in the medical record. Further review of Resident #182's medical record indicated the measurements obtained on [DATE] documented by Nurse #11, was the first documented measurement of his/her coccyx wound since admission. The note did not reference wound depth. During an interview on [DATE] at 12:01 P.M., Nurse #1 said Resident #182 had a Stage 2 pressure ulcer on admission that progressed to a Stage 4, a pressure ulcer on the lower back, and said he/she documented it in the medical record as well as notified the unit manager of the change in condition. Nurse #1 said she had been a nurse for a long time and knows when a wound is not healing and getting worse. Nurse #1 said she notifies the NP if she has any concerns so the NP can visit the resident and make changes to medications or treatments. Nurse #1 said her training in the facility consisted of online videos that are assigned to nurses each year and that she had not completed any competencies in years. Nurse #1 said she does remember a training conducted by the rehabilitation department on the use of Hoyer lifts but reported no additional hands-on competencies completed. Review of Nurse #1 education files failed to include any demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Review of the education files failed to include recognizing and reporting wound deterioration, evaluation, measurments, and hands on clinical competency evaluations. Nurse #1's education files indicated he/she did not have the nessecary skills to properly evaluate Resident #182's Stage 2 pressure ulcer that deteriroated to a Stage 4 pressure ulcer. Review of Nurse #11's education files failed to include demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Review of the education files failed to include recognizing and reporting wound deterioration, evaluation, measurments, and hands on clinical competency evaluations.Nurse #2's education files indicated he/she did not have the nessecary skills to properly evaluate Resident #182's Stage 2 pressure ulcer that deteriroated to a Stage 4 pressure ulcer. 2) Review of 10 personnel files of actively working clinical nursing staff in the facility on [DATE] and [DATE] indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Further review of the education files indicated licensed clinical staff did not have the nessecary skills to evaluate, documenet, or recognize a change in condition related to skin integrity and proper wound management. Review of 10 out of 10 licensed nurses working in the facility, educational records, failed to indicate competencies were completed annually, per the Facility Assessment. Competencies reviewed included Skin and wound care, Medication Management, Pain Management, Infection Control, Basic Nursing Skills, Basic Restorative Services, Identification of Changes in Condition, Cultural Competency, Dementia Training, Person Centered Care, and Communication. There was no documented evidence that licensed clinical staff had the required clinical training or that competencies were completed as indicated in the facility assessment. During an interview on [DATE] at 10:02 A.M., the Nursing Home Administrator (NHA) said the Assistant Director of Nursing (ADON) was filling in for the Nurse Practice Educator position from [DATE] providing education along with the Director of Nursing to provide clinical training. The NHA said the wound nurse who resigned in [DATE] completed competencies on nurses for the Swift Phone (Phone used to track wound evaluations and measurements). The NHA said the DON and ADON manage all required nursing competencies in the facility because they are clinical. The NHA said the DON is certified in wound care. The NHA said the DON, ADON and Unit Managers take on all responsibility of training, and weekly wounds rounds. The NHA said she met with the DON, ADON and Unit managers to come up with a plan when the wound nurse submitted her one-month notice. The NHA said the team would review plans to transition the management of wound rounds and competencies during that time. During an interview on [DATE] at 10:35 A.M., with the Nursing Home Administrator (NHA), the Director of Nursing (DON) and Regional Nurse #1, the DON said new clinical staff are assigned mentors and given an orientation checklist to tack trainings. The DON said the mentor is responsible for checking off the orientation checklist. The DON said staff utilize an online video training system to watch videos and that human resources assigns the training to staff. The DON said this packet is to track training and not a competency packet. During an interview on [DATE] 10:59 A.M. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON said she is not certified in wound care and that she was trained on the use of the Swift Phone to evaluate wounds but does not use it because it is not user friendly, and she can't log into it. The DON said weekly wound rounds and wound evaluations needed to be addressed by all clinical staff. The ADON said wound rounds and evaluations were done by unit managers with swift phone access. The DON and ADON said they do not know what nurses have completed training with the use of the Swift phone. The DON said she expects documentation, evaluation including measurements of skin and wounds to be documented manually if the Swift Phone was not used. During an interview on [DATE] at 2:38 P.M., the Director of Nursing (DON) said the facility does not conduct training with competencies, only online video modules are assigned. The DON said they only do online videos for all new hires and no yearly training, just online training. The DON said wound basics is an online training that is not required and they just have staff do the online video's with no hands on competencies. The DON said human resources tracks the online modules. The DON said clinical staff come off orientation once the check list is completed and the mentor confirms the orientee is ready. The DON said she did not have any orientation checklists, competencies, or documented trainings for clinical staff aside from printed transcripts from the online video modules. During an interview on [DATE] at 12:42 P.M., the Medical Director said she expects new and existing clinical staff to be competent in resident care and complete the required training and competencies before providing care to residents. The Medical Director said she would expect staff to be competent in wound care needs including competency to assess, evaluate and measure skin issues. The Medical Director said she expects the facility to conduct weekly wound evaluations as indicated and expects clinical oversight by staff and management. The Medical Director said she would expect staff to document and report changes in condition right away and for clinical management to be notified. During an interview on [DATE] at 12:55 P.M., Unit Manager #1 said she would expect competencies to be completed by all staff before working with residents. The unit manager said she has not completed or signed off on any competencies and that the only training completed is online video modules. Unit Manager #1 said competencies were done a long time ago, but the facility no longer does them. The Unit Manager said new hires have a check off sheet to indicate when they are ready to come off orientation. During a follow-up interview on [DATE] at 1:40 P.M, the Director of Nursing (DON) confirmed that the facility had no orientation packets or clinical competencies for the Nursing Department, indicating staff were not assessed for hands on competency. The DON said clinical staff should have documented hands on competencies and training before patient care. During an interview on [DATE] at 1:45 P.M, the Nurse Practitioner (NP) #1 said treatments are based on the nurse's assessment, he doesn't look at the documented assessments, and he goes by what the nurses tell him verbally. NP #1 said staff would tell him if there was a change, and said the nurses should assess the area. NP #1 said it doesn't matter if they come to him with specifics and measurements and that he goes by if he is told the area is worse, not by measurements, color, or drainage. NP #1 said if nurses change the dressing orders, ninety nine percent of the time he will say it's good. NP #1 said these are good nurses; they do a good job and he has faith their order changes are for good reason. NP #1 said the facility gets a ton of wound vac and dressing changes. The NP said he is not aware of any training, education, or hands on competencies the nursing staff have completed and said he couldn't care less about continuing education. NP #1 said online video crap doesn't mean anything and is a waste of time. NP #1 said he would expect the nurses to complete hands on training and he would expect them to have competencies to know what they are doing. The NP said he has not conducted any teaching or training to staff. Review of Nurse #1 education files failed to include demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Review of Nurse #11's education files failed to include demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. 2) Review of 3 personnel files of actively working clinical nursing staff in the facility on [DATE] indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment for 1 out of 3 actively working clinical nursing staff. Review of Nurse #8's education files failed to include demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. During an interview on [DATE] at 11:49 A.M., Nurse #8 said skin and wound training was conducted in the conference room last Wednesday and he/she watched videos on the television and answered questions as a group. The surveyor asked Nurse #8 if there was any hands-on training conducted and he/she said no. Nurse #8 said there were no supplies in the conference room at the time of his/her training and that only videos were shown on the television. Nurse #8 said he/she did not complete a hands-on competency and said I haven't done that part yet. He/she has only watched videos. Other staff did the competency part later when they brought supplies in to measure, but he/she wasn't there for that part. Nurse #8 said they still need to do it. Nurse #8 said after his/her video training he/she was told staff did complete a hands on competency later in the day with the use of supplies and a mannequin, but he/she did not and still needs to complete the hands on competency. Nurse #8 said he/she did not conduct any measuring, or wound dressing change competencies as there were no supplies or competency equipment set up during the video training he/she attended. Nurse #8 said he/she was instructed to sign in to the facilities online learning portal to conduct additional training. Nurse #8 said he/she would complete the hands-on competency portion this week. During an interview on [DATE] at 11:56 A.M., Nurse #7 said, he/she completed skin and wound training last Thursday in the conference room and then completed a hands-on competency with a mannequin. Nurse #7 said he/she completed the competency on dressings changes and wound measurements. Nurse #7 said she was trained on the use of the Swift Phone by Unit Manager #2. During an interview on [DATE] at 11:59 A.M., Unit Manager #2 said skin and wound training was conducted in the conference room last week and the competency portion included hands on measurements and dressing changes. UM #2 said all Nurses have completed trainings including competencies for skin assessment and wounds. During an interview on [DATE] at 10:35 A.M., Regional Nurse #1 said all clinical staff must complete online training and complete demonstrated competency prior to treating residents. Regional Nurse #1 said hands-on competency demonstration is documented by the evaluation conducted, and once completed the training and competency is tracked online. Regional Nurse #1 said clinical staff must pass the competency evaluation to meet the requirements to receive an online portal certificate. Regional Nurse #1 said she expects all clinical staff to be educated and have hands-on demonstrated competencies as required to meet the clinical needs of the residents.

Based on observations, interviews and record review the facility failed to ensure its administration used its resources effectively to provide appropriate wound care. Specifically, the facility administration failed to: 1) provide nursing staff education and training to provide competent, safe, and effective wound care management; 2) provide continuation of the wound care program following the resignation of its Wound Nurse and implement an effective wound care program for pressure ulcer (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care per the Facility Assessment Tool. These failures resulted in the development of a Stage 4 pressure ulcer with purulent drainage and odor for one Resident (#182) out of a total sample of 44 residents. Findings Include: During the survey process it was identified that the Administration's failure to perform wound care competencies for nursing staff that were delegated to assume the responsibilities of wound care management in the absence of a wound nurse resulted in a failure to perform skin checks and wound evaluations, implement physician orders, updated the physician and plan of care when significant changes occurred, and the development of a stage 4 pressure ulcer with purulent drainage and an odor. Review of the Facility Assessment Tool, dated as reviewed with the QAPI committee in November 2022, indicated the facility offers pressure ulcer prevention and care, skin care, wound care (surgical, other wounds). Further review of the Facility Assessment Tool indicated, but was not limited to, the following: -The team also discusses current termination/resignations of staff and develops a plan on how to meet the staffing needs of the center proactively. -Staff receive training/education and competencies that are necessary to provide the level and types of support and care needed for our patient/resident population. Staff receive a comprehensive orientation program that is designed based on their job title and responsibilities. Additional training is required for specialty areas such as wound care, for example. Training is conducted online, in the classroom, and on the nursing units as appropriate. Nurses obtain additional certification in areas of specialty required to care for our populations ex: IV certification, wound care certification etc. The facility also has a full-time Nurse Practitioner who is available for teaching and training of staff. The facility will also contract vendors or hospitals to provide additional training on new clinical programs. The governing body has an extensive library of clinical policies and procedures that are developed through a shared governance model using clinical practice councils. Policies and procedures are based on federal regulations, standards from professional organizations (APIC, CDC, NPUAP, etc.) and professional clinical resources. ([NAME] and other evidence-based resources). An annual review is performed by the Practice Councils and the center Quality Improvement Committee to determine if updates are needed. However, policies and procedures are also updated throughout the year if practice standards change. New policies and procedures are developed as new population trends and needs are identified. 1) The facility failed to provide nursing staff education and training to provide competent, safe, and effective wound care management. According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Resident #182 was admitted to the facility in November 2023, and had diagnoses which included a Stage 2 pressure ulcer (a break in the top two layers of skin because of pressure), diabetes and congestive heart failure (a heart disease resulting in poor blood circulation). Review of the Minimum Data Set assessment dated [DATE] indicated Resident #182 was admitted to the facility with a Stage 2 pressure ulcer on the coccyx, was at risk for skin breakdown, and had a Brief Interview for Mental Status score of 15, indicating intact cognition. Review of the Hospital discharge summary dated 11/2/23, indicated Resident #182 was discharged to the facility with a Stage 2 coccyx wound. Review of the nursing note dated 11/2/23, indicated Resident #182 was admitted with a Stage 2 pressure ulcer located on the coccyx. Further review of the medical record indicated on 11/8/23, the wound progressed to a Stage 4 pressure ulcer (Stage 4 ulcers are defined as deep wounds that may impact muscle, tendons, ligaments, and bone, which indicates Resident #182's wound deteriorated since admission) and that on 11/18/23 the wound had purulent drainage and an odor. Review of the nursing notes, physician notes and wound evaluations failed to indicate staff evaluated and monitored the wound, implemented preventative interventions and treatments, or notified the physician of a change in condition to prevent the worsening of Resident #182's wound. According to the Mayo Clinic, complications and outcomes of Stage 4 pressure ulcers include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization . It may develop within the first 2 weeks of pressure ulcer formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). Further review of the medical record indicated Nurse #1 signed off as completing Resident #182's coccyx wound dressing on 11/8/23, 11/10/23, 11/11/23 and 11/12/23. There were no wound measurements in the medical record for these dates. Further review of the medical record indicated Nurse #11 obtained the first documented wound measurement for Resident #182's coccyx wound on 11/18/23. The note did not reference wound depth. During an interview on 12/05/23 at 12:01 P.M., Nurse #1 said Resident #182 had a Stage 2 pressure ulcer located on the coccyx. Nurse #1 said this wound progressed to a Stage 4 pressure ulcer and that she documented the Stage 4 wound in the nursing notes and notified the unit manager of the change in condition. Nurse #1 said she had been a nurse for a long time and knew when a wound was not healing and getting worse. Nurse #1 said she notifies the Nurse Practitioner (NP) if she has any concerns so the NP can visit the resident and make changes to medications or treatments. Nurse #1 said her training in the facility consisted of online videos that are assigned to nurses each year and that she had not completed any competencies in years. Nurse #1 said she does remember a training conducted by the rehabilitation department on the use of Hoyer lifts but reported no additional hands-on competencies completed. Review of Nurse #1's education files failed to include demonstrated competencies necessary to provide wound care needed for the resident population as required per the facility assessment. Review of Nurse #11's education files failed to include demonstrated competencies necessary to provide wound care for the resident population as required per the facility assessment. Resident #65 was admitted to the facility in March 2023, and had diagnoses which included dementia, cellulitis, cerebral ischemia, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #65 scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of Resident #65's nursing skin check note dated 3/10/23, indicated he/she was admitted with a left lower extremity abrasion, pressure area to coccyx, and Prevalon heel protectors (a device used to reduce the risk of pressure injuries by keeping the heel floated, relieving pressure), applied to bilateral lower extremities. His/her skin was warm and dry. Review of Resident #65's nurse practitioner note dated 3/20/23, indicated the presence of pressure area to the Right buttock but failed to indicate the wound was evaluated or measured. There was no documentation of the left lower extremity abrasion and had no documented evaluations including measurements or observations of the Residents skin. Review of Resident #65's admission documentation failed to indicate measurements or further description of the pressure area to coccyx or left lower extremity. Review of Resident #65's nursing note dated 9/26/23, indicated the presence of a new unstageable wound to mid back measuring 7 centimeters (cm) x 7 cm, mostly white/yellow slough. Review of Resident #65's physician notes, nurses notes and wound evaluations failed to indicate staff completed wound evaluations and assessments to include measurements and description of wound status. Review of physician's orders dated 3/6/23 indicated the following: BUTTOCKS WOUND: Cleanse wound with soap and water. Apply skin prep to peri wound, apply TRIAD nickel thickness to open wound. every day and evening shift. L HEEL PRESSURE INJURY: Cleanse with normal saline and apply skin prep to wound. Leave open to air. Every evening shift. Moisture Barrier - Apply every shift and as needed to peri-area and buttocks every shift. L HEEL PRESSURE INJURY: Cleanse with normal saline and apply skin prep to wound. Leave open to air. Every evening shift. Moisture Barrier - Apply every shift and as needed to peri-area and buttocks every shift. Off-load heels with Prevalon boots or pillows while in bed. Every shift. On 11/16/23 at 10:38 A.M., the surveyor observed Resident #65 lying supine in bed. Resident #65 said his/her bottom and back were painful and that staff will sometimes place pillows behind his/her back or legs for comfort. Resident #65 did not have any pillows placed behind his/her back, under his coccyx area, legs and heels were flat on the bed and Resident #65 was not wearing Prevalon boots. During an interview with Nurse #10 on 11/16/23 at 10:21 A.M., she said Resident #65 has a wound to his/her thoracic spine, and a deep tissue injury on his/her heel, and moisture area to the coccyx that is treated daily. Nurse #10 said the facility had a dedicated wound nurse, but they resigned over the summer and weekly wound rounds are no longer conducted. Nurse #10 said she would expect heels to be offloaded, should not be flat on bed, pillows are to be placed for offloading pressure and Resident #65 should be wearing Geri sleeves and using Prevalon boots to both feet. Nurse # 10 said she would expect the orders and care plan interventions to be updated and followed to prevent skin issues. Resident #97 was admitted to the facility in November 2023, and had diagnoses which included fractures with multiple trauma, kidney disease and diabetes. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #97 was cognitively intact, at risk for skin breakdown, and admitted with an unhealed Stage 2 pressure ulcer. Review of the Nurse Practitioner note dated 11/4/23, indicated Resident #97 had a Stage 2 pressure ulcer located on the right buttock. Review of Resident #97's physician orders indicated: * Comprehensive skin check to be completed by licensed nurse weekly, every day shift every Sunday for skin check, dated 11/5/23. Review of the care plan for skin breakdown dated 11/12/23, indicated Resident #97 had skin breakdown located on the left side of the back and buttocks. Interventions included: * Provide wound treatment as ordered. * Weekly skin check by licensed nurse. * Weekly wound assessment to include measurements and description of wound status. Review of Resident #97's nursing progress notes, treatment administration record, and provider notes for the month of November 2023 indicated there were no measurements obtained or documented descriptions of Resident #97's Stage 2 pressure ulcer. Resident #101 was admitted to the facility in September 2023, and had diagnoses which included heart disease, diabetes, and dementia. Review of the Admission Nursing Documentation dated 9/29/23, indicated Resident #101 had a Stage 2 pressure ulcer located on the coccyx, and redness to the skin in the area of the coccyx. The Admission Nursing Documentation failed indicate measurements for Resident #101's wound. Review of the Skin and Wound Evaluation dated 12/8/23, indicated Resident #101 had a Stage 2 pressure ulcer located on the coccyx, which measured 3.5 centimeters (cm) x 0.6 cm. The evaluation indicated the wound was covered with a foam dressing, and no secondary dressing, and the wound was stable. Review of Resident #101's physician orders from admission through 12/10/23 failed to indicate an order for a dressing to be placed on his/her Stage 2 coccyx wound. Review of Resident #101's nursing, nurse practitioner and physician progress notes from his/her admission through 12/10/23 indicated there were no references to nursing staff notifying any providers that he/she had a Stage 2 coccyx wound or a discussion of wound treatment. Review of these notes indicated there was no reference to the NP or Physician examining Resident #101's coccyx wound. Review of the physician orders and nursing progress notes indicated that on 12/11/23 (day of survey) an order was placed for cleansing and a dressing to be applied to Resident #101's Stage 2 coccyx wound. During an interview with Regional Nurse #1 on 12/11/23 at 12:30 P.M., she said she had reviewed the medical record and interviewed nursing staff and determined staff had not informed Resident #101's Nurse Practitioner (NP) or Physician that he/she had a Stage 2 pressure ulcer on the coccyx, until today (12/11/23). Regional Nurse #1 said there had been no order for a dressing to be placed on the coccyx wound until today. Regional Nurse #1 said staff should have notified either the NP or Physician of Resident 101's wound and obtained orders wound treatment when he/she was admitted to the facility with the wound. Resident #67 was admitted to the facility in February 2023 with diagnosis including cancer. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #67 scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Further review of the MDS indicated the Resident is on hospice services. Review of the wound nurse progress note dated 6/27/23, indicated Resident #67 had a Stage V (sic.) coccyx wound and recommended packing the wound with Aquacel Ag rope (an antimicrobial wound dressing which controls the development and growth of biofilms to better manage infection and absorb exudate). Review of the medical record including the Nurse Practitioner notes and nursing notes failed to indicate the wound nurse recommendation was reviewed. Review of personnel files for 10 of 10 licensed nurses actively working in the facility on 12/4/23 and 12/5/23 indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Competencies were not completed annually, per facility assessment. Competencies reviewed included Skin and Wound care, Medication Management, Pain Management, Infection Control, Basic Nursing Skills, Basic restorative services, Identification of Changes in Condition, Cultural Competency, Dementia Training, Person Centered Care, and Communication. There was no documented evidence these or other competencies were completed as required by the facility assessment. During an interview on 12/5/23 at 2:38 P.M., the Director of Nursing (DON) said the facility does not conduct training with competencies, only online Vital Learning video modules are assigned. The DON said the facility only does online videos for all new hires and no yearly trainings, just online stuff. Wound basics is online and not required. We just have them do the online stuff with no competencies. The DON said human resources tracks the online modules. The DON said clinical staff come off orientation once the check list is completed and the mentor confirms the orientee is ready. The DON said she did not have any orientation checklists, competencies, or trainings for clinical staff aside from printed transcripts from the online video modules in Vital Learning. The DON said there was no evidence of return demonstration practice for nursing staff. During an interview on 12/5/23 at 12:42 P.M., the Medical Director said she expects new and existing clinical staff to be competent in resident care and complete the required training and competencies before providing care to residents. The Medical Director said she would expect staff to be competent in wound care needs including competency to assess, evaluate and measure skin issues. The Medical Director said she expects the facility to conduct weekly wound evaluations as indicated and expects clinical oversight by staff and management. The Medical Director said she would expect staff to document and report changes in condition right away and for clinical management to be notified. During an interview on 12/5/23 at 12:55 P.M., Unit Manager #1 said she would expect competencies to be completed by all staff before working with residents. Unit Manager #1 said she has not completed or signed off on any competencies and that the only training completed is online video modules. Unit Manager #1 said competencies were done a very long time ago, but the facility no longer does them. Unit Manager #1 said new hires have a check off sheet to indicate when they are read to come off orientation. During a follow-up interview on 12/5/23 at 1:45 P.M, the DON confirmed the facility had no orientation packets or clinical competencies for the Nursing Department, indicating staff were not assessed for competency. During an interview on 12/05/23 at 9:28 A.M., NP #1 said he does not look at a wound unless there is a change because his expectation is that nurses are assessing the wound and will tell him if there is a change. NP #1 said that his trust for nursing assessments of wounds is based, in part, on the assumption that nurses have completed hands-on training/competencies related to wound care and evaluation. The NP said he has not provided wound care or wound evaluation training to the nursing staff. 2) The facility failed to provide continuation of the wound care program following the resignation of its Wound Nurse and implement an effective wound care program for pressure ulcer prevention and care per the Facility Assessment Tool. During an interview on 12/4/23 at 10:02 A.M., the Administrator said the facility had employed a full-time wound nurse who was responsible for oversight of wounds in the building and training nurses how to treat and evaluate wounds. The Administrator said a Nurse Practice Educator was hired to replace the Wound Nurse but went on a leave of absence shortly after starting and did not return. The Administrator provided documentation stating the wound nurses' last day was 6/28/23, and that the Nurse Practice Educator hired to replace the Wound Nurse started on 7/11/23 and went on leave of absence on 8/1/23. The Administrator said that in the absence of the Wound Nurse her responsibilities, as outlined in the wound nurse job description, were delegated to the DON, Assistant Director of Nursing (ADON), and Unit Managers. The Administrator said the Wound Nurse gave a month's notice for her resignation which left the facility enough time to plan a transition of responsibilities. The Administrator said there was nothing on paper about specific divided responsibilities, and that no outside services were consulted or contracted to facilitate the wound care management program in the facility. Review of the Wound Nurse Job Description indicated, but was not limited to, the following responsibilities: 1) The Skin Health Lead develops and facilitates a person-centered team approach to prevention and management of wounds among the center leaders, the patient and family, the nursing team, CRC, providers, therapists 2) Coordinates and leads weekly team wound rounds and post-meet-ups for follow-up discussions. 3) Communicates and coordinates readiness for any potential admissions with skin/wound needs; with CAD and center leadership, as indicated. 4) Lead and/or ensure team review of all new admissions/readmissions for skin integrity needs. a. Identifies skin risk factors and discusses interventions. b. Identifies actual skin impairments. c. Facilitates team discussion to recognize patient/family skin/wound related needs, including but not limited to psychosocial, physical, nutritional, medical, and others. d. Coordinates skin, wound, and incontinence related to supplies with central supply and or DME companies, as indicated. e. Coordinates and or provides any needed skin/wound education with patient/family and staff, as indicated. 5) Ensures and/or leads team evaluation of all new skin/wound conditions for any new admissions within 48 hours. a. Reviews skin check, wound evaluation/documentation, risk assessment, orders, and care plan for completion and accuracy. b. Provides actual inspection of wounds (in-person or via wound app) to ensure accuracy of wound type. c. Reviews and/or coordinates team discussion to determine patient-wound goal. d. Ensures that the patient/responsible party/family has information regarding benefits and risks of interventions. During an interview on 12/4/23 at 10:58 A.M., the DON said she does not have a wound care certification. The DON said that in the absence of the wound nurse the unit managers should be completing weekly wound rounds and as the Orchard unit has not had a unit manager for around six weeks they have been trying to schedule an extra nurse to complete weekly wound rounds. The DON said the facility implemented a Swift Phone (a clinically calibrated wound imaging system) to track wounds when the Wound Nurse started, but the swift phone is not user friendly and that the DON is unable to use it. The DON said the Wound Nurse was responsible for training staff how to use the Swift Phone, but nobody has been designated for providing Swift Phone training since the Wound Nurse left in June. The DON also said that the Swift Phone has been malfunctioning intermittently. During an interview on 12/5/23 at 12:55 P.M., Unit Manager #1 said there have been no weekly wound rounds since the Wound Nurse left in June 2023. During an interview on 12/4/23 at 1:00 P.M., the DON said she was unable to provide evidence of weekly wound rounds because none have been done on any unit. During an interview on 12/05/23 at 9:28 A.M., NP #1 said the previous Wound Nurse sent him regular updates regarding wounds in the facility and once she left the updates stopped. See F686 and F726

Based on observation, interview and record review the facility failed to ensure it completed a baseline care plan for one Resident (#182) out of 44 sampled residents. Specifically, the facility failed to complete a baseline care plan to address a Stage 2 pressure ulcer present on admission. The baseline care plan failed to include goals and interventions. The Stage 2 coccyx pressure ulcer then developed into a Stage 4 pressure ulcer on 11/8/23. Findings include: Review of the facility's policy Skin Integrity and Wound Management dated 2/1/23, indicated: - Complete comprehensive evaluation, and risk evaluation on admission and weekly for the first month. - The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continuously observe and monitor patients for changes and implement revision to the plan of care as needed. - Review care plan and revise as needed. The Skin Integrity and Wound Management policy did not make reference to baseline care plans. Resident #182 was admitted to the facility in November 2023, and had diagnoses which included a Stage 2 pressure ulcer (a break in the top two layers of skin because of pressure), diabetes and congestive heart failure (a heart disease resulting in poor blood circulation). Review of the Hospital discharge summary dated 11/2/23, indicated Resident #182 was discharged to the facility with a Stage 2 coccyx wound. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #182 was admitted to the facility with a Stage 2 pressure ulcer on the coccyx, was at risk for skin breakdown, and had a Brief Interview for Mental Status score of 15 out of a possible 15, indicating intact cognition. Review of the nursing note dated 11/2/23, indicated Resident #182 was admitted with a Stage 2 pressure ulcer located on the coccyx with scattered bruising. Resident #182's skin was warm and dry and the skin on the right and left lower extremity was red. Review of the [NAME] Pressure Ulcer Scale assessment dated [DATE], indicated Resident #182 scored 11, signifying he/she was at medium-risk for developing pressure ulcers. Review of the baseline care plan dated 11/3/23, indicated Resident #182 was at risk for skin breakdown related to diagnoses of diabetes and age-related frail skin, and was admitted to the facility with a Stage 2 pressure ulcer located on the coccyx. The baseline care plan was incomplete and failed to include goals or nursing interventions for wound treatment. Review of the Skin Check assessment, dated 11/8/23, indicated: The following skin injury/wound(s) were previously identified and were evaluated as follows: Rash(s): Description: fungal rash groin Pressure Area(s): Location(s): coccyx wound. Midspine thoracic wound. The Skin Check assessment included the following care plan interventions: * Weekly skin check by licensed nurse. * Weekly wound assessment to include measurements and description of wound status. * Provide wound treatment as ordered. * Pat do not rub skin when drying. * Obtain dietitian consult as needed/ordered. * Provide supplements as ordered. * Provide patient and/or healthcare decision maker education regarding risk factors and interventions. * Provide preventative skin care lotions barrier creams as ordered. * Apply barrier cream with each dressing. * Assist resident with turning and repositioning every 2 hours. * Encourage resident to consume all fluids of choice. * Observe skin for signs and symptoms of skin breakdown. * Evaluate for any localized skin problems. * Observe skin condition daily during ADL care and report abnormalities. * Observe for verbal and non-verbal signs of pain related to wound/Tx. Review of Resident #182's care plan for skin breakdown indicated the interventions recommended from the Skin Check assessment were not initiated until 11/11/23. Review of the nursing note dated 11/8/23, indicated Resident #182 had a Stage 4 pressure ulcer on the coccyx, (Stage 4 ulcers are defined as deep wounds that may impact muscle, tendons, ligaments, and bone, which indicates Resident #182's wound deteriorated since admission). Resident #182 presented with some discomfort and was relieved with repositioning and scheduled pain medication. Resident #182's pain level was rated as mild and located on the coccyx. The following skin injury/wound(s) were previously identified and were evaluated as follows: Rash(s): Description: fungal rash groin, pressure area(s): Location(s): coccyx wound, midspine thoracic wound. Review of the care plan dated 11/11/23 for skin breakdown indicated goals and interventions were added and initiated on this date. The goal was for the coccyx wound to remain free of infection for 90 days. Interventions included: * Weekly skin check by licensed nurse * Weekly wound assessment to include measurements and description of wound status. * Provide wound treatment as ordered. * Pat do not rub skin when drying * Obtain dietitian consult as needed/ordered. * Provide supplements as ordered. * Provide patient and/or healthcare decision maker education regarding risk factors and interventions. * Provide preventative skin care lotions barrier creams as ordered. * Apply barrier cream with each dressing. * Assist resident with turning and repositioning every 2 hours. * Encourage resident to consume all fluids of choice. * Observe skin for signs and symptoms of skin breakdown. * Evaluate for any localized skin problems. * Observe skin condition daily during ADL care and report abnormalities. * Observe for verbal and non-verbal signs of pain related to wound/Tx. On 11/20/23 at 11:03 A.M., the surveyor observed Resident #182 lying supine in bed. Resident #182 said his/her bottom was painful and the surveyor informed Nurse #1. Resident #182 said he/she did not want the surveyor to observe his/her coccyx wound. During an interview with the Director of Nurses (DON) on 11/16/23 at 1:30 P.M. and 11/20/23 at 10:45 A.M., she said it was her expectation that staff develop baseline care plans within 48 hours of admission and that the baseline care plans include goals and nursing interventions.

Based on record review and interviews, the facility failed to provide supervision for one Resident (#94) out of a total sample of 44 residents. Specifically, the facility failed to implement the fall intervention, which resulted in the Resident falling and fracturing his/her left hip. Findings include: Review of the facility's policy titled 'Falls Management' with a revision date of 8/7/23, indicated the following: -Patients will be assessed for risk of falling as part of the nursing assessment process. -Interventions to reduce risk and minimize injury will be implemented as appropriate. -A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. -Patients experiencing a fall will receive appropriate care and post fall interventions will be implemented. Resident #94 was admitted to the facility in May 2022 with diagnoses including a history of falls and Parkinson's disease. A review of the most recent Minimum Data set (MDS) dated [DATE], failed to indicate a Brief Interview for Mental Status (BIMS) score. A review of the cognition care plan initiated 5/17/22, indicated the Resident has impaired thought processes. A review of the fall care plan initiated 5/17/22, indicated the following intervention initiated 4/6/23: -After Resident's shower, bring Resident to a supervised common area A review of a fall incident report dated 10/31/23, with a time of incident at 9:55 A.M., indicated the following: -At 0955, hear Resident yelling, help him/her, he's/she's on the floor, when approached the dining room, Resident was laying on his/her left side, small abrasion noted to left forehead, guarding left hip, when attempted to transfer, yelling out don't touch it wheelchair not in reach, it appears resident had gotten up and attempted to walk and fell . Nurse Practitioner (NP) came to assess the patient and determined to send to emergency department (ED) for further eval (evaluation). Son called and updated at 10:15 A.M., Emergency Medical Services (EMS) arrived at 10:30 A.M. [SIC] Further review of the incident report indicated the following internal investigations narrative and corrective measures after the internal investigation: -Staff reported his/her wheel chair was behind him/her. He/she was sent to the hospital for evaluation and X-ray revealed a non displaced proximal left greater trochanter fracture. He/she was deemed not to be a candidate for surgical repair. He/she was admitted to the hospital for pain management. -Plan: Upon return from the hospital he/she will be assessed for pain and medicated per the physicians's orders. Any changes in pain will be reported to the physician for further orders. He/she will seen by therapy and a plan of care will be developed as appropriate. Further review of the fall incident report investigation included the following staff witness statements dated 10/31/23: -Nurse #7-Around 10:00 A.M. I was doing medication when the nurse called me and said the patient is on the floor, when I get there, I found the patient laying in his/her left side in the living room. [SIC] -CNA #8 (Certified Nurse's Assistant) -I see nothing. [SIC] -CNA #7-I was taking care of another patient, at the time I wasn't present. [SIC] -Nurse #6-A resident approached me and stated someone had fallen, I went to the recreation area proximal to the main entrance to the unit and found the resident lying on the floor on his/her left side. [SIC] -CNA #1-I was giving ice water to the patients when I saw him/her on the floor. [SIC] A review of the Nurses progress notes dated 10/31/23 at 10:29 A.M., indicated the following: -At 0955, hear Resident yelling, help him, he's on the floor, when approached the dining room. Resident noted on the floor , laying on his/her left side, small abrasion noted to left forehead, guarding left hip, when attempted to transfer via transfer resident yelling out don't touch it. Wheelchair not in reach, it appears resident had gotten up and attempted to walk and fell . NP came to assess patient and determined to send to emergency department (ED) for further eval (evaluation). Son called and updated at 10:15 A.M. Emergency Medical Services (EMS) arrived at 10:30 A.M. [SIC] A review of the Nurse Practitioner #1's progress note dated 10/31/23, at 10:26 A.M., indicated the following: -Assessment and Plan: Fall, left hip pain, probable head strike. Nursing found him/her down, on the ground, in the dining room, about 8 feet from his/her wheelchair. Unwitnessed fall. He/she reported left hip pain. There is a significant risk for fracture, given his/her presentation, we have elected to transfer him/her to the emergency room for imaging and evaluation. He/she needs supervision and assistance, very high risk for falls. A review of the emergency department consultation notes dated 10/31/23, at 9:43 P.M., indicated the following: -CT (Computed Tomography) scan of left hip shows well aligned total hip with non-displaced greater trochanter fracture. During an interview with Resident #27 on 11/17/23, at 2:27 P.M., he/she said he/she was sitting in the dining room with Resident #94 on 10/31/23, after breakfast, it was just the two of them in the area, he/she observed Resident #94 stand up from his/her wheelchair and fall face down. Resident #27 yelled out for help because there was no staff member in the dining room. A review of Resident #27's most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) Score of 10 out of a possible 15 indicating moderate impairment. During an interview on 11/17/23, at 7:15 A.M., Nurse #2 said that fall interventions in the care plan should be followed as indicated, and supervision for this particular Resident (#94) means having eyes on him/her at all times. Nurse #2 said she works evening and night shifts, she said the Resident is very impulsive. When she is working on the medication cart, she has to make sure he/she is sitting next to her cart at all times. When she moves her cart, she moves the Resident with her around the unit to keep her eyes on him/her. She said if staff need to take a break and attend to another Resident while supervising him/her, they have to alert another staff member to take over. During an interview on 11/17/23, at 11:13 A.M., the Activities Director said the Resident was sitting next to the fireplace on the day he/she fell , there were no activities in progress at that time. During a telephone interview on 11/17/23, at 1:18 P.M., Nurse #6 said fall interventions should be followed as care planned, the expectation is for the Resident to be supervised at all times while he/she is in the common area, he said someone should have eyes on him/her at all times. Nurse #6 said he worked on the day the Resident fell , he was down the hall on his medication cart when he heard another Resident in the dining room scream for help because Resident #94 had fallen, he ran down the hall to find the Resident on the floor. Nurse #6 said there were no staff members in the dining room when the Resident fell , it was just Resident #94 and the other Resident who called for help. During an interview on 11/17/23 at 2:19 P.M., Nurse #7 said she worked on the morning the Resident fell , she said she was on her medication cart in the hallway when she heard a Resident in the dining room scream for help because Resident #94 had fallen. She said there were no staff in the vicinity of the dining room at the time of the fall, they all had to run to the dining area when they heard the scream, it is the expectation that staff have eyes on the Resident (#94) at all times when he/she is in the common area. During a telephone interview on 11/17/23 at 4:42 P.M., CNA #1 said she worked on the day Resident #94 fell , there were no staff members actively supervising the Resident when he/she fell , she said Resident #94 requires supervision at all times while in the common area. She said CNAs should alert other CNAs to take over supervision if they have to leave the common area, so the Resident is not left without supervision. During an interview on 11/17/23, at 8:46 A.M., Unit Manager #2 said fall interventions should be followed as indicated in the care plan. She said supervision for Resident #94 means having eyes on him/her at all times when he/she is out in the common area. She expects staff to notify other staff members if they have to leave the common area so other staff members can step in and continue to supervise the Resident. During an interview on 11/17/23 at 9:18 A.M., the Director of Nurses and Consulting Staff both said that fall interventions should be followed by staff. They both said when Resident #94 is in the common area, staff should make sure they have eyes on him/her at all times, if they have to take a break or leave the area, they should alert another staff member to take over.

Based on observation, interviews, and records reviewed for one Resident (#381) of 44 sampled residents, the facility failed to provide mental health services to a Resident with a known history of trauma and a diagnosis of post-traumatic stress disorder (PTSD). Specifically, for Resident #381 the facility failed to implement a physician's order for a psychiatric evaluation or develop a comprehensive plan of care, resulting in increased depression, thoughts of being better off dead, and an emergent hospital evaluation. Findings include: Review of the facility policy titled Behavioral Health Care and Services, revised 1/1/22, indicated, but was not limited to the following: -Each patient/resident (hereinafter patient) must receive, and the Center must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident #381 was admitted in November 2023 with the following diagnoses: anxiety, depression, and PTSD. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #381 had a Brief Interview for Mental Status (BIMS) exam score of 15 out of 15, indicating he/she was cognitively intact. On 11/14/23, at 9:47 A.M., the surveyor observed Resident #381 in bed, crying. Resident #381 said he/she is depressed and feels lonely. Resident #381 said he/she has flashbacks from PTSD that upset him/her. Resident #381 said he/she has been making phone calls to find a therapist but was only able to get onto wait lists. Resident #381 said he/she did not know there were mental health services available in the facility and would be interested in mental health services in the facility. Resident #381 said it was not offered to him/her. Review of the care plan, dated 11/10/23, indicated Resident #381's reported past experience of trauma. Resident #381's care plan failed to indicate goals or interventions. Review of Nurse Practitioner (NP) #1's initial evaluation dated 11/3/23, indicated Resident #381 had a history of PTSD, depression, and anxiety. NP #1's initial evaluation also indicated Resident #381 presented as nervous with pressured speech and reported intense anxiety. NP #1's initial evaluation indicated a request for nursing staff to obtain a psychiatric evaluation. Review the physician order dated 11/3/23, indicated Resident #381 required a psychiatric evaluation. Review of Resident #381's medical record failed to indicate a psychiatric evaluation was completed. Review of Resident #381's nursing note dated 11/3/23, indicated the purpose of the admission to the facility included, but was not limited to, psychiatric/behavioral/mental health care. Review of the medication administration record (MAR) dated 11/16/23, indicated staff administered to Resident #381 clonazepam (antianxiety medication) 0.5 milligrams (mg) scheduled daily and as needed, and Venlafaxine (antidepressant) 150 mg scheduled since his/her admission. Review of the nursing note dated 11/7/23, indicated Resident #381 had verbal behaviors directed toward others, occurred daily or almost daily, and that other behaviors not directed towards others occurred daily or almost daily. The note further indicated Resident #381 experienced agitation/restlessness and anxiety around surroundings. The note also indicated Resident #381 experienced loss of interest daily or almost daily and exhibited frustration. Review of the Physician Assistant (PA) note dated 11/8/23, indicated Resident #381 had a history of PTSD, depression, anxiety, and several previous suicide attempts. The PA note indicated Resident #381 said he/she was depressed, had suicidal ideation and verbalized feelings of uselessness. The PA note indicated the plan for Resident #381's suicidal ideation included monitoring, providing supportive care, and appreciating psychiatric evaluations and recommendations, as well as outpatient therapy follow-up. Review of the primary physician note dated 11/8/23, indicated Resident #381 had a history of PTSD, depression, and anxiety and he/she appeared depressed. The note failed to indicate a plan or treatment interventions for Resident #381's depression. Review of the PA note dated 11/13/23, indicated Resident #381 felt very depressed and he/she requested to speak with Social Worker #1. The PA note indicated Resident #381 said he/she left voice messages for Social Worker #1 in tears. The PA note indicated the plan for Resident #381's suicidal ideation included monitoring, providing supportive care, and appreciating psychiatric evaluations and recommendations, as well as outpatient therapy follow-up. Review of the Patient Health Questionnaire-9 (a depression screening tool) completed by Social Worker #1 dated 11/3/23, indicated Resident #381 felt down, depressed, or hopeless 7 to 11 days in the last 14 days. Resident #381 denied thoughts he/she would be better off dead, or of hurting his/herself in some way during the last 14 days. Review of Social Worker #1's note dated 11/3/23, indicated Resident #381's Post Traumatic Stress Disorder Checklist was completed and the score indicated a positive screening for symptoms related to possible PTSD. Review of the nursing note dated 11/15/23, indicated Resident #381 told staff he/she no longer wanted to live and had nothing to live for. The note indicated the nurse would relay this information to the physician or NP. Review of the medical record on 11/16/23, at 12:15 P.M., failed to indicate staff notified Resident #381's physician or NP that the Resident said he/she no longer wanted to live and had nothing to live for. During an interview on 11/16/23, at 11:54 A.M., Social Worker #1 said she was not aware Resident #381 told staff on 11/15/23, that he/she no longer wanted to live and had nothing to live for. Social Worker #1 said psychiatric services in the facility did not treat Resident #381, but that the Resident has a registered nurse case manager in the community that he/she is able to contact if he/she needs psychiatric services. During an interview on 11/16/23, at 10:58 A.M., Nurse #4 said Resident #381 had a physician's order for a psychiatric evaluation, but that it was entered into the computer incorrectly. Nurse #4 said a psychiatric evaluation was never offered or initiated for the Resident because the incorrect data entry prevented staff from being notified of the order. Nurse #4 said he was not aware of any psychiatric services being offered or provided to Resident #381, either within the facility or on an outpatient basis. During an interview on 11/16/23, at 11:26 A.M., Nurse #3 said Resident #381 has only female caregivers due to a history of PTSD. Nurse #3 said Resident #381 was anxious about medical care. During an interview on 11/17/23, at 11:07 A.M., CNA #4 said when she provides care, Resident #381 does not require much assistance, but likes reassurance. She said Resident #381 is lonely and likes the company. CNA #4 said Resident #381 has spoken to her about her diagnosis of PTSD and his/her fear of men. During an interview on 11/16/23, at 1:53 P.M., NP #1 said he was not made aware of Resident #381's statements regarding thoughts of no longer wanting to live until this surveyor told Social Worker #1 about two hours ago. NP #1 said Resident #381 has a long history of psychiatric concerns including multiple psychiatric hospitalization s and a suicide attempt in 2018. NP #1 said Resident #381 is very negative and teary most days and that this is not new. NP #1 said a psychiatric evaluation was ordered and he expects the order to be followed. Review of Social Worker #1's note dated 11/16/23, indicated Resident #381 verbalized thoughts of wanting to die and that he/she had tried to kill his/herself in the past. The note indicated Resident #381 said he/she felt like a burden to his/her son. The note indicated a mental health team needed to assess Resident #381 and would be transferred to the hospital for an evaluation. Review of NP #1's note dated 11/16/23, indicated Resident #381 reported suicidal ideation to staff on the evening on 11/15/23. NP #1's note indicated Resident #381 had high anxiety and worsening depression. NP #1's note indicated a plan to send Resident #381 to the hospital emergency room to evaluate these symptoms. 48990

Based on observations, interviews, and records reviewed for one Resident (#78) of 44 sampled residents, the facility failed to provide pain management that met professional standards of practice. Specifically, the facility failed to obtain a physician's order for pain medication prior to administration. Findings include: Review of the facility policy titled Pain Management revised 11/1/23, indicated, but was not limited to: -Staff will continually observe and monitor patients for comfort and presence of pain and will implement strategies in accordance with professional standards of practice, the patient-centered plan of care, and the patient's choices relating to pain management. -The nurse will notify the physician/advanced practice provider (APP) as appropriate to obtain treatment orders as indicated. -The care plan will be evaluated for effectiveness until satisfactory pain management is achieved. Resident #78 was admitted in March 2023 with the following diagnosis: osteoarthritis. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #78 had a Brief Interview for Mental Status (BIMS) exam score of 14 out of 15, indicating he/she was cognitively intact. On 11/15/23, at 9:15 A.M., the surveyor observed the medication administration for Resident #78 with Nurse #7. Nurse #7 applied a topical lidocaine patch (used to relieve pain) to Resident #78's left knee as per physician's order. Resident #78 said his/her right knee also was hurting. Nurse #7 offered to get another topical lidocaine patch for his/her right knee. The surveyor observed no patch on his/her right knee. Following administration, Nurse #7 said she would get it later because Resident #78 appeared agitated. On 11/15/23, at 11:43 A.M., the surveyor observed lidocaine patches on Resident #78's left and right knees. The patch on his/her right knee was the same as the patch on his/her left knee that was applied during the medication administration the surveyor previously observed. Resident #78 said the same nurse came back and brought one for his/her right knee. Resident #78 said his/her right knee usually has pain and he/she gets a pain patch for his/her right knee whenever he/she needs it. Review of Resident #78's Medication Administration Record (MAR) for November 2023 indicated an order to apply a lidocaine patch, without a dosage, to the left medial knee, in the morning daily. The November 2023 MAR indicated Resident #78 had a lidocaine patch applied to his/her left medial knee daily from 11/1/23 to 11/15/23. On the November 2023 MAR, under supplemental documentation for the lidocaine order for the left knee, it was indicated that a lidocaine patch was applied to Resident #78's right knee on 11/9/23, 11/10/23, 11/11/23, and 11/16/23. Review of the medical record failed to indicate an order for any type of pain patch for Resident #78's right knee. On 11/15/23, at 12:51 P.M., Nurse #7 said she put a lidocaine patch on Resident #78's right knee. Nurse #7 said she put the lidocaine patch on because she thought Resident #78 had an order for it. Nurse #7 checked orders and said she was wrong, and Resident #78 did not have an order for a lidocaine patch for his/her right knee. She said that a lidocaine patch needs to have an order. On 11/15/23, at 12:30 P.M., the Director of Nursing (DON) said a lidocaine patch requires a physician's order. On 11/16/23, at 12:08 P.M., the DON said a lidocaine patch needs a physician's order prior to applying it to a resident. The DON said the nurse should not have applied the lidocaine patch on Resident #78's right knee. 48990

Based on observation, interview, and policy review for four Residents (#25, #93, #118, #381) of 39 sampled residents, the facility failed to ensure medications were dated and unexpired, and securely stored. Specifically: - For Resident #25, the facility failed to ensure outdated medications were not available for administration and ensure medications with shortened expiration dates after being opened were labeled with open dates. - For Resident #93, #118 and #381, the facility failed to secure medications found in their bedrooms. Findings include: 1. Review of the facility policy titled General Dose Preparation and Medication Administration revised [DATE], indicated, but was not limited to: -Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins, irrigation solutions, etc.) On [DATE], at 8:03 A.M., the surveyor observed Nurse #7 during the medication pass. The surveyor observed an insulin glargine-yfgn subcutaneous solution pen-injector open and undated. At this time, Nurse #7 said she would expect the pen-injector to have an open date, but that it does not. During an interview on [DATE], at 8:31 A.M., the Director of Nursing (DON) said insulin pens should be dated when opened and should also have a stop using date. The stop using date should be 28 days after opening. 2. Review of the facility policy titled Storage and Expiration Dating of Medication, Biological's, Syringes and Needles dated as revised [DATE], indicated, but was not limited to: -The facility should ensure that all medication and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. -Facility should store bedside medications or biologicals in a locked compartment within the resident's room. 2a. Resident #93 was admitted to the facility in [DATE], and had diagnoses which included cancer. On [DATE], at 9:20 A.M., the surveyor observed clotrimazole cream 1% on Resident #93's bedroom dresser. Resident #93 said he/she was unaware of the medication and did not know its purpose. On [DATE], at 8:39 A.M., the surveyor observed clotrimazole cream 1% on Resident #93's bedroom dresser. Review of Resident #93's physician order dated [DATE], indicated clotrimazole cream 1%. Apply to skin folds topically every day and evening shift for fungal rash. There was no order for Resident #93 to keep medications in the bedroom. 2b. Resident #118 was admitted to the facility in [DATE], and had diagnoses which included chronic obstructive pulmonary disease and asthma. On [DATE], at 9:15 A.M., the surveyor observed an albuterol inhaler (for the treatment of shortness of breath) located on Resident #118's overbed table. Resident #118 said he/she keeps the inhaler on his/her overbed table all the time in the event he/she needs it in an emergency. On [DATE], at 8:31 A.M., the surveyor observed an albuterol inhaler located on Resident #118's overbed table. Review of Resident #118's physician orders dated [DATE], indicated there was no active order for an albuterol inhaler. There was no order for Resident #118 to keep medications in the bedroom. 2c. Resident #381 was admitted to the facility in [DATE] and had diagnoses which included pain and hemorrhoids. On [DATE], at 10:22 A.M., the surveyor observed on Resident #381's overbed table one tube of hydrocortisone cream 2.5% (for the treatment of pain) and one tube of proctozone cream (for the treatment of hemorrhoids). On [DATE], at 8:44 A.M., the surveyor observed on Resident #381's overbed table one tube of hydrocortisone cream 2.5% and one tube of proctozone cream. Review of Resident #381's physician orders for [DATE], indicated: - hydrocortisone external cream 2.5%. Insert 1 application rectally every morning and at bedtime for pain. - No active order for proctozone cream. - There was no order for Resident #381 to keep medications in the bedroom. During an interview with Nurse #1 on [DATE], at 9:50 A.M., she said only residents who have a physician's order are allowed to have medications at their bedside. Nurse #1 said inhalers and medicated ointments should be locked in the medication cart. 48990

Based on observation, record review, policy review and interviews, the facility failed to maintain and implement an infection control program designed to help prevent and identify the development and transmission of disease and infection. Specifically: - The facility failed to monitor, track, and analyze infectious diseases during the month of November 2023. - For Resident #381, the facility failed to implement transmission-based precautions for the management of active Clostridioides difficile disease. Findings include: Review of the facility policy titled Infection Control Outcome and process Surveillance and Reporting dated 9/1/2004, and revised on 11/28/2017, indicated but was not limited to the following: - Outcome surveillance which consists of collecting/documenting data on individual cases and comparing the collective data of standard, written definitions of infection. The monthly infection control report will be used. - Process surveillance to review practices directly related to patient care. Examples of this type of surveillance include monitoring of compliance with transmission-based precautions, proper hand hygiene, the use and disposal of gloves, and observations of the environment. The infection control process surveillance monitoring tool will be used. - Purpose: To detect possible communicable diseases or infections, plan control activities before communicable diseases of infections can spread to others and identify and manage potential outbreaks of disease. - To identify whether the practices comply with established prevention and control procedures and policies based on recognized standards. 1. Review of the infection control program failed to indicate the monitoring, tracking, and analyzing of current infections in the facility during the month of November 2023. During an interview on 11/16/23, at 9:11 A.M., the Assistant Director of Nursing (ADON) said residents are removed from precautions once their antibiotic therapy is completed and they have no symptoms of any loose stools, diarrhea, fever, or upset stomach. The ADON said the facility has one case of C.diff. on the [NAME] unit. The ADON said the resident is on contact precautions and is expected to remain on contact precautions until antibiotic therapy is completed and the resident has no symptoms. The ADON said each unit manager is responsible for tracking signs and symptoms of infections to identify outbreaks and trends prior to antibiotic use. The ADON said she reviews the monthly line listings submitted by each unit manager and reviews the data at the end of the month. The ADON said Resident #381 should be on the November Line listing due to being admitted with C.diff. and currently taking antibiotic therapy. The ADON said all residents on precautions are expected to be on the line listings and proper personal protective equipment utilized and available outside of the residents' room. The ADON said staff should not be providing care unless they are wearing the appropriate protective equipment. Review of the monthly Line Listing dated November 2023, indicated Resident #381 was not identified as having an infection. During an interview on 11/16/23, at 1:59 P.M., Unit Manager #1 said signs and symptoms of infections are not tracked daily. Unit Manager #1 was asked to show the current line listing for November and said she does not maintain a line listing until the end of the month and gives it to the ADON to review. The Unit Manager #1 said she only adds residents that were on antibiotics and does not add residents for signs and symptoms because she does not have time to monitor and track them every day for each resident, and she said signs and symptoms are documented in the nursing notes. Unit Manager #1 said there are no current residents on precautions and that Resident #381 is on antibiotics and does not meet the criteria for contact precautions. Unit Manager #1 said she did not know Resident #381 has loose mucous in his/her stools and that she would still not place her on precautions because she is on antibiotics. During an interview on 11/16/23, at 2:52 P.M., The Director of Nursing (DON) said unit managers are responsible for monitoring the use of antibiotics along with signs and symptoms daily and line listings should be updated. The DON said all new admissions will be screened for positive infections as well as signs and symptoms and C.diff. positive residents are expected to be placed on contact precautions. The DON said residents do not come off precautions until they have a formed stool for a couple of days. The DON said Resident #381 should be listed on the current monthly line listing, contact precautions in place, and retested for C.diff. once antibiotics are completed and no loose stools are reported. The DON said the care plan should be updated to indicate an infection with contact precautions in place. The DON said a precaution cart and sign should be placed outside of Resident #381's door. The DON said she was not aware that precautions had not been followed. 15016 2. Review of the facility's policy titled Contact Precautions, revised 10/24/22, indicated, but was not limited to the following: -Contact precautions will be used for diseases transmitted by direct or indirect contact with the resident/patient (hereinafter patient) or the patient's environment (e.g., Clostridium difficile, norovirus, scabies). -Contact precautions should also be used in situations when a resident is experiencing wound drainage, fecal incontinent or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, even before a specific organism has been identified. -Place a STOP. Please see nurse before entering room sign on door. -Instruct staff, patient and their representative, and visitors regarding precautions and the use of personal protective equipment (PPE). -PPE must be worn before contact with the patient or the patient's environment. -Wear gown and gloves. -Change gown and gloves during care if gloves/gowns contact with infection material. -Before exiting room, remove and bag gown and gloves and wash hands upon exiting the room. -Once the patient is no longer a risk for transmitting the infection (i.e., duration of the illness and/or can contain secretions), discontinue precautions. Review of the facility's policy titled Procedure: Clostridioides Difficile Infection (CDI), revised 11/15/22, indicated but was not limited to the following: -Place patients with three or more liquid or watery stool in a 24-hr period in presumptive contact precautions while waiting for Clostridium difficile test results to come back. Patients suspected of recurrent Clostridium difficile should be placed in contact precautions even sooner. -Maintain a separate line listing of all patients in the center that have or had Clostridium difficile. According to the Centers for Disease Control and Prevention (2023), contact precautions are intended to prevent transmission of infection agents. Healthcare personnel caring for residents on contact precautions must wear a gown and gloves for all interactions that involve contact with the resident and the resident ' s environment. Resident #381 was admitted from the hospital in November 2023 with the following diagnoses: sepsis, diarrhea, and Clostridium difficile infection (a contagious bacterial infection). Review of the hospital laboratory results dated [DATE], indicated Resident #381 tested positive for Clostridium difficile infection. Review of the hospital discharge summary dated 11/2/23, indicated Resident #381 was to continue contact precautions and to continue vancomycin 125 milligrams (an antibiotic used to treat infections) twice daily. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #381 had a Brief Interview for Mental Status (BIMS) exam score of 15 out of 15, indicating he/she was cognitively intact. The MDS further indicated Resident #381 required partial/moderate assistance to ambulate 10 feet, supervision/touching assistance with toileting transfers, and supervision/touching assistance with toileting hygiene. Review of the Physician's Orders and Medication Administration Record (MAR) for November 2023, indicated Resident #381 received vancomycin 125 milligrams (mg) capsule twice a day from 11/2/23 until 11/10/23 and vancomycin 50 mg/ml 2.5 ml oral suspension (total dose 125 mg) from 11/10/23 until 11/20/23. Further review of the Physician's Orders and MAR dated 11/2/23 to 11/16/23, and care plan dated 11/16/23, failed to indicate contact precautions were in place for Resident #381 while being treated in the facility for Clostridium difficile. Review of Nurse Practitioner notes dated 11/10/23, 11/13/23, 11/14/23 and 11/16/23, indicated Resident #381 had a diagnosis of active Clostridium difficile colitis. Review of Physician Assistant notes dated 11/8/23, 11/13/23, and 11/15/23, indicated Resident #381 was on Clostridium difficile treatment and precautions. Review of nursing notes dated 11/12/13, 11/15/23, and 11/17/23, indicated Resident #381 is on Clostridium difficile precautions. Review of the medical record failed to indicate staff discontinued Resident #381's contact precautions. During an interview on 11/14/23 at 10:22 A.M., Resident #381 said he/she has Clostridium difficile infection. Resident #381 said he/she had loose stool with mucus yesterday and today. The surveyor observed there was no STOP sign or precaution cart at Resident #381's doorway indicating he/she was on precautions. On 11/17/23 at 11:10 A.M., the surveyor observed Certified Nurse Aide #4 entering Resident #381's room without wearing a gown or gloves. There was no STOP sign or precaution cart at Resident #381's doorway indicating he/she was on precautions. During an interview on 11/14/23 at 2:30 P.M., Unit Manager #1 said Resident #381 has not been on precautions for Clostridium difficile during this admission. She said Resident #381 receives vancomycin 125 mg for prophylaxis (to prevent recurrence) for a history of Clostridium difficile. The surveyor told Unit Manager #1 that Resident #381 said he/she was having loose stool with mucous, and that Resident #381 said he/she has Clostridium difficile. During an interview on 11/16/23 at 1:53 P.M., Nurse Practitioner (NP) #1 said Resident #381 has had an active diagnosis of Clostridium difficile that could be contagious at any time. He said the facility should be following their policy for active Clostridium difficile. During an interview on 11/17/23 at 8:32 A.M., the Director of Nursing (DON) said that based on the discharge summary from the hospital dated 11/2/23, she would expect the admission nurse to call the hospital to clarify the need for contact precautions for Clostridium difficile. The DON said she was unable to provide documentation to indicate staff contacted the hospital to clarify the need for contact precautions. During an interview on 11/17/23 at 9:02 A.M., the Assistant Director of Nursing (ADON) said based on the discharge summary from the hospital dated 11/2/23, she would expect Resident #381 to be put on precautions immediately on admission. The ADON said she expected the interdisciplinary team would then discuss the need for further precautions. The ADON said she should be aware of all infections in the facility, but she was not aware of Resident #381's Clostridium difficile. The ADON said there had been no interdisciplinary discussion after admission of Resident #381's infection or required precautions. The ADON said Resident #381 was not on the November 2023 infection line listing for Clostridium difficile infection. Review of medical record failed to indicate an interdisciplinary team review or discontinuation of contact precautions for Resident #381. During an interview on 11/17/23 at 2:43 P.M., the DON and Regional Nurse #1 reviewed Resident #381's medical record with the surveyor present and were unable to locate documentation to indicate why Resident #381 was not on contact precautions. During an interview on 11/20/23 at 8:39 A.M., the DON said she has no documentation for why contact precautions were not put into place for Resident #381. She said the Resident was put back on precautions Friday 11/17/23, after the surveyor alerted her of the situation. 48990

Based on observations, interviews, policy review, and record review the facility failed to provide care in a dignified manner for one Resident (#96) out of 44 sampled residents. Specifically, the facility failed to cover a urinary catheter bag for privacy. Findings include: Review of the facility policy titled Treatment: Considerate and Respectful, revised 8/7/23, indicated, but was not limited to: -Staff will refrain from practices that are demeaning to patients such as keeping urinary catheter bags uncovered. Resident #96 was admitted in October 2023 with the following diagnosis: pressure ulcer of sacral region. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/25/23, indicated Resident #96 had a Brief Interview for Mental Status (BIMS) exam score of 12 out of 15, indicating he/she had moderate cognitive impairment. Further review of the MDS indicated Resident #96 has an indwelling catheter, requires partial/moderate assistance with toileting hygiene, and supervision or touching assistance with personal hygiene. On 11/14/23 at 9:35 A.M., the surveyor observed Resident #96 was in the hallway sitting in a wheelchair with a urinary catheter bag visible on the right leg close to the knee. The urinary catheter bag had clear yellow urine visible. This urinary catheter bag was uncovered and did not have a privacy bag. Resident #96 said he/she is incontinent of stool and has a urinary catheter bag for urine. Review of Resident #96's medical record indicated the following physician orders: -Indwelling catheter 14 far with 10 cc balloon to bedside straight drainage. -Foley catheter output. -Change Indwelling Catheter when occluded or leaking. -Replace drainage system if disconnections or leakage occur. -Provide indwelling catheter care. Review of Resident #96's indwelling catheter care plan dated 11/16/23, indicated, but was not limited to: -Catheter care twice a day and as needed. -Provide privacy bag. The care plan failed to indicate Resident #96 refused a privacy bag. On 11/16/23 at 10:09 A.M., the surveyor observed Resident #96 walking in the unit hallway with a urinary catheter bag visible. This urinary catheter bag had clear, yellow urine visible. This urinary catheter bag was uncovered and did not have a privacy bag. On 11/16/23 at 10:59 A.M., the surveyor observed Resident #96 walking in the unit hallways working with therapy staff, with a urinary catheter bag visible. This urinary catheter bag had clear, yellow urine visible. This urinary catheter bag was uncovered and did not have a privacy bag. During an interview on 11/17/23 at 7:19 A.M., Resident #96 said he/she has never been offered a privacy bag or something to cover his/her urinary catheter bag. Resident #96 said he/she would be interested in using one because he/she didn't like it showing. During an interview on 11/17/23 at 7:20 A.M., Nurse #5, who was Resident #96's assigned nurse for the day, said she was familiar with Resident #96. Nurse #5 said the exposed urinary catheter bag should have been covered with a privacy bag or Resident #96's clothes should have been changed into something that would cover the urinary catheter bag. Nurse #5 said she was unaware if Resident #96 refused to cover the urinary catheter bag. During an interview on 11/17/23 at 7:43 A.M., Nurse #4 said if a staff member saw an exposed urinary catheter bag in the hallway the she would expect staff to get a privacy cover or to cover it. Nurse #4 said it should be in the care plan if Resident #96 refused to cover the urinary catheter bag. During an interview on 11/17/23 at 8:32 A.M., the Director of Nursing (DON) said she would expect Resident #96's urinary catheter bag to be covered with a privacy bag or to wear clothing that covered it. The DON said she would expect the care plan to be updated if Resident #96 had refused a privacy bag. 48990

Based on observations, interviews and records reviewed the facility failed to evaluate for the self-administration of albuterol (an emergency inhaler) for one Resident (#118) out of 44 sampled residents. Specifically for Resident #118, the facility failed to ensure it assessed for self-administration, obtain physician orders for self-administration, or care plan for medication self-administration, resulting in a risk for pulmonary complications. Findings include: Review of the facility policy titled Medications: Self-Administration, dated 3/1/22, indicated: Patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self-administer: - A physician/advanced practice provider (APP) order is required. - Self-administration and medication self-storage must be care planned. - When applicable, patient must be provided with a secure, locked area to maintain medications. - Patient must be instructed in self-administration. - Evaluation of capability must be performed initially, quarterly, and with any significant change in condition. Resident #118 was admitted to the facility in October 2023, and had diagnoses which included chronic obstructive pulmonary disease and asthma. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #118 was cognitively intact and independent with self-care. On 11/14/23 at 9:15 A.M., the surveyor observed an albuterol inhaler (for the treatment of shortness of breath) located on Resident #118's overbed table. Resident #118 said he/she keeps the inhaler on his/her overbed table all the time in the event he/she needs it in an emergency. On 11/16/23 8:31 A.M., the surveyor observed an albuterol inhaler located on Resident #118's overbed table. Review of the physician orders dated November 2023, indicated Resident #118' had no active order for an albuterol inhaler or to keep medications in the bedroom. Review of Resident #118's care plan dated November 2023, indicated there was no reference to the self-administration of medications. Review of the medical record indicated Resident #118 had no evaluation of capability for the self-administration of medications. During an interview with Nurse #1 on 11/16/23 at 9:50 A.M., she said only residents who have a physician's order are allowed to have medications at their bedside, and residents need an assessment and order for self administration.

Based on interviews and record review the facility failed to notify the physician or other provider of a significant decline in health status for two Residents (#182, #101) of 44 sampled residents. Specifically: 1. For Resident #182, the facility failed to notify the physician his/her skin deteriorated from a Stage 2 to a Stage 4 and had signs of possible infection. In addition, the facility failed to notify the physician that Resident #182 developed a midspine thoracic wound. 2. For Resident #101, the facility failed to notify the physician he/she was admitted to the facility with a Stage 2 pressure ulcer on the coccyx and to request treatment orders. Findings include: Review of the facility's policy titled Skin Integrity and Wound Management, dated 2/1/23, indicated but was not limited to: * Notify physician to obtain orders. 1. Resident #182 was admitted to the facility in November 2023, and had diagnoses which included a Stage 2 pressure ulcer, diabetes, and congestive heart failure (a heart disease resulting in poor blood circulation). Review of the Hospital discharge summary dated 11/2/23, indicated Resident #182 was discharged to the facility with a Stage 2 coccyx wound (a break in the top two layers of skin because of pressure). Review of the Minimum Data Set (MDS) assessment, dated 11/5/23, indicated Resident #182 was admitted to the facility with a Stage 2 pressure ulcer on the coccyx, was at risk for skin breakdown, and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, signifying intact cognition. Review of the nursing note dated 11/2/23, indicated Resident #182 was admitted with a Stage 2 pressure ulcer located on the coccyx with scattered bruising. His/her skin was warm and dry. The skin on the right and left lower extremity was red. Review of the baseline care plan dated 11/3/23, indicated Resident #182 was at risk for skin breakdown related to diagnoses of diabetes and age-related frail skin, and was admitted to the facility with a Stage 2 pressure ulcer located on the coccyx. Review of the physician orders for Resident #182 dated 11/3/23, indicated: *Silver sulfadiazine cream 1% apply to coccyx topically every day shift for ulcer after normal saline wash and cover with foam dressing. Review of the physician orders for Resident #182 dated 11/4/23, indicated an as-needed order (PRN): * Gently cleanse coccyx wound with vashe wash, allow a vashe soaked gauze to remain in place over the wound for 5 minutes and gently pat dry. Apply sure prep peri wound. Apply cut to fit, moistened hydrofera blue to the wound bed. Cover with a foam dressing as needed for soiling/dislodgement. This order was discontinued the same day, on 11/4/23. A revised physician order for a scheduled treatment dated 11/4/23 and with a start date of 11/6/23, replaced the above PRN order: * Gently cleanse coccyx wound with vashe wash, allow a vashe soaked gauze to remain in place over the wound for 5 minutes and gently pat dry. Apply sure prep peri wound. Apply cut to fit, moistened hydrofera blue to the wound bed. Cover with a foam dressing every day shift every other day for wound care. * Daily weights. Review of the nursing note dated 11/5/23, indicated Resident #182's buttocks were red and an open area was present on the skin. The nurse applied barrier cream to the skin. Review of the nursing notes dated 11/2/23 through 11/7/23 indicated there was no change in Resident #182's wound status. Review of the nursing note dated 11/8/23, indicated Resident #182 had a Stage 4 pressure ulcer on the coccyx, (Stage 4 ulcers are defined as deep wounds that may impact muscle, tendons, ligaments, and bone, which indicates Resident #182's wound deteriorated since admission). The following skin injury/wound(s) were previously identified and were evaluated as follows: Rash(s): Description: fungal rash groin. Pressure area(s): Location(s): coccyx wound, midspine thoracic wound. Review of the nursing note dated 11/8/23 failed to indicate staff notified the Nurse Practitioner (NP) or other provider that Resident #182's coccyx wound progressed from a Stage 2 to a Stage 4, and he/she had a newly identified midspine thoracic wound. Review of the NP note dated 11/8/23 indicated the NP visited Resident #182. The note indicated a decubitus and to continue with regular dressing changes. The note did not indicate the NP examined the coccyx or midspine thoracic wounds. The note did not indicate nursing staff made the NP or other provider aware that the coccyx wound deteriorated from a Stage 2 to a Stage 4, or that he/she had a new midspine thoracic wound. Review of the nursing note dated 11/10/23, indicated Resident #182 had a Stage 4 coccyx wound, was alert and oriented to self only. Resident #182 was pleasant and cooperative with care and presented with pressure area to coccyx. Staff repositioned the Resident side to side and he/she presented with moderate pain relieved from repositioning and scheduled acetaminophen. The nursing note did not indicate staff made the NP or other provider aware Resident #182's coccyx wound had deteriorated from a Stage 2 to a Stage 4, or that he/she had a midspine thoracic wound. Review of the NP note dated 11/10/23, indicated: Decubitus. Continue with regular dressing changes. The NP note did not indicate nursing staff made the NP or other provider aware that Resident #182's coccyx wound deteriorated from a Stage 2 to a Stage 4, or the presence of a midspine thoracic wound. The note did not indicate the NP examined Resident #182's coccyx or midspine thoracic wounds. Review of the nursing and provider notes dated 11/8/23 through 11/13/23, failed to indicate nursing staff or providers examined or measured #182's wounds, or that nursing staff notified the NP or other provider that the coccyx wound had deteriorated from a Stage 2 to a Stage 4, or the presence of the midspine thoracic wound. Review of the NP note dated 11/13/23, indicated Resident #182 had a sacral decubitus measuring about 3 inches x 1-1 1/2 inches. The bed of the wound is dark necrotic tissue [necrosis is the death of body tissue, often due to illness, infection, or lack of blood flow to the tissue], with a thin ring of yellow slough, and pink granulation. The necrotic center is not entirely dried out, but obviously very thin and, with palpation, is lying directly over the bone. There is no subcutaneous tissue between the necrotic base and [his/her] bone. Still, technically, this is unstageable. There was no significant surrounding erythema or induration consistent with soft tissue infection. The NP note dated 11/13/23 was the first documented NP examination and measurement of Resident #182's coccyx wound since admission on 11/2/23. The NP note was the first documentation by a provider to indicate Resident #182's coccyx wound progressed from a Stage 2 to a Stage 4/unstageable wound. The NP note did not reference the midspine thoracic wound. Review of the NP note dated 11/14/23, indicated Resident #182 had a very advanced decubitus, very likely Stage 4, but technically unstageable. The note indicated there was a a likelihood of underlying sacral osteomyelitis and the focus of treatment is transitioning to comfort. The note indicated nursing staff will continue with dressing changes. The note indicated the NP did not believe the coccyx wound was healable. Review of the nursing note dated 11/18/23, indicated Resident #182 presented with a wound to the coccyx 9 centimeters (cm) x 6.4 cm in total. 5/4 cm x 4 cm center necrotic area. Necrotic area surrounded by 0.2 cm yellow ring followed by red ring. Moderate purulent drainage noted on dressing. Odor noted. Dressing applied and pressure offloaded. Staff turned the Resident side to side throughout shift. The NP's coccyx wound measurement on 11/13/23 of approximately 29 square cm and the nursing staff measurement on 11/18/23 of approximately 58 square centimeters indicated a 100% increase in Resident #182's wound size over five days. Review of the nursing and provider notes failed to indicate nursing staff made the NP or other provider aware that as of 11/18/23 Resident #182's coccyx wound had moderate purulent drainage and an odor (signs of soft tissue infection). These notes also failed to indicate that during Resident #182's admission period the facility notified the NP or other provider that Resident #182 had a midspine thoracic wound. Review of the nursing note dated 11/20/23, indicated Resident #182 was discharged to home on this date. On 11/20/23 at 11:03 A.M., the surveyor observed Resident #182 lying supine in bed. Resident #182 said his/her bottom was painful and the surveyor informed Nurse #1. Resident #182 said he/she did not want the surveyor to observe his/her coccyx wound. During an interview with the Director of Nurses (DON) on 11/16/23 at 1:30 P.M. and 11/20/23 at 10:45 A.M., she said it was her expectation that nursing staff notify the NP or other provider when a wound deteriorates from a Stage 2 to a Stage 4 or unstageable wound, when a wound shows new signs of infection, and the discovery of a new wound. During interviews with Nurse #1 on 11/19/23 at 10:40 A.M. and on 12/5/23 at 9:00 A.M., she said she was Resident #182's primary nurse, but was not working when Resident #182 was admitted so did not see his/her coccyx wound on 11/2/23. Nurse #1 said the first time she was assigned to Resident #182 was 11/8/23. Nurse #1 said at this time she examined Resident #182's coccyx wound and determined it was a Stage 4 pressure ulcer. Nurse #1 said the coccyx bone was visible. Nurse #1 said she had been staging wounds for over [AGE] years. Nurse #1 said she reported the wound to the Unit Manager (#1) that day but not to the Nurse Practitioner, or other provider. Nurse #1 said staff nurses are not responsible for measuring wounds or notifying the NP or other providers of change in wound status because this was the responsibility of the Unit Manger. Nurse #1 said the Unit Manager, DON and ADON are responsible for wound management. During an interview with Unit Manager #1 on 11/19/23 at 10:50 A.M., she said she was aware of Resident #182's coccyx wound but she had not informed the NP or other provider that Resident #182's wound deteriorated to a Stage 4. Unit Manager #1 said she was unaware if other staff notified Resident #182's NP or other provider that the wound had deteriorated from Stage 2 to Stage 4. During an interview with the DON on 12/4/23 at 10:01 A.M., she said unit managers were responsible for notifying the physician if a wound worsens. The DON said there was no indication that between 12/8/23 and 12/13/23 nursing staff notified the NP or other provider that Resident #182's coccyx wound had worsened. During an interview with the NP on 12/5/23 at 9:27 A.M., Resident #182's record was reviewed with the surveyor. The NP said the first time he visually assessed Resident #182's coccyx wound was on 11/13/23 and during that assessment determined it to be unstageable due to dead tissue present. He said he could palpate the bone under the layer of dead tissue and said the wound was likely present as an unstageable wound for months but could provide no documented wound history. The Nurse Practitioner said he was unaware that Resident #182's wound was staged as a Stage 2 according to the hospital paperwork and on the admission assessment and had progressed to a Stage 4 on 11/8/23 as documented by the nursing staff in the medical record. The NP said he did not recall nursing staff informing him on 11/8/23 that Resident #182's wound had worsened. The NP said he expects nursing staff to inform him if a wound is present on admission and if the wound worsens, but that he does not always examine a wound on admission and relies on nursing assessments completed by the facility staff. The NP said he did not recall nursing staff making him aware of the drainage and odor associated with Resident #182's coccyx wound. The NP said purulent drainage and odor may or may not have been signs of wound infection. During an interview with the Physician on 12/5/23 at 1:54 P.M., he said nursing staff should inform providers if a wound is not healing or worsening. The Physician said staff should notify the provider if a wound has purulent drainage and odor because these are signs of infection. 2. Resident #101 was admitted to the facility in September 2023, and had diagnoses which included heart disease, diabetes and dementia. Review of the Admission Nursing Documentation dated 9/29/23, indicated Resident #101 had a Stage 2 pressure ulcer located on the coccyx, and redness to the skin in the area of the coccyx. Review of the [NAME] Pressure Ulcer Scale dated 9/29/23, indicated Resident #101 scored an 8, signifying a very high risk for skin breakdown. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #101 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, signifying severely impaired cognition. The MDS indicated Resident #101 was at risk for skin breakdown. Review of the care plan for skin breakdown dated 10/8/23, indicated Resident #101 was admitted to the facility with a Stage 2 pressure ulcer located on the coccyx. The care plan indicated he/she was at risk for skin breakdown related to advanced age, frail and fragile skin, incontinence, impaired cognition, limited mobility, refusal to aspects of care, poor safety awareness and shear/friction risks. Care plan interventions included, but were not limited to: * Provide wound treatment as ordered. * Weekly skin check by licensed nurse. * Weekly wound assessment to include measurements and description of wound status. * Provide preventative skin care. * Apply barrier cream with each cleansing. Review of the Skin Check dated 12/6/23, indicated Resident #101 had a pressure ulcer located on the coccyx. Interventions to manage the wound included, but were not limited to: * Provide wound treatment as ordered. Review of the Skin Check dated 12/8/23, indicated Resident #101 had a pressure ulcer located on the coccyx. Interventions to manage the wound included, but were not limited to: * Provide wound treatment as ordered. Review of the Skin and Wound Evaluation dated 12/8/23, indicated Resident #101 had a Stage 2 pressure ulcer located on the coccyx, which measured 3.5 centimeters (cm) x 0.6 cm. The evaluation indicated the wound was covered with a foam dressing, and no secondary dressing, and the wound was stable. Review of Resident #101's physician orders indicated: * House barrier cream to bilateral buttocks and groin area, every shift for protection (dated 11/30/23). Review of Resident #101's physician orders indicated from admission through 12/10/23 there was no order for a dressing to be applied to his/her Stage II coccyx wound. Review of the Treatment Administration Record dated December 2023, indicated Resident #101 had no documented dressing treatments through 12/10/23. Review of the nursing, nurse practitioner and physician progress notes from his/her admission through 12/10/23 indicated there were no references to nursing staff notifying any providers that Resident #101 had a Stage II coccyx wound or a discussion of wound treatment. Review of the physician orders and nursing progress notes indicated that on 12/11/23 (day of survey) an order was placed for cleansing and a dressing to be applied to Resident #101's Stage II coccyx wound. On 12/11/23 at 2:05 P.M., the surveyor observed nursing staff change a foam dressing located on Resident #101's coccyx wound. The wound appeared to have partial-thickness skin loss into but no deeper than the dermis. During an interview with the Administrator on 12/11/23 at 8:30 A.M., she said the Director of Nurses was on vacation and Regional Nurse #1 had assumed the director of nursing services role while she was away. During an interview with Regional Nurse #1 on 12/11/23 at 12:30 P.M., she said she had reviewed the medical record and interviewed nursing staff and determined staff had not informed Resident #101's Nurse Practitioner (NP) or Physician that he/she had a Stage II pressure ulcer on the coccyx, until today (12/11/23). Regional Nurse #1 said there had been no order for a dressing to be placed on the coccyx wound until today. Regional Nurse #1 said staff should have notified either the NP or Physician of Resident 101's wound and obtained orders for wound treatment when/he she was admitted to the facility in September 2023.

Based on observation, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents, specifically, the facility failed to provide assistance with showers for one Resident (#78) out of a total sample of 44 Residents. Resident #78 was admitted to the facility in March 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified lack of coordination, muscle weakness, and abnormal posture. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #78 has a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicating he/she has intact cognition. The MDS also Indicated Resident #78 requires extensive assistance for bed mobility and is dependent for bathing. During an interview on 11/14/23 at 8:18 A.M., Resident #78 told the surveyor that he/she has not had a shower in months and would like one. Review of Resident #78's activity of daily living (ADL) care plan last revised 3/22/23, indicated the following: - Requires assistance/is dependent for ADL care in; bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. - Provide (Resident) with limited, assist of 1 for personal hygiene (grooming). - Provide (Resident) with limited, assist of 1 for bathing. - It is important for me to choose between a shower, bed bath or sponge bath. Review of Resident #78's Resident Daily Flow Sheet (a form indicating level of assistance each Resident needs) indicated the Resident is dependent for bathing. Review of the shower schedule indicated that Resident #78's scheduled shower day is on Friday, the 3-11 shift. Review of the shower schedule for the months of October - November 2023 failed to indicate that staff have documented the Resident had received a shower. There are no refusals documented in Resident #78's medical record. During an interview on 11/15/23 at 10:11 A.M., Certified Nursing Assistant (CNA) #6 said shower schedules are documented on the staff assignment sheet and are documented in the chart. Residents that refuse a shower will be documented in Point Click Care (PCC). CNA #6 said Resident #78 refuses showers and that refusals are documented in the ADL flow sheet. During an interview on 11/16/23 at 9:38 A.M., Nurse #9 said Resident #78 refuses to leave his/her room and that all care is provided in bed. Nurse #9 said she was not aware of his/her last shower. During an interview on 11/16/23 at 01:30 P.M., the Director of Nursing (DON) said Resident #78 will refuse care and expects staff to document refusals in the chart. The DON said Resident #78 can have a shower and that staff must offer the Resident a shower as indicated on the assignment sheet. The DON said she expects staff to follow the ADL care plan for each resident.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure services provided by nursing were in accordance with professional standards of practice. On 5/08/22, Nurse #1 administered [MEDICATION(S)] (opioid) 5 milligrams (mg) to Resident #1 in error, however Nurse #1 did not report the error to the Nurse Supervisor or Physician. Later that day, Resident #1 was sleepy, groggy, dizzy, and nauseous, and told Nurse #2 that he/she was administered a liquid medication by Nurse #1 on the previous shift that he/she had never gotten before. Findings include: The Facility Policy, titled, Nursing Services, dated as revised on 6/01/21, indicated, the Facility would provide sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychological well-being of each resident, and provide nursing care in accordance with nursing standards of care and approved policies and procedures. The Facility Policy, titled, Medication Administration, dated as revised on 6/01/21, indicated, nursing staff would administer medications to residents following accepted standards of practice, and if discrepancies occur, nursing staff would notify the physician/nurse practitioner and pharmacy as indicated. The Facility Procedure, titled, Medication Errors, dated as revised on 5/01/22, indicated, nursing staff would report medication errors immediately to the Director of Nurses or designee, the resident's physician or nurse practitioner, resident, and resident representative. The Policy indicated staff would initiate physician orders, if indicated. The Facility's Internal Investigation Report, undated, indicated that on 5/08/22, at 4:00 P.M., Resident #1 told Nurse #2 that he/she had been given a medication from a syringe by mouth that he/she had never been given before, and that he/she felt sleepy. The Investigation Report indicated a urine toxicology screen showed Resident #1 had opiates in his/her system, which were not prescribed to him/her. Resident #1 was admitted to the Facility in March 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Order Summary Report for all physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was admitted to the Facility in June 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's and Resident #2's first names were the same, and their rooms were next door to each other on the unit. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse Progress Note, dated 5/08/22 timed 7:12 P.M., indicated Resident #1 reported he/she felt dizzy, groggy, lightheaded, and very tired. The Note indicated Resident #1 said he/she was given a liquid medication in a syringe which he/she had never gotten before earlier that day, and said he/she had fallen asleep at the lunch table until another resident woke him/her up. The Note indicated a urine toxicology screen was ordered for Resident #1. Review of Resident #1's Urine Drug Screen, dated, 5/09/22, indicated his/her urine was positive for opiates, which he/she was not prescribed. During an interview on 6/07/22 at 11:39 A.M., Nurse #1 said that on 5/08/22, she worked as an agency staff nurse at the Facility. Nurse #1 said that at around 10:00 A.M., on 5/08/22, she administered Resident #2's [MEDICATION(S)] 5 mg to Resident #1, in error. Nurse #1 said that immediately after she administered the [MEDICATION(S)] to Resident #1, Resident #1 said he/she had never been given that medication before. Nurse #1 said she realized she had made an error, and said she told Nurse #6 she thought she gave Resident #1 the wrong medication, but that Nurse #6 did not respond. Nurse #1 said that throughout the rest of the day, Resident #1 was sleepy, and said she thought there was something wrong. Nurse #1 said she did not report the medication error to anyone else. During interview on 6/10/22 at 12:45 P.M., Nurse #6 said that on 5/08/22, at 12:00 P.M., Nurse #1 came to her and said she had given a resident his/her [MEDICATION(S)], and that the resident told her (Nurse #1) that he/she didn't take that medication. Nurse #6 said she asked Nurse #1 who the resident was, and Nurse #1 responded with Resident #2's name. Nurse #6 said she knew Resident #2, and said she told Nurse #1 that Resident #2 did take [MEDICATION(S)], and that he/she was confused at baseline. Nurse #6 said Nurse #1 did not actually say she made a medication error. During an interview on 6/08/22 at 11:19 A.M., Nurse #2 said that on 5/08/22, she received report from Nurse #1 during the 3:00 P.M., shift change, and said Nurse #1 did not report that there had been a medication error. Nurse #2 said that later in the shift at 4:00 P.M., Resident #1 told her that he/she had been given a liquid medication from a syringe that he/she had never had before, and said he/she did not feel well, was sleepy, groggy, and had an upset stomach. Nurse #2 said Resident #2 who resided in the next room, had the same first name, and was prescribed liquid [MEDICATION(S)]. Nurse #2 said Resident #1's description of the medication in a syringe and his/her symptoms were consistent with [MEDICATION(S)] use, and said she notified the on-call Physician at that time, and obtained the order for the urine toxicology screen. During interview on 6/07/22 at 2:58 P.M., The Assistant Director of Nurses (ADON) said that she was acting as the Director of Nurses on 5/08/22, and said she was not notified of the Medication Error until 5/10/22, which was a Monday. The ADON said medication errors should be reported to the physician immediately upon recognition. On 6/07/22, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. The Medication Error Action Plan, dated, 5/09/22, indicated: -Nurse #1 and Licensed Staff would be re-educated to the Medication Pass Procedure, including the five rights and resident identifiers. -An initial and weekly audit would be conducted of resident pictures. -An initial and daily audit would be conducted for resident wrist bands. -An audit would be conducted for name alerts. B. The Staff Education Sign in Sheet, dated, 5/11/22, indicated, Licensed staff were re-educated on the Facility Policies, Identification of Patient, dated as revised on 6/01/21; Medication Errors, dated as revised on 6/01/21; and Medication Administration, dated as revised on 6/01/21. C. The Staff Education Sign in Sheet, dated, 5/16/22, indicated, Licensed staff were re-educated on the Facility's Policy, titled, Nursing Services, dated as revised on 6/01/21. D. The QAPI Meeting Sign in Sheet, dated, 5/18/22, indicated there was a Root Cause Analysis with the Interdisciplinary Team performed to review the education provided to Licensed staff on 5/16/22 and 5/18/22. E. The Name Alert Audits, dated 5/16/22 through 6/07/22, indicated, the Facility conducted an initial and ongoing audits to ensure Residents with similar or same names had a name alert in place, residents were given name bracelets to wear, and resident photos were in the electronic medical record. F. Agency Staff Orientation Process Audit, dated, 5/22/22 through 6/04/22, indicated the Facility conducted an audit to ensure agency staff were oriented to the Facility. G. During interview on 6/07/22, at 2:16 P.M., the DON said the Facility audits and ongoing monitoring would be brought to QAPI weekly for four weeks, then monthly for three months. H. The Director of Nurses and/or Designee will be responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error. On 5/08/22, Resident #1, despite not having a valid physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1, which resulted in Resident #1 experiencing symptoms of opioid toxicity including feeling dizzy, nauseous, and lethargic. Findings include: The Facility's Policy, titled, Medication Errors, dated as revised on 6/01/21, indicated medication errors were defined as a discrepancy between what the physician/advanced practice provider ordered and what the resident received. Types of errors included medication omission, wrong resident, dose, route, rate, or time; incorrect preparation; and/or incorrect administration technique. The Facility's Policy, titled, Identification or Patient, dated as revised on 6/01/21, indicated staff would use at least two patient identifiers to verify patient identity while being evaluated prior to undergoing procedures or treatments. The Facility's Internal Investigation Report, undated, indicated that on 5/08/22, at 4:00 P.M., Resident #1 told Nurse #2 that he/she had been given a medication from a syringe by mouth that he/she had never been given before, and that he/she felt sleepy. The Investigation Report indicated a urine toxicology screen was obtained which showed Resident #1 had opiates in his/her system, which were not prescribed to him/her. Resident #1 was admitted to the Facility in March 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's and Resident #2's first names were the same, and their rooms were next door to each other on the unit. Review of the Nurse's Note, dated, 5/08/22, (for the 3:00 P.M. to 11:00 P.M. shift) indicated Resident #1 reported he/she felt dizzy, groggy, lightheaded, and very tired. The Note indicated Resident #1 said he/she was given a liquid medication in a syringe which he/she had never gotten before, earlier that day, and said he/she had fallen asleep at the lunch table until another resident woke him/her up. The Note indicated a urine toxicology screen was ordered for Resident #1. Review of Resident #1's Urine Drug Screen, dated, 5/09/22, indicated his/her urine was positive for opiates, (which he/she was not prescribed). During an interview on 6/08/22 at 11:19 A.M., Nurse #2 said that on 5/08/22 at 4:00 P.M., Resident #1 told her that he/she had been given a liquid medication from a syringe (by the nurse on the previous shift) that he/she had never had before, and said he/she did not feel well, and was sleepy, groggy, and had an upset stomach. Nurse #2 said Resident #1's description of the medication in a syringe and his/her symptoms were consistent with [MEDICATION(S)] use, said she notified the on-call Physician at that time, and obtained the order for the urine toxicology screen. Nurse #2 said, Resident #2, whose room was right next door to Resident #1's, did have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 said Resident #1 and Resident #2 had the same first name. During an interview on 6/07/22 at 11:39 A.M., Nurse #1 said that on 5/08/22, she worked as an agency staff nurse at the Facility. Nurse #1 said that at around 10:00 A.M., on 5/08/22, she administered Resident #2's [MEDICATION(S)] 5 mg to Resident #1, in error. Nurse #1 said she did not report the medication error. During an interview on 6/07/22 at 2:16 P.M., the DON said Nurse #1 should have properly identified Resident #1 and ensured she the right correct medications to the right resident before administering medications to him/her. On 6/07/22, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. The Medication Error Action Plan, dated, 5/09/22, indicated: -Nurse #1 and Licensed Staff would be re-educated to the Medication Pass Procedure, including the five rights and resident identifiers. -An initial and weekly audit would be conducted of resident pictures. -An initial and daily audit would be conducted for resident wrist bands. -An audit would be conducted for name alerts. B. The Staff Education Sign in Sheet, dated, 5/11/22, indicated, Licensed staff were re-educated on the Facility Policies, Identification of Patient, dated as revised on 6/01/21; Medication Errors, dated as revised on 6/01/21; and Medication Administration, dated as revised on 6/01/21. C. The Staff Education Sign in Sheet, dated, 5/16/22, indicated, Licensed staff were re-educated on the Facility's Policy, titled, Nursing Services, dated as revised on 6/01/21. D. The QAPI Meeting Sign in Sheet, dated, 5/18/22, indicated there was a Root Cause Analysis with the Interdisciplinary Team performed to review the education provided to Licensed staff on 5/16/22 and 5/18/22. E. The Name Alert Audits, dated 5/16/22 through 6/07/22, indicated, the Facility conducted an initial and ongoing audits to ensure Residents with similar or same names had a name alert in place, residents were given name bracelets to wear, and resident photos were in the electronic medical record. F. Agency Staff Orientation Process Audit, dated, 5/22/22 through 6/04/22, indicated the Facility conducted an audit to ensure agency staff were oriented to the Facility. G. During interview on 6/07/22, at 2:16 P.M., the DON said the Facility audits and ongoing monitoring would be brought to QAPI weekly for four weeks, then monthly for three months. H. The Director of Nurses and/or Designee will be responsible for overall compliance.