Every finding on record at Health Care Center Lucy Corr

Based on Resident interviews, facility staff interviews and facility documentation review, the facility staff failed to permit the Resident Council to meet without a staff member being present which had the potential to affect Residents who attend resident council. The findings included: The facility staff attended Resident Council meetings without the approval of the group. On 1/31/23, Surveyor D met with the Resident Council President obtained permission to review the Resident Council meeting minutes. On 2/2/23 at 10:30 AM, the facility Administrator provided Surveyor D the Resident Council meeting minutes which were reviewed. This review revealed that during each meeting held, facility staff were in attendance. The minutes from the September 30, 2022, meeting read, .Questions asked about follow up of a secretary position [Resident # name redacted] asked if she could hold two positions . During the meeting held October 20, 2022, the following notation was made in the minutes, [Activities Director name redacted] followed up about the conversation from last meeting about secretary position. [Activities Director name redacted] explained that we only need a President and [NAME] President position since we have staff member appointed to assist with Resident Council Meetings . On 2/2/23 at 11 AM, Surveyor D met with the Resident Council, 14 Residents were in attendance. During the meeting, the Residents expressed that they were not permitted to meet without facility staff being present. Multiple Residents verbalized this was a concern. When asked if any of them had approved for the facility staff to attend the meeting they responded no. On 2/2/23 at 2:50 PM, an interview was conducted with Employee F, the Activities Director. When asked if she always attends the Resident Council Meetings, Employee F said, Yes. When asked, do they have right to meet without staff present? Employee F said, Yes. When asked if she was aware that the Resident Council didn't want her present she said, Not from a group consensus, No. Review of the facility policy titled; Resident Council Meetings was conducted. This policy read, . 5. The Activity Director shall be designated, if approved by the group, to serve as a liaison between the group and the facility's administration and any other staff members. a. If the Activity Director is not approved by the group, the group's designee shall serve as the liaison, and documentation shall be maintained to reflect the group's designation. b. The designated liaison shall be responsible for providing assistance with facilitating successful group meetings and responding to written requests from the group meetings. 6. The group may appoint a resident to take notes/maintain meeting minutes or may elect that the Activity Director/designated liaison to take notes/maintain minutes. Meeting minutes may include, but are not limited to: a. Names of the residents in attendance. b. Follow up from previous meetings. c. Issues discussed. d. Recommendations from the group to facility staff. e. Names of staff members, speakers, and other guests present in the meeting (as invited by the group to attend) . On 2/2/23, during the afternoon, during an end of day meeting, the facility Administrator confirmed that Resident Council has the right to meet without staff being present. The Administrator was made aware that the Residents desire to hold meetings without staff being present. No further information was provided.

Based on Resident Interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide services to maintain personal hygiene for 2 Residents (#222, and #375) in a survey sample of 73 Residents. The Findings included: 1. For Resident #222, the bed ridden and incontinent Resident did not receive bathing nor personal hygiene care on multiple days. Resident #222 had an admission minimum data set assessment dated [DATE] which coded the Resident with a Brief Interview of Mental Status score of 1 indicating severe cognitive impairment. The Resident was incontinent of bladder and bowel, and was totally dependent on staff for transferring, toileting, hygiene and bathing. The Resident's closed record ADL Care sheets documented by certified nursing assistants (CNA's) for Activities of Daily Living care were reviewed on 2-2-23. No ADL (activities of daily living) hygiene care was documented as being provided for the Resident on the following days and shifts. 7a.m. to 3p.m. shift - 4-3-21, 4-4-21, 4-13-21, 4-14-21, 4-15-21, 4-16-21, 4-17-21, 4-18-21, 4-19-21, 4-20-21, 4-23-21, 4-24-21, 4-25-21, 4-26-21, 4-27-21, 4-28-21, 4-30-21. The Resident was only documented as receiving hygiene care 13 times in 30 shifts. 3p.m. to 11p.m. shift - 4-1-21, 4-2-21, 4-4-21, 4-5-21, 4-6-21, 4-7-21, 4-9-21, 4-12-21, 4-13-21, 4-14-21, 4-15-21, 4-16-21, 4-17-21, 4-18-21, 4-21-21, 4-22-21, 4-24-21, 4-25-21, 4-26-21, 4-27-21, 4-28-21, 4-29-21, 4-30-21. The Resident was only documented as receiving hygiene care 7 times in 30 shifts. 11p.m. to 7a.m. shift - none was documented as being given during this shift. A tub bath or shower was documented as given only once during the Resident's 32 day stay, on 4-23-21. The ADL care policy was reviewed and under hygiene read Scheduled showers or baths with assistance are provided. Resident #222's care plan was reviewed and revealed that the Resident was incontinent of bladder and bowel. On 2-3-23 The Director of Nursing and Administrator were asked if the ADL documents should be signed correctly indicating care was given, and they stated if it's not documented, it's not done. The DON stated that the facility policy is to provide incontinence care hygiene per policy. They were asked what the expectation was for numbers of baths or showers per week and they stated 2 per week with daily hygiene as needed. The Administrator and Director of Nursing (DON) were notified of the missing documentation and the complaint allegation, at the end of day meeting on 2-3-23. No further information was provided by the facility. 40452 2. For Resident #375, the facility staff failed to provide personal hygiene, namely shaving. On 02/03/2023 at 3:00 P.M., Resident #375 was observed sleeping in his bed wearing a white T-shirt and covered with a blanket. It appeared Resident #375's face had not been shaved for several days. On 02/06/2023 at 12:15 P.M., Resident #375 was observed sleeping in his bed wearing a white T-shirt and covered with a blanket. It appeared Resident #375's face had not been shaved for several days. Resident #375's sister was visiting. When asked about Resident #375's preference, the family member stated [Resident #375] would prefer to be clean shaven. According to the nursing admission assessment dated [DATE] in Section M entitled ADL's/Functional Devices and subpart (1)(h) entitled, Personal Hygiene it was documented that [Resident #375] requires assistance of staff with personal hygiene. According to Resident #375's baseline care plan, Resident #375 needed the assistance of staff with grooming and hygiene. A review of Resident #375's Activities of Daily Living flowsheet for January and February 2023 were reviewed. According to the flowsheets, Resident #375 received personal hygiene (which includes shaving) on 01/26/2023, 01/28/2023, 01/29/2023, 01/30/2023, and 02/02/2023 - 02/06/2023. However, observations on 02/03/2023 and 02/06 2023 clearly showed that the resident was not clean shaven. On 02/06/2023 at approximately 4:10 P.M., the Administrator and Director of Nursing were notified of findings. The facility staff provided a copy of their policy entitled, Activities of Daily Living (ADL). Under the header Policy in Sections 1 and 2 it was documented, The capability of each resident to meet the demands of daily living is assessed by a licensed nurse. Assistance and instruction in ADL skills is provided to residents as designated by the individual care plan.

Based on interview and record review, the facility failed to ensure one Resident (R)141 out of one reviewed for advanced directives was provided written information of the right to accept or refuse medical or surgical treatment and formulate an advance directive. Findings include: On [DATE] at 3:30 PM the facility's policy and procedure was requested regarding Advanced Directives. None was provided by the time of the exit. Review of R141's admission Minimum Data Set (MDS) located in the resident's EMR under the RAI tab with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R141 was cognitively intact. Review of R141's clinical record showed no documentation that the facility provided written information to the resident regarding the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview with R141 on [DATE] at 11:00 AM the resident stated that she was never provided information regarding advanced directives and what treatment, or life sustaining treatment options (such as tube feedings, intravenous fluids, comfort care, etc.) were available for her to choose. She stated that she was just given a piece of paper and she had to decide if she wanted CPR or be a DNR, in the event of a cardiac arrest. During an interview on [DATE] at 4:23 PM, with the Social Services Director, Staff D confirmed no information regarding Advanced Directives were provided or discussed with the resident.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure written acknowledgement of the Notice of Medicare Non Coverage for two Residents (Resident # 81 and # 123) in a survey sample of 3 Residents reviewed for Beneficiary Notices. The findings included: 1. For Resident # 81, the facility staff failed to have the NOMNC (Notice of Medicare Non Coverage) form signed by the Resident and/or the Resident Representative. A copy of the form was not acknowledged by the beneficiary or beneficiary's representative. Review of the clinical record was conducted on 2/3/2023 and 2/6/2023. Review of the Beneficiary notices revealed the notice stated Skilled Nursing Services would end on 1/16/2023. The form was not signed by Resident or representative. There was documentation in the Additional information section of verbal notification to the beneficiary representative on 1/13/2023 at 4:50 p.m. The bottom of the notice form was not signed or dated in the section that had the statement: Please sign below that you received and understood this notice. I have been notified that the coverage if not services will end on the effective date indicated and I may appeal this decision by contacting my QIO. The signature line and date line were blank. On 2/6/2023 at 12:51 p.m., an interview was conducted with the Social Worker (Employee G) who stated Beneficiary notices should be given to Residents or the Resident Representative by the Social Worker. Employee G stated verbal notices were given if the resident or representative were not available to sign. On 2/7/2023 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings. The Administrator stated the expectation was that the beneficiary notices would be signed by the Resident or Resident Representative. The Administrator stated that if the Social Worker gave verbal notification, there should have been follow up with attempts to notify the Resident and/or Representative in writing such as a Certified letter. No further information was provided. 2. For Resident # 123, the facility staff failed to have the NOMNC (Notice of Medicare Non Coverage) form signed by the Resident and/or the Resident Representative. A copy of the form was not acknowledged by the beneficiary or beneficiary's representative. Review of the clinical record was conducted on 2/3/2023 and 2/6/2023. Review of the Beneficiary notices revealed the notice stated Skilled Nursing Services would end on 1/19/2023. The form was not signed by Resident or representative. There was documentation in the Additional information section of verbal notification to the beneficiary representative on 1/13/2023 at 1:15 p.m The bottom of the notice form was not signed or dated in the section that had the statement: Please sign below that you received and understood this notice. I have been notified that the coverage if not services will end on the effective date indicated and I may appeal this decision by contacting my QIO. The signature line and date line were blank. On 2/6/2023 at 12:51 p.m., an interview was conducted with the Social Worker (Employee G) who stated Beneficiary notices should be given to Residents or the Resident Representative by the Social Worker. Employee G stated verbal notices were given if the resident or representative were not available to sign. On 2/7/2023 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings. The Administrator stated the expectation was that the beneficiary notices would be signed by the Resident or Resident Representative. The Administrator stated that if the Social Worker gave verbal notification, there should have been follow up with attempts to notify the Resident and/or Representative in writing such as a Certified letter. No further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to provide ensure that the appropriate information regarding a transfer was communicated to the receiving health care institution or provider for one Resident (Resident # 8) in a survey sample of 73 Residents. The findings included: For Resident # 8, the facility staff failed to document that the reason for the transfer to the hospital was communicated with the hospital staff. Review of the clinical record was conducted 2/3/2023 and 2/6/2023. Review of the Progress Notes revealed Resident # 8 was sent to the hospital on 3/16/2022 due to a change in condition related to involuntary muscle movement and confusion. Review revealed no documentation of the information provided to the receiving hospital. On 2/6/2023 at 12:24 p.m., an interview was conducted with LPN (Licensed Practical Nurse) H, the Unit Manager, who stated when a resident is transferred to the hospital, we print a facesheet, transfer sheet, x-rays, labs, medication list and bed hold to send. When asked where the nurses document the information, the LPN H stated it should be in PCC (Point Click Care-the electronic medical record). Review of the electronic Clinical record revealed no documentation of any information reviewed with the resident and/or the family representative. LPN H stated some documents might be in the hard chart. A copy of the documents sent with Resident #8 to the hospital was requested. The Administrator presented scanned copies of documents that were sent with Resident # 8 during the transfer to the hospital. Review of the scanned documents revealed no evidence of communication with the hospital of the reason for the transfer. On 2/7/2023 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings The Administrator stated the expectation was that the reason for the transfer to the hospital should be communicated to the hospital and documented. No further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to provide Notice to the Ombudsman of discharge for one Resident (Resident # 8) in a survey sample of 73 Residents. The findings included: For Resident # 8, the facility staff failed to notify the ombudsman of transfer to the hospital. Resident # 8 was sent to the hospital on 3/16/2022 due to a change in condition related to involuntary muscle movement and confusion. Resident # 8 was readmitted to the facility on [DATE]. On 2/6/2023 at 12:51 p.m., an interview was conducted with the Social Worker (Employee G) who stated she did not notify the Ombudsman. Employee G stated she was unsure of who notified the Ombudsman. On 2/6/2023 at 12:53 p.m., an interview was conducted with the Business Office Manager (Employee K) who stated she did not notify the Ombudsman of the transfer to the hospital. Employee K stated she would check to see if she could find out who would notify the Ombudsman. During the end of day debriefing on 2/6/2023, the Administrator and Director of Nursing were informed of the findings. The Administrator stated the Ombudsman should have been notified. The Administrator stated the Unit Secretary used to do it. The Administrator stated normally, the list of discharges would be printed from PCC (Point Click Care) and faxed to the Ombudsman. No further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to provide the bed hold policy to the resident and resident representative for one Resident (Resident # 8) in a survey sample of 73 Residents. The findings included: For Resident # 8, the facility staff failed to provide the resident and/or resident representative with the bed hold policy at the time of transfer to the hospital. Resident # 8 was sent to the hospital on 3/16/2022 due to a change in condition related to involuntary muscle movement and confusion. Resident # 8 was readmitted to the facility on [DATE]. Review of the clinical record was conducted 2/3/2023 and 2/6/2023. Review of the Nursing Notes, Social Services Notes, and Physician Progress notes revealed no evidence that Resident # 8 or the resident representative was made aware of the facility's bed hold policy. On 2/6/2023 at 12:24 p.m., an interview was conducted with LPN (Licensed Practical Nurse) H, the Unit Manager, who stated when a resident is transferred to the hospital, we print a facesheet, transfer sheet, x-rays, labs, medication list and bed hold to send. The unit manager stated the nurses should document what was reviewed with the resident and family. When asked where the nurses document the information, the unit manager stated it should be in PCC (Point Click Care-the electronic medical record). Review of the electronic Clinical record revealed no documentation of any information reviewed with the resident and/or the family representative. LPN H stated some documents might be in the hard chart. A copy of the documents sent with Resident #8 to the hospital was requested. Review of the scanned documents from the hard chart presented by the Administrator revealed a Bed Hold Agreement form that was incomplete. The form had Resident # 8's name written in the section that stated I DO wish to hold the bed for ____________ [Resident # 8's name was written on that line], Beginning date 3/16/22 The space for Ending date was blank. There was no amount written in the section to denote the cost of each day. The rest of the form was blank. There was no signature nor any documentation that the information on the form was discussed with Resident # 8 and/or the family representative. On 2/7/2023 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings that there was no evidence to indicate the facility did communicate with Resident # 8 or Resident # 8's representative about the facility bed hold policy at the time of discharge. The Administrator stated the expectation was that the bed hold policy would explained and signed by the Resident or Resident Representative. No further information was provided.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure care plan measures were developed and implemented to prevent skin injury during care for one Resident (Resident #222) in a survey sample of 73 Residents. The findings included: For Resident #222, the facility staff failed to develop a care plan for effective measures to prevent and intervene in skin injuries. Resident #222 had an admission minimum data set assessment dated [DATE] which coded the Resident with a Brief Interview of Mental Status score of 1 indicating severe cognitive impairment. Progress notes, skin evaluation sheets, physician's orders, and Treatment Administration Records (TAR) were reviewed and revealed the following chronology of events; 3-31-21 - On admission Left elbow & Left posterior knee skin tears treated and healed 4-5-23. No further skin tears nor skin problems were documented as having occurred in the clinical records until a room change on 4-21-21 at 2:52 P.m 4-21-21 - 8:50 p.m., Skin tears Left lower leg, & Left outer fore arm. 4-23-21 - Skin tears Right lower leg, Left anterior fore arm, & Right fore arm 4-26-21m - Geri legs & sleeves protection begun on evening shift, and not documented as applied on 4-27-21 during the day shift. 4-30-21 - Skin tears Right shin & Left upper leg. Resident #222's care plan was reviewed and revealed that the Resident was to have daily skin inspections, and baths 2 times per week, and as needed or requested. The Skin Tears care plan was initiated on 4-26-21 after 5 days of known skin tears. On 2-3-23, the DON stated that skin checks were completed during hygiene care. The Administrator was asked for any investigations involving this Resident's skin injuries, and she stated we don't have any. No investigation was conducted to ascertain why so many skin injuries occurred in such a short time for this Resident, and after none had occurred until the transfer to a new room in the facility. The Resident incurred 8 skin injuries in 9 days. The Administrator and Director of Nursing (DON) were notified at the end of day meeting on 2-3-23. No further information was provided by the facility.

Based on staff interview and clinical record review, the facility staff failed to ensure a discharge summary was written for one Residents (# 171) in a survey sample of 73 Residents. The findings included: 1. For Resident # 171, the facility staff failed to document a Discharge Summary. Resident # 171 discharged on [DATE] to an Independent Living apartment on the facility's campus . Review of the clinical record was conducted on 2/6/2023. An interview was conducted on 02/6/2023 at 12:24 p.m. with LPN (Licensed Practical Nurse) H who stated notes should be written in PCC (Point Click Care) in the Progress Notes about discharges. LPN H reviewed the Progress Notes and stated she did not see the information about Resident # 171. On 2/6/2023 at 12:51 p.m., an interview was conducted with the Social Worker (Employee G) who stated she did remember the resident but could not find the information in the clinical record. Employee G stated Resident # 171 chose to move back to the Independent Living apartment on the facility's campus. Employee G stated she would check with the Business Office about dates of the stay. On 2/6/2023 at 12:53 p.m., an interview was conducted with the Business Office Manager (Employee K) who stated Resident # 171 had been in the facility for 4 days from 12/8/2022 until 12/12/2022. Employee K explained how to find the information for Resident # 171 in the electronic clinical record. She stated that since Resident # 171 was still on the campus but in Independent Living, the system had the documentation in a different place. Review of the electronic clinical record revealed no Discharge Summary was written for Resident # 171 upon discharge to the Independent Living apartment. Review of a Social Worker Progress Note revealed the following : 12/12/2022 16:38 Administrator, PT(Physical Therapy) and OT (Occupational Therapy) met with (Resident # 171's name redacted), her son, and her SIL (Son in law) this afternoon. Reviewed ADL (Activity of Daily Living) status and progress. Discussed home health vs. outpatient therapy follow up. The note further stated that Per Resident # 171's and family choice, the resident returned to her (name of facility) apartment this afternoon, with therapy follow up from (name of facility redacted) in-house therapy department. The note was electronically signed by the Social Worker (Employee G). On 2/7/2023 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings of no recapitulation of the stay at the facility. The Administrator stated the expectation was that the Discharge Summary would be completed after discharge. The Administrator stated that a Discharge Summary should have been documented even though the resident was only in the facility for a few days before returning to the previous living arrangement of an apartment on the facility's campus. No further information was provided.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to prevent, and treat timely, a stage 2 pressure ulcer prior to development for one Resident (Resident #222) in a survey sample of 73 residents. The findings included: For Resident #222, the facility staff failed to identify (prior to the development of a stage 2) a pressure ulcer, and failed to treat for 5 further days after identification was documented in the care plan. Resident #222 had a minimum data set assessment dated [DATE] which coded the Resident with a Brief Interview of Mental Status score of 1 indicating severe cognitive impairment. The Resident was incontinent of bladder and bowel. Resident #222's care plan was reviewed and revealed that the Resident was incontinent of bladder and bowel and wore incontinence disposable briefs. The Resident could not feed herself, nor turn and reposition without extensive help from staff. The Resident was to have daily skin inspections, and baths 2 times per week, and as needed or requested. The care plan review also revealed an entry on 4-19-21 indicating the Resident had a stage 2 pressure ulcer on the right buttock which was the first pressure ulcer care plan documented for the Resident. The care plan entry on 4-19-21 was the only documentation of the pressure ulcer until 4-23-21 when it was documented in a progress note, and on a skin sheet document. On 4-24-21 a treatment was ordered for the pressure sore 5 days after the care plan denoted the wound. The Resident was assessed upon admission as at risk for developing pressure sores. Progress notes, skin evaluation sheets, physician's orders, and Treatment Administration Records (TAR) were reviewed and revealed the following chronology of events; 3-31-21 - On admission Left elbow & Left posterior knee skin tears treated and healed 4-5-23. No further skin tears nor skin problems were documented as having occurred in the clinical records until a room change on 4-21-21 at 2:52 P.M. 4-21-21 - 8:50 p.m., Skin tears Left lower leg, & Left outer fore arm. 4-23-21 - Skin tears Right lower leg, Left anterior fore arm, & Right fore arm 4-24-21 - Stage 2 pressure sore right inner buttock On 2-3-23, The DON stated that skin checks were completed during that care. The Administrator and Director of Nursing (DON) were notified at the end of day meeting on 2-3-23. No further information was provided by the facility.

Based on observation, Resident interviews, staff interviews, clinical record reviews, and facility documentation review, the facility staff failed to provide timely pain management measures for 2 Residents (Resident #144, Resident #376) in a sample size of 73 Residents. The findings included: 1) For Resident #144, the facility staff delayed assessment and treatment of Resident #144's left leg pain on 02/01/2023. On 02/01/2023 at 10:10 A.M., Resident #144 was observed in her bed. Resident #144 was grimacing, signing, and restless. When asked about this, Resident #144 stated that her entire left leg was having muscle spasms. When asked to rate the severity of the muscle spasms [0=no pain to 10=worst pain], Resident #144 stated the pain severity was 9. When asked if the nurse was aware, Resident #144 stated she did tell the nurse but didn't know her name because she was new. Resident #144 stated that, many times, she receives her medications late, not as scheduled. On 02/01/2023 at 10:30 A.M., Licensed Practical Nurse E (LPN E) was interviewed. LPN E verified she was Resident #144's nurse and this was her first time working with Resident #144. When asked to share what she knew about Resident #144, LPN E referred to her notes and stated that Resident #144 needed to have her medications crushed. LPN E also stated that she knew Resident #144 was in pain. When asked about this, LPN E stated that Resident #144 told her she was in pain around 9:00 A.M. When asked where Resident #144's pain was located, LPN E stated that Resident #144 couldn't say where the pain was. When asked what happened next, LPN E stated she brought Resident #144 some water and told her she would be back later to assess. This surveyor and LPN E then entered Resident #144's room. LPN E asked Resident #144 if she was in pain. Resident #144 stated her entire left leg was having muscle spasms. LPN E asked Resident #144 to rate the pain severity and Resident #144 stated 9. Upon exiting the room, LPN E stated that Resident #144 has not received her scheduled medications yet and will be given now. LPN E administered the medications that were scheduled for 8:00 A.M. and 9:00 A.M. at 10:39 A.M. which included Robaxin (a muscle relaxer). On 02/01/2023, the facility staff provided a copy of Resident #144's Medication Administration Record (MAR) for January and February 2023 with the exact medication times included as requested. A review of the January 2023 MAR revealed that Robaxin was scheduled to be given at 8:00 A.M., 4:00 P.M., and 12:00 A.M. For the 8:00 A.M. scheduled administration of Robaxin, it was administered late at the following times: 01/01/2023 at 11:23 A.M. 01/02/2023 at 9:33 A.M. 01/04/2023 at 9:45 A.M. 01/06/2023 at 9:46 A.M. 01/07/2023 at 10:26 A.M. 01/08/2023 at 3:20 P.M. 01/14/2023 at 11:20 A.M. 01/15/2023 at 11:59 A.M. 01/21/2023 at 11:36 A.M. 01/22/2023 at 11:23 A.M. 01/25/2023 at 12:55 P.M. 01/28/2023 at 11:09 A.M. 01/29/2023 at 11:10 A.M. 01/30/2023 at 10:27 A.M. 01/31/2023 at 11:47 A.M. On 02/03/2023 at 5:30 P.M., the Administrator and Director of Nursing were notified of the delay in assessment and treatment of Resident #144's left leg pain on 02/01/2023. According to Resident #144's Minimum Data Set with an Assessment Reference Date of 10/21/2022, the Brief Interview for Mental Status was coded as 14 out of 15 indicative of intact cognition. On 02/06/2023, Resident #144's care plan was reviewed. A focus initiated on 11/29/2021 contained goals and interventions for Resident #144's osteoarthritis and low back pain. There was no evidence of goals or interventions addressing Resident #144's left leg pain/muscle spasms. On 02/06/2023 at 3:40 P.M., the Director of Nursing (DON) was interviewed. When asked about Resident #144's left leg pain/muscle spasms, the DON stated that they would have to get a physician in to evaluate why Resident #144 was having muscle spasms in her left leg. The facility staff provided a copy of their policy entitled, Pain Management - Stop the Pain Program. Excerpts in Section 2 entitled, The principles of the STOP program include: documented, prompt and accurate assessment of pain; use of non-drug approaches as important parts of a pain management program; use of pharmacological interventions individualized for each resident . 2) For Resident #376, the facility staff delayed assessment and treatment of Resident #376's chest pain and lower right leg pain on 02/02/2023. On 02/02/2023 at 9:46 A.M., this surveyor observed a therapist (Employee J) approach Licensed Practical Nurse F (LPN F) while she was passing medications to explain that Resident #376's right lower leg was tender and swollen. LPN F asked the therapist if Resident #376 was in pain and the therapist stated, Yes. LPN F did not go to Resident #376 at that time to assess the pain. LPN F did continue with passing medications to three Residents (Resident #378, Resident #379, Resident #166). After completing passing medications at approximately 10:15 A.M. on the three Residents, LPN F called to schedule Resident #376 for a doppler study to rule out deep vein thrombus of the right lower leg. On 02/02/2023 at 10:20 A.M., Resident #376 was interviewed. Resident #376 was observed in her bed. When asked about her right leg pain, Resident #376 stated her right leg had been hurting all night. Resident #376 stated it hurt from her knee to her ankle. Resident #376 was observed to be grimacing and moaning at times. When asked to rate the severity of the pain [0=no pain to 10=worst pain], Resident #144 stated the pain severity was 10. On 02/02/2023 at 10:34 A.M., Certified Nursing Assistant C (CNA C) entered Resident #376's room to assist with Activities of Daily Living (ADL) care. Three times during ADL care, Resident #376 verbalized to the CNA C that my leg hurts my leg is sore and my leg hurts so bad. As CNA C was assisting Resident #376 to her wheelchair at 10:52 A.M., Resident #376 stated, My chest hurts, too. When asked about the severity level of the chest pain, Resident #376 stated, 10. Resident #376 stated she thinks the pain is related to fall she had prior to coming to the facility. At 11:00 A.M., CNA C notified LPN F that Resident #376 complained of chest pain. LPN F did not go to Resident #376 to assess the chest pain or the right lower leg pain as reported to her at 9:46 A.M. At 11:37 A.M., LPN F entered Resident #376's room and assessed Resident #376's right lower leg pain. Resident #376 stated she had pain in leg all night long but now it's not as bad as it was. Resident #376 currently rated the right leg pain severity 5. LPN F administered Tylenol to Resident #376 at 11:41 A.M. and left the room. When asked why it took so long to assess and treat Resident #376's leg pain, LPN F stated that she should've gotten there sooner but was doing other things. At 11:55 A.M., LPN F was asked if she assessed Resident #376 for the chest pain. LPN F indicated she did not assess for chest pain but would do so now. LPN F entered Resident #376's room, listened to her heart and lungs, and asked about current chest pain severity. Resident #376 stated she currently didn't have chest pain so LPN F left the room. When asked about what else would be done concerning Resident #376, LPN F stated she could let the physician know. On 02/02/2023 at 1:55 P.M., LPN F was interviewed. When asked if physician was notified, LPN F stated she put a call out and was waiting for a call back. On 02/02/2023 at approximately 2:00 P.M., this surveyor interviewed Resident #376. When asked chest pain, Resident #376 stated it was better than it was. When asked to rate the pain severity, Resident #376 stated, 2. And that the pain comes and goes. On 02/02/2023 at approximately 2:10 P.M., the Director of Nursing was notified of findings. On 02/02/2023, Resident #376's clinical record was reviewed. A nurse's note dated 02/02/2023 at 2:34 P.M. documented, Resident reassessed s/p [status post] chest pain rates pain 2/10 currently in room participating with therapy, spoke with MD [medical doctor] made aware of change in condition v/s [vital signs] and pain level 97.0 [temperature] 20 [respirations] 126/66 [blood pressure] 82 [pulse] 98% [oxygen saturation]. Received new order from MD to send to ER [emergency room ] for further evaluation r/t [related to] pervious [sic] medical history. Rp [responsible party] made aware of change in condition and MD order to send resident to the hospital for further evaluation. According to the physician's admission note dated 01/27/2023, Resident #376 was admitted to the facility having chest pain around where she was caught by her son from her fall. Resident #376's baseline care plan was reviewed. The chest pain was not addressed on the care plan. There was no recent Minimum Data Set completed due to Resident #376's recent admission. According to Resident #376's admission nursing progress note dated 01/26/2023 at 8:52 P.M., Resident #376 was alert and oriented. On 02/02/2023 at 5:30 P.M., the Administrator and Director of Nursing were notified of findings.

Based on record review, resident interview, staff interview, the facility failed to ensure routine dental services were offered to one of one Resident (R)26 reviewed for dental services. Findings include: Review of R26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/23 indicated that R26 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating the resident was cognitively intact. During an interview on 02/02/23 at 10:10 AM, R26 stated that she knew she needed dental work or dentures but was unsure if she could get an appointment with a dentist. She revealed she had been at the facility for two years and has not had seen a dentist. Review of R26's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admitted in February 2021. During an interview on 02/03/23 at 2:00 PM with the Social Services Director, Staff D, who is responsible for arranging resident dental appointments, with the in house free dental clinic stated, We do not automatically get everyone a dental appointment, unless their family or the resident requests it, or unless they have weight issues. During an interview on 02/03/23 at 3:45 PM with the Director of Nursing, (DON) she stated her expectations of residents being made dental appointments was if the resident or family request an appointment, if the nurse notices a concern (no teeth, broken teeth, or pain), or have dietary issues.

Based on staff interview and facility documentation review, the facility staff failed to ensure Committee Members were present for QAPI meetings for 4 of 4 QAPI meetings. The Findings included: For the QAPI meetings, the facility staff failed to ensure core members were present for each meeting. On 02/06/23 at 2:56 p.m., Meeting with DON and Administrator- Administrator stated the QAA, QAPI meets quarterly, The dates of the meetings in the past year were 11/15/2022, 8/31/2022, 5/18/2022 and 2/9/2022. Those in attendance were: 11/15/2022- The Administrator, Director of Nursing, Medical Director and 3 LPNs. (the Infection Preventionist was not present) 8/31/2022- The Administrator, Director of Nursing, Medical Director and 1 LPN. (the Infection Preventionist was not present and 1 other facility staff was not present) 5/18/2022- There were no signatures. All names were printed in the same penmanship. There were 3 listed on the top section as Healthcare Center Advisory Members on Web-ex. The bottom section listed 6 printed names including the Administrator, Director of Nursing, Chief Executive Officer, Unit Managers, one unidentified position and one via Web ex (The printed names did not document the positions held by each person.) 2/9/2022-The Administrator, Director of Nursing, Medical Director and 1 LPN. the Infection Preventionist was not present and 1 other facility staff was not present) On 2/6/23 at 2:52 p.m., Administrator stated We need to get back on track Post COVID- some members were not present She also stated Core group meets every day. The Administrator stated Clin ops (Clinical Operations) meeting is Campus wide,Transparent with each other and meet daily The Administrator stated Department heads, Certified Nursing Assistants, Rehab, Administrator, DON (Director of Nursing) Staffing, Unit Secretary, Dietary, etc were involved in the daily meeting. The Administrator stated the Infection Preventionist did not attend any of the QAPI meetings. She also stated a Certified Nursing Assistant did not attend the QAPI meetings. No further information was provided.

Based on observation, Resident interviews, staff interview, and facility documentation review, the facility staff failed to have posted the list of names, addresses and telephone number of all pertinent State agencies and advocacy groups affecting Residents on all 5 nursing units. The findings included: For Residents residing on all 5 nursing units, the facility failed to post in a manner accessible to Residents, a list of names, addresses, and telephone numbers of all pertinent State Agencies and advocacy groups. On 2/2/23 at 11 AM, during a Resident Council meeting, the 13 of the 14 Residents verbalized they did not know where the posting of required agencies was located. Several Residents who resided on the 2nd floor of the facility reported that it was not posted on their floor. On 2/2/23 at approximately 12:30 PM, Surveyor D toured the entire facility to include the upstairs 400 and 500 units, to include the activities room, dining rooms, communication boards and hallways. It was noted that there were no posting of state agencies and advocacy groups. The tour continued downstairs on the ground level, which included but was not limited to the facility lobby, outside of the elevator used by Residents and visitors, the auditorium, dining rooms, 3 Resident units to include common areas and communication boards. The only posting noted on the ground level was on a wall prior to entering the rehabilitation gym and hall entering the secure memory care unit. On 2/2/23, during the afternoon an interview was conducted with Employee G the social worker. Employee G reported that the posting of state survey agency and advocacy groups was located on each unit. Employee G and Surveyor D walked to the 100 and 300 units and noted no such posting. Employee G also indicated that she had this posting in her office, and it was available to Residents upon request. On 2/2/23, during the end of day meeting, the facility Administrator was made aware of the above findings. The Administrator stated that it was posted outside of the elevator on the second floor. Following the meeting, the facility Administrator and Surveyor D toured the second floor finding no posting of the state survey agency and advocacy groups contact information. The Administrator commented that they had done some painting and it must have been removed during that process. The tour with the Administrator and Surveyor D continued downstairs on the ground level. The Administrator confirmed that there was no such posting in the lobby or other common areas accessible to all Residents and families. The facility policy regarding Resident Rights was requested. The facility provided a document titled, Exhibit B, Resident Rights Policy & Notice. The Administrator reported that this document was an attachment to their admissions agreement. The policy/notice did provide the state survey agency and advocacy groups contact information within the document but made no reference of the posting of this information within the facility. On 2/6/23 at 2:40 PM, a facility policy titled, Resident Right- ROP was received. This document was reviewed and it read, .8. A posting of names, addresses and phone numbers of all pertinent state client advocacy groups will be available in the facility . No further information was provided.

Based on Clinical Record review, facility document review, and facility staff interview, the facility staff failed to offer and vaccinate one eligible Resident (Resident #3) with the pneumococcal vaccine, out of six residents in the Resident sample. Resident #3 was not offered nor administered the pneumococcal vaccine upon admission in December of 2019. The findings included; Resident #3 was admitted to the facility in December 2019. Review of the Resident's clinical record on 12-21-2020 revealed no immunization for pneumonia. On 12-21-2020 at the end of day debrief at 5:45 p.m., the administrator was requested to supply the vaccination record for Resident #3. On 12-22-2020 during an interview at the end of day debrief at 1:00 p.m., the administrator, Director of nursing, and Corporate RN agreed that the Resident had not been vaccinated but that the responsible party for the Resident had agreed to the vaccination, and Resident #3 would receive it immediately. The facility supplied no further evidence.

Based on staff interview, facility documentation review, clinical record review and in the course of a complaint investigation, the facility failed to ensure Residents were free from significant medication errors for 3 Residents (Resident #1, #2, #3) in a survey sample of 3 Residents. This happened multiple times. The findings included: 1. For Resident #1, the facility staff failed to administer significant anticoagulation and insulin medications, or administer timely, per physician orders. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1-2-2020 was coded as a quarterly assessment. Resident #1 was coded as having had a BIMS (brief interview for mental status) score of 14, which indicated mild to no cognitive impairment. Resident #1 was coded as extensive to limited assistance needed from one staff member for ADL's (activities of daily living), however, could eat, and wheel herself in a wheel chair, with supervision. On 2-21-2020 a review of the clinical record physician's orders [REDACTED]. The order began 1-30-2020, and was discontinued on 2-14-2020. A new order was received on 2-14-2020 for an change to [MEDICATION NAME] 6.5 mg to be given every day at 6:00 p.m. The Medication Administration Record (MAR), and audit report review revealed that Resident #1 received the [MEDICATION NAME] dosage as prescribed, however, not at the hour it was prescribed. The anticoagulant drug was given late on 4 occasions out of the 14 days reviewed from 2-7-2020 to 2-20-2020. Those days and times follow below; 2-8-2020 due at 6:00 p.m., given at 1:31 a.m., on 2-9-2020 2-10-2020 due at 6:00 p.m., given at 11:30 p.m. 2-16-2020 due at 6:00 p.m., given at 8:39 p.m. 2-19-2020 due at 6:00 p.m., given at 7:19 p.m. A further MAR and audit report review revealed Finger Stick Blood Sugar (FSBS) testing, with Sliding Scale Insulin Dosing (SSI) physician's orders [REDACTED]. The order for [MEDICATION NAME] (R) Insulin solution, was dictated by a sliding scale dose. The dose of insulin depended each time on the blood sugar readings obtained by way of FSBS. The testing time and resulting Insulin administration were ordered to be before meals and at bedtime, (7:30 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m.). The four times per day order began 8-26-19, and was current at the time of survey. The Medication Administration Record (MAR) and audit report review revealed that Resident #1 received the SSI dosage amount as prescribed, however, not at the hour it was prescribed, and on 3 occasions it was omitted. On (2-4-2020, 2-6-2020, and 2-15-2020) all three days at 11:00 a.m The FSBS and SSI was given late on 34 occasions, out of the 56 opportunities reviewed from 2-7-2020 to 2-20-2020. Those days and times follow below; 2-7-2020 due at 7:30 a.m., given at 9:46 a.m. 2-7-2020 due at 11:00 a.m., given at 1:17 p.m. 2-8-2020 due at 11:00 a.m., given at 2:35 p.m. 2-8-2020 due at 4:00 p.m., given at 1:30 a.m. on 2-9-2020 2-8-2020 due at 9:00 p.m., given at 1:30 a.m. on 2-9-2020 2-9-2020 due at 7:30 a.m., given at 9:17 a.m. 2-9-2020 due at 11:00 a.m., given at 2:44 p.m. 2-10-2020 due at 7:30 a.m., given at 8:00 p.m. 2-10-2020 due at 11:00 a.m., given at 8:05 p.m. 2-10-2020 due at 4:00 p.m., given at 6:10 p.m. 2-10-2020 due at 9:00 p.m., given at 11:30 p.m. 2-11-2020 due at 11:00 a.m., given at 1:38 p.m. 2-11-2020 due at 4:00 p.m., given at 6:03 p.m. 2-12-2020 due at 11:00 a.m., given at 2:45 p.m. 2-12-2020 due at 4:00 p.m., given at 6:40 p.m. 2-13-2020 due at 7:30 a.m., given at 8:49 a.m. 2-13-2020 due at 11:00 a.m., given at 2:42 p.m. 2-14-2020 due at 7:30 a.m., given at 9:12 a.m. 2-14-2020 due at 11:00 a.m., given at 2:54 p.m. 2-14-2020 due at 4:00 p.m., given at 5:58 p.m. 2-15-2020 due at 11:00 a.m., given at 3:55 p.m. 2-16-2020 due at 7:30 a.m., given at 9:35 a.m. 2-16-2020 due at 11:00 a.m., given at 1:03 p.m. 2-17-2020 due at 7:30 a.m., given at 9:34 a.m. 2-17-2020 due at 11:00 a.m., given at 2:43 p.m. 2-17-2020 due at 4:00 p.m., given at 6:10 p.m. 2-18-2020 due at 7:30 a.m., given at 9:04 a.m. 2-18-2020 due at 11:00 a.m., given at 12:28 p.m. 2-18-2020 due at 4:00 p.m., given at 6:03 p.m. 2-19-2020 due at 11:00 a.m., given at 12:53 p.m. 2-19-2020 due at 4:00 p.m., given at 7:15 p.m. 2-19-2020 due at 9:00 p.m., given at 10:59 p.m. 2-20-2020 due at 7:30 a.m., given at 9:14 a.m. 2-20-2020 due at 11:00 a.m., given at 2:10 p.m. 2. For Resident #2, the facility staff failed to administer significant anticoagulation and insulin medications, or administer timely, per physician orders. Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1-29-2020 was coded as a quarterly assessment. Resident #2 was coded as having had a BIMS (brief interview for mental status) score of 12, which indicated mild cognitive impairment. Resident #2 was coded as needing supervision only for ADL's (activities of daily living). On 2-21-2020 a review of the clinical record physician's orders [REDACTED]. The order was current as of the date of survey. The Medication Administration Record (MAR) review revealed that Resident #2 received the Aspirin dosage as prescribed, however, not at the hour it was prescribed. The anticoagulant drug was given late on 2 occasions out of the 14 days reviewed from 2-7-2020 to 2-20-2020. Those days and times follow below; 2-10-2020 due at 9:00 a.m., given at 8:23 p.m. 2-16-2020 due at 9:00 a.m., given at 10:48 a.m. A further MAR and audit report review revealed Finger Stick Blood Sugar (FSBS) testing, with Sliding Scale Insulin Dosing (SSI) physician's orders [REDACTED]. The order for Humalog (Insulin [MEDICATION NAME]) Insulin solution, was dictated by a sliding scale dose. The dose of insulin depended each time on the blood sugar readings obtained by way of FSBS. The testing time and resulting Insulin administration were ordered to be before meals and at bedtime, (7:30 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m.). The four times per day order began 8-10-19, and was current at the time of survey. The Medication Administration Record (MAR) and audit report review revealed that Resident #2 received the SSI dosage amount as prescribed, however, not at the hour it was prescribed, and on 2 occasions it was omitted. On (2-6-2020 at 4:00 p.m., and 2-20-2020 at 11:00 a.m.). The FSBS and SSI was given late on 25 occasions, out of the 56 opportunities reviewed from 2-7-2020 to 2-20-2020. Those days and times follow below; 2-7-2020 due at 7:30 a.m., given at 8:49 a.m. 2-7-2020 due at 11:00 a.m., given at 1:17 p.m. 2-8-2020 due at 11:00 a.m., given at 2:34 p.m. 2-8-2020 due at 4:00 p.m., given at 1:47 a.m. on 2-9-2020 2-8-2020 due at 9:00 p.m., given at 1:51 a.m. on 2-9-2020 2-9-2020 due at 11:00 a.m., given at 2:43 p.m. 2-10-2020 due at 7:30 a.m., given at 10:23 a.m. 2-10-2020 due at 11:00 a.m., given at 8:39 p.m. 2-10-2020 due at 4:00 p.m., given at 9:37 p.m. 2-11-2020 due at 11:00 a.m., given at 1:37 p.m. 2-11-2020 due at 4:00 p.m., given at 5:57 p.m. 2-12-2020 due at 11:00 a.m., given at 2:45 p.m. 2-12-2020 due at 4:00 p.m., given at 6:12 p.m. 2-13-2020 due at 7:30 a.m., given at 8:43 a.m. 2-13-2020 due at 11:00 a.m., given at 2:41 p.m. 2-14-2020 due at 11:00 a.m., given at 2:52 p.m. 2-15-2020 due at 11:00 a.m., given at 1:37 p.m. 2-16-2020 due at 7:30 a.m., given at 10:20 a.m. 2-16-2020 due at 11:00 a.m., given at 1:57 p.m. 2-16-2020 due at 4:00 p.m., given at 6:07 p.m. 2-17-2020 due at 11:00 a.m., given at 2:41 p.m. 2-18-2020 due at 11:00 a.m., given at 12:26 p.m. 2-19-2020 due at 7:30 a.m., given at 8:54 a.m. 2-19-2020 due at 11:00 a.m., given at 1:07 p.m. 2-20-2020 due at 11:00 a.m., given at 2:09 p.m. 3. For Resident #3, the facility staff failed to administer significant anticoagulation medications timely, per physician orders. Resident #3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 12-2-19 was coded as a quarterly assessment. Resident #3 was coded as having had a BIMS (brief interview for mental status) score of 8, which indicated significant cognitive impairments. Resident #3 was coded as extensive assistance needed from one staff member for toileting and bed mobility ADL's (activities of daily living), however, only supervision was required with other ADL's. On 2-21-2020 a review of the clinical record physician's orders [REDACTED]. The order was discontinued on 2-10-10 and a new order received that day for an increase to 6.5 mg to be given at 9:00 a.m. The Medication Administration Record (MAR) review revealed that Resident #3 received the [MEDICATION NAME] dosage as prescribed, however, not at the hour it was prescribed. The anticoagulant drug was given late on 6 occasions out of the 14 days reviewed from 2-7-2020 to 2-20-2020. Those days and times follow below; 2-8-2020 due at 6:00 p.m., given at 1:38 a.m., on 2-9-2020 2-13-2020 due at 9:00 a.m., given at 10:34 a.m. 2-15-2020 due at 9:00 a.m., given at 11:38 a.m. 2-16-2020 due at 9:00 a.m., given at 12:13 p.m. 2-19-2020 due at 9:00 a.m., given at 2:14 p.m. 2-20-2020 due at 9:00 a.m., given at 10:29 a.m. On 2-21-2020 at 2:00 p.m., during the end of day meeting, the facility Administrator and DON were made aware. No further information was provided.

Based on observation, staff interview, physician interview, facility documentation review, clinical record review, hospital record review, and in the course of a complaint investigation, the facility failed to provide prevention, timely identification, assessment/documentation, and treatment of [REDACTED].#3 and #1) in a survey sample of 5 residents, resulting in harm for both Residents. The findings included: 1. For Resident #3 the facility staff failed to prevent, identify timely, fully assess and document progress or worsening, of pressure ulcers. Resident #3 was originally admitted to the facility on [DATE], and most recently readmitted [DATE]. [DIAGNOSES REDACTED]. Resident #3's most recent Minimum Data Set (MDS) assessment was a significant change full assessment for deterioration in cognitive status with an Assessment Reference Date (ARD) of 8-2-19. The MDS revealed that Resident #3 was coded on the most recent MDS with a Brief Interview of Mental Status score of 3 points out of 15 points possible, indicating severe cognitive impairment. The Resident required extensive to total assistance of one to two staff members with all activities of daily living (ADL's) including bed mobility and transferring. Resident #3 was coded as always incontinent of bowel and bladder. The 2 current pressure ulcers involved during survey were as follows; #1. One pressure ulcer identified at a stage 3, Right buttock/ Ischium, with tunneling and significant slough. #2. An unstageable wound was found with 80% necrotic tissue on 6-20-19, which was identified in the wound physician notes to the Right buttocks. The 2 wounds were distinctly different in location, description, and measurement. The Director of Nursing (DON) was asked for copies of all Braden scale assessments for this Resident for 2019. Three Bradens scale assessment documents were presented. The Assessment purpose was to predict pressure sore risk, and only 3 were completed and found in the clinical record. All 3 assessments documented that the Resident was at risk for skin breakdown. The dates for the 3 documented assessments were 10-21-15, 12-7-18, and 3-20-19. No other Braden scale assessments were found in the clinical record. The facility policy for Skin Risk Assessment for Prevention and Treatment stated the Braden scale assessments would be completed quarterly. Weekly skin integrity review documents were requested for all wounds for Resident #3 since identification of each wound, for 2019 and were reviewed. Those follow; On 2-25-19 there were no skin issues. On 3-29-19 had 2 added open areas. They were described as the right buttock, and, an area under the right buttock. Treatment was initiaited on 3-29-19 for Triad [MEDICATION NAME] (zinc) wound paste (moisture barrier cream) topically every shift. The Triad paste treatment continued until 5-27-19 (2 more months). The Weekly skin integrity review sheets only the word buttocks, with no other descriptions as to location or number of wounds, and no changes in treatment. On 5-24-19 the Assistant Director of Nursing (ADON) documented in the nursing notes Wound to right buttock improved, no change to wound care. On 5-31-19 the nursing notes describe unpleasant odor and dark drainage during care. No other assessments were performed at that time, no description of the wounds and no measurements were documented by the facility. Physician's orders and the computerized Medication Administration Audit Record were requested, received, and reviewed. and revealed that on 5-31-19 a new order was received and started on 6-1-19 to the right buttock. The weekly skin integrity sheets revealed that on 6-4-19, the sacrum and left buttock had open areas, however, gave no other measurements or descriptions. These 2 wounds were observed in the weekly skin reviews through 7-22-19, when the left buttock was no longer documented on the weekly skin sheets, and only the sacrum remained. The sacrum was also healed on 10-17-19 before the survey began. On 8-12-19, and 8-19-19 the Right buttock was newly notated on the weekly skin sheets, however not mentioned the following week on 8-26-19. Beginning 9-2-19 through 10-21-19 and the time of survey, the weekly skin sheets documented sacrum and buttocks treatment in place, and no other descriptions or locations were documented nor number of wounds at the time. During this chronology of events the sacrum, and left ischium healed, and only the right ischium (previously known as right buttock), and right upper buttock pressure sores were being treated. General prevention orders prior to identification of the current 2 pressure ulcers remaining at the time of survey were as follows; 1. 1-23-19 - Air mattress for prevention. 2. 3-29-19 & 4-1-19 Triad [MEDICATION NAME] wound paste (ingredients; [MEDICATION NAME], cellulose gum, zinc oxide, dimethicone). Manufacturer instructions state if no improvement or if condition worsens within 10 to 14 days, consult a physician or wound care specialist. On 6-10-19 the Primary Care Physician (PCP) evaluated the Resident at the facility and wrote a progress note. The PCP Registered Nurse Practitioner was from the PACE all inclusive care program that the Resident attended. The note stated; Notified of patient's stage 3 ischium pressure ulcer last week (6-3-19). Wound care orders were initiated by (name of facility) facility wound nurse (orders written 5-31-19, and 6-3-19) and order was written and sent last Friday (6-7-19) for patient to be evaluated by (name) wound care MD (doctor). No activity or appetite change. New stage 3 pressure ulcer. Area with tunneling and undermining, Right ischium stage 3 wound bed with significant amount of slough deep with undermining that may require debridement. Recommend that patient stay at (name of facility) for the time being in order to avoid being out of bed all day at pace. (The Resident had no PACE attendance since 5-31-19.) RD (registered dietician) ordered pro-stat daily, will add zinc supplementation for 2 weeks. Physicians orders, Wound Specialist Physician's notes, and Primary care physician's notes, were reviewed on 10-23-19 and revealed the progression of the 2 (current to survey) pressure ulcers which were as follows, and are dated in chronological order; (Right buttock (site 1) ) 1. 5-30-19 (site 1) Right buttock pressure ulcer was first identified (ID) by Wound doctor shear wound right buttock for duration of at least 20 days, 100% thick adherent devitalized necrotic tissue. 4.7 cm (centimeters) long (L) x 3.8 cm wide (W) x 0.1 cm deep (D). The wound was surgically debrided at that time by cutting out 17.86 cm squared of dead tissue and dead subcutaneous fat to a depth of 0.2 cm. The treatment plan was for Santyl ointment (enzyme [MEDICATION NAME] ointment) and discontinue zinc moisture barrier ointment, then cover with a dry dressing, and the notes went on to state re-evaluation would occur in 7 days and the procedure was explained to the resident on this day. 2. 6-13-19 (site 1) was the next evaluation date, 2 weeks later. The wound was described as 4.6 cm (L) x 3.4 cm (W) x 0.1 cm (D) with 65% thick adherent devitalized necrotic tissue, and 35% granulation tissue. The wound doctor again debrided the wound surgically removing another 10.17cm squared of dead tissue and dead subcutaneous fat to a depth of 0.2 cm. and the note documented that the procedure was explained to the resident on 5-30-19. 3. 6-20-19 (site 1) was the next evaluation date, 1 week later. The wound was described as 7.2 cm (L) x 5.6 cm (W) x 0.1 cm (D) with 35% thick adherent devitalized necrotic tissue, and 35% granulation tissue, and 30% skin. The wound doctor again debrided the wound surgically removing another 14.11cm squared of dead tissue, dead subcutaneous fat, and surrounding connective tissues to a depth of 0.2 cm. and the note documented that the procedure was explained to the resident on 5-30-19. No changes were made to the treatment. At this evaluation on 6-20-19 a second wound on the right buttock (site 2) was identified as a shear wound first identified with 80% necrotic tissue. That wound will be described below. Right Buttock (re-classified as Right Ischium on 6-27-19 by wound doctor) Site 2 1. 6-20-19 first identification of the unstageable pressure sore. The wound was described as 5.5 cm (L) x 5.4 cm (W) x 2.5 cm (D) with 80% thick adherent devitalized necrotic tissue, and 20% granulation tissue. The wound doctor debrided the wound surgically removing 23.76 cm squared of dead tissue, dead muscle, and fascia fibers to a depth of 2.7 cm. and the note documented that the patient has been spending most of the day sitting up in his wheel chair while at PACE, now with stage 4 wound with odor, start Dakins (for 30 days) with crushed [MEDICATION NAME] (for 14 days) 250 mg (milligrams) antibiotic. Cover with dry dressing. procedure was explained to the resident on 6-20-19. The Resident had not been to PACE since 5-31-19 (3 weeks) when this wound was identified. The wound doctor continued to see the Resident and treat both right buttock wounds on the following dates; 6-27-19, 7-11-19, 7-18-19, 7-25-19, 8-1-19, 8-15-19 2 week gap, 8-22-19, 8-29-19, 9-5-19, 9-12-19, 9-19-19, 9-26-19, 10-10-19 2 week gap, 10-17-19. Full body weekly nursing Skin Integrity Assessments were documented as completed, however none gave descriptions of wounds, measurements, numbers of wounds, or exact locations. The (Director of Nursing) DON was asked to supply all wound assessments for 2019. The Wound evaluation flow sheets were only completed from 7-25-19 to the time of survey. These assessments revealed descriptions and measurements, however, only for the right buttock, Right ischium, and sacrum which was resolved on 10-17-19 according to the document, and remained healed at the time of survey. The Resident's full care plan for 2019 was requested on 10-22-19, and received and reviewed on 10-23-19. The care planned interventions for the 2 wounds which were acquired in the facility, were as follows; 1. Shearing right upper buttock - weekly skin assessments current/active added 3-29-19 (for old healed wound), and not removed. Wound to be followed by Vohra wound care current/active added late on 7-19-19. Administer medications as ordered current/active added for an earlier wound 4-26-19 and not removed. Keep skin clean and dry. Use lotion on dry skin (ordered for left leg). Apply barrier Zinc cream if needed current/active added 9-13-16 (for old healed wound) and not removed, even though the order was discontinued on 6-1-19. Check air pressure in air mattress current/active added 7-24-19 (after it was not functioning 7-9-19, and 7-10-19. The document reveals that it was revised on 10-22-19, however, there are no new interventions dated for this date. No treatments, assessments, or dressings were included nor updated in the care plan for this wound. Dakins solution, and normal saline were used to clean the wound, and santyl ointment was used as an enzymatic debridement agent. 2. Stage 3 pressure wound right ischium will show signs of resolve by the target date, Initiated late on 7-19-19. The care plan also identified the same wound as a Stage 4 pressure wound to right ischium will show signs of healing and remain free from infection by/through review date. Initiated late (same date as the stage 3 entry) on 7-19-19. (Revealing staff are identifying the same wound as both a stage 3, and stage 4 wound at the same time.) Interventions were; - administer treatments as ordered and monitor for effectiveness. Assist to shift weight in wheel chair frequently when resident is up in wheel chair. The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. Wound to be followed by wound MD (doctor) until healed. And the final intervention was, resident has antibiotic therapy (crushed and sprinkled in the wound) initiated 10-11-19, and resolved 10-22-19. The antibiotic was ordered initially on 6-21-19, for 30 days, however, not added to the care plan until 10-11-19. No treatments, assessments, or dressings were included nor updated in the care plan for this wound. Dakins solution, and normal saline were used to clean the wound, and santyl ointment was used as an enzymatic debridement agent. [MEDICATION NAME] was ordered for wound odor abatement on 6-20-19 for 30 doses, to be sprinkled in the Right ischium wound, which was completed. [MEDICATION NAME] was ordered again on 8-20-19 for 30 doses, however, only 10 doses were administered and stopped abruptly with no explanation. [MEDICATION NAME] was again ordered on 10-11-19 for 14 days/doses, however, was not administered on 10-11-19, nor 10-18-19, and was discontinued on 10-18-19 with no explanation, and only 6 doses given. RD notes revealed no significant weight loss, and the Resident received a regular mechanical soft diet. The following 7 supplements were ordered for the Resident, however, not until after the pressure ulcers were identified. 1. Ordered 6-3-19 - Pro-stat AWC 30 ml (milliliters) by mouth daily in the morning for 4 weeks for wound. Ordered a second time on 7-11-19 every day, and again on 9-25-19 every day for 4 weeks. 2. Ordered 6-11-19 - Zinc sulfate capsule 220 mg every day for 14 days, and again on 7-11-19 for 14 days 3. Ordered 7-11-19 -Ensure Plus 120 ml three times per day, and [MEDICATION NAME] Acid (vitamin C) 500 mg every day and 4. Ordered 7-11-19 - A Reese's cup candy every day shift for supplement. 5. Ordered 8-15-19 - Magic cup supplement in the evening for supplement. 6. Ordered 8-15-19 - Ensure pudding 3 times per day for supplement. 7. Ordered 10-10-19 - Ensure Plus drink 120 ml decreased to twice per day On 10-23-19 at 11:00 a.m., during wound care observation with LPN C and LPN D (Licensed Practical nurses, the Resident's brief was removed, and there was no dressing on the ischial wound. The brief was examined by the surveyor and nurses to be certain the dressing was not inside of it. They stated no, it's not there. The Resident's Right ischium measured 2.0 cm (L) x 2.3 cm (W) x 4.0 cm (D). The wound was a stage 4 ulcer with necrotic tissue and slough inside of the wound bed margins, and silver fascia and bone was visualized. There was also a 6.0 cm tunnel into the wound under the skin pointing toward the Resident's head at the 12 o'clock location. The wound had in it a moderate amount of foul smelling (spoiled milk odor) purulent (pus) drainage and stringy green and tan exudate. The second wound located on the upper right buttock resting just below the Iliac crest and lateral to the spine was an unstageable pressure ulcer measuring 7.0 cm (L) x 10.0 cm (W) with no depth able to be visualized. The wound bed could not be seen secondary to a yellow slough covered center, with the entire outer circumference of the wound being a complete border of 1.0 cm of hard black dead necrotic tissue. The nurse had just taken the Resident's vital signs to include temperature. The Resident was febrile (had a fever) with a temperature of 101.4. The Resident stated I don't feel good. in a soft panting voice. The nurse stated she had given the Resident Tylenol, and when she listened to the Resident's lungs, she could hear wheezing. When asked if she had contacted the Resident's doctor, she stated, No, they may come in and see him this evening, the Tylenol has not had time to work yet, I just gave it. The surveyor asked how an antibiotic or other treatment could be prescribed if a resident had an infected wound, which was indicated by some of the Resident's symptoms, and she responded I don't know. On 10-23-19 at 12:16 p.m., an interview was conducted with Resident #3's daughter. She stated that no one notified her of the wound until she started smelling a bad smell and called the PACE doctor to find out what the problem was. He hasn't been to PACE in 5 months. The daughter stated I feel the staff are hiding things from me, and one staff member told me about wounds on my father, and she was reprimanded, so they are scared to even talk to me now. The Resident's daughter was not notified of the Resident's skin breakdown until the wounds were noted to have a foul odor. Email document communications, from (MONTH) 2019 through (MONTH) 2019, to include a grievance for dated 6-18-19 were reviewed between the daughter and the facility, and between the daughter and the PACE program. The Resident's daughter was interviewed on site, and she was not notified and fully aware of the numbers of wounds, nor severity of the wounds even up until the time of survey. On 10-23-19 at 2:00 p.m., the nurse LPN C was asked again if the doctor had been contacted, and she stated no, but if they don't come in, I will have the next shift call them. 10-23-19 at 2:50 p.m., RN B (PACE nurse) was interviewed. RN B stated that she sees the Resident weekly, and he has had a significant decline since last week. The PACE nurse stated that the daughter was very involved with her father's care. RN B was asked if the Resident could be suffering from an infected wound, she stated no one had said anything to her about it, and that he didn't look bad like this last week. She went on to say that she only saw the Resident once per week, and if the staff had concerns they could call the doctor at PACE. She stated the only way they know what is going on with the Resident is if the facility calls them, as the Resident has not been to PACE in months, and she can't act as an intermediary between the facility and the doctor. That is for the facility to do. On 10-23-19 at 4:00 p.m., the DON was made aware of the Resident's symptoms and asked if the staff had notified the doctor. She stated she would look into it. At 6:00 p.m., the Resident was sent to the hospital at the request of the daughter. On 10-24-19 at 1:50 p.m., the wound care physician (employee F) was interviewed. The physician was asked why the wound locations were re-classified/changed in the documentation in the clinical record. He stated that the nurses were not describing the wounds with the correct anatomical location, and so he changes it to the correct one. The doctor also stated that if the wound worsens or changes the nurses will describe it to him over the phone, and he will make treatment changes as needed. He expects the nurses to carry out the orders immediately. The DON stated the facility can have treatments products on a stat (needed immediately) basis in house within 2 hours filled from the pharmacy. On 10-24-19 Hospital records were requested, and obtained on 10-25-19. Those documents revealed a fever of 100.9 degrees Fahrenheit, Gangrene of the left toes noted stage 4, large stage 4 decubitus ulcer involving the right gluteal region noted The ulcers with significant drainage of foul smelling bacteria. The emergency room document goes on to say that a CT (Computed [NAME]ography) radiology scan resulted in findings of Abdomen and pelvis showing right ischial decubitus ulcer and osteo[DIAGNOSES REDACTED], resulting in pelvic abscess, which may require surgery to drain. White blood cell count at 21.7 (normal is 4.5 to 11.0) indicating severe infection or inflammation. The Resident was diagnosed with [REDACTED]. On 10-25-19 at 4:00 a.m., the Resident was admitted as an in-patient admission, with final [DIAGNOSES REDACTED]. Consider comfort care as the patient is critically ill and unlikely to tolerate surgical intervention. No documents existed in the clinical record to describe the gangrene of the remaining toes, and treatment records showed only skin prep preventative to left great toe., Apply firm podus boot during the day to left foot, remove every shift for skin checks and hygiene, and Apply soft podus boot to left foot every night at bedtime, and remove in the morning. During the wounds observation the Resident was wearing a sock, no boot was present, and no wound dressing was applied. The DON was asked for wound policies used for the facility, and she delivered the copies. On 10-23-19 a review was conducted of Facility policy and procedure guidelines for Review of the facility policy titled skin risk assessment: skin prevention and treatment protocol read on page 3, Part one: risk assessment/prevention: a. each admission or readmission of the resident will have a thorough head to toe skin assessment. This also includes a Braden scale assessment on admission, followed by one per week for 4 weeks; then quarterly. c. Determination of risk assessment for pressure ulcers, using the Braden Scale; in addition to using the input from Nutrition Risk assessment. This scale ensures systematic evaluation of individual risk factors. Factors which place a resident at risk for pressure ulcers: general physical condition (including poor nutrition), mental status, activity, mobility, incontinence, braden scale. This same policy stated on page 5: Prevention Protocol: Rehab screening upon admission and yearly according to the MDS schedule; and as needed. Review of the therapy notes for Resident #3 revealed that therapy had not treated even after the development of and progression of wounds to a stage 3 and 4. The issues with Resident #3's upper right buttock and right ischial pressure wounds, include lack of an adequate measurable pressure ulcer prevention care plan, lack of appropriate preventive assessment, documentation, and treatment, late identification, late timing of interventions and treatments for the avoidable wounds. Assessment and treatment were instituted, only after development of an un-stageable wound, and a stage 3 wound which progressed rapidly to a stage 4 wound. Hospital records further show gangrene to the left foot great toe, which was not documented anywhere in the clinical record, even after the Resident suffered an above the knee right leg amputation previously, and secondary to [MEDICAL CONDITION]. On 10-24-19 at 5:14 p.m., during an end of day meeting, the facility administrator and DON were made aware of the facility staff's failure to provide care and treatment to prevent the development of pressure ulcers for Resident #3, resulting in HARM. No further information was provided. COMPLAINT DEFICIENCY. 2. For Resident #1 the facility staff failed to provide care and treatment to prevent the development of pressure ulcers, resulting in HARM. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 8/6/19 was coded as a quarterly assessment. Resident #1 was coded as having had a BIMS (brief interview for mental status) score of 3, which indicated severe cognitive impairments. Resident #1 was coded as total care with assistance of one staff members for ADL's (activities of daily living), which included bed mobility, dressing, eating, toileting, personal hygiene and bathing. On 10/23/19-10/24/19 a review of Resident #1's clinical record and wound records was conducted. A nursing note entry dated 3/25/19 read, CNA notified nurse of open area to right neck crevice, nurse assessed area. Area is red with no discolorations noted. Area cleaned and tx initiated. MD and RP aware. The wound evaluation flow sheet identified the area as an abrasion. On 4/4/19, Employee F, the wound specialist physician identified the area as a stage III pressure wound. On 5/23/19, Employee F indicated the right chest wound was now a stage IV wound. This wound eventually healed on 10/10/19. On 10/24/19 a review of Resident #1's careplan revealed that facility staff initiated a careplan focus for the Stage IV pressure wound to the right chest area and indicated resident is mostly bed bound and contracted. The careplan further revealed that Resident #1 was totally dependent on staff for turning, positioning and pressure relief. On 10/24/19 a review of the ADL (activities of daily living) documentation from May-Oct. 2019 was reviewed. It revealed that Resident #1 was totally dependent upon nursing staff for all movement and pressure relief. While the facility staff was aware that Resident #1 had contracture's, a referral was not made to Occupational Therapy (OT) until 5/28/19 for contracture management. The OT Plan of Care dated 5/28/19 read, referred to skilled OT services by nursing for neck contracture management. Pt (patient) has a wound over her right clavicle and has a tendency for lateral flexion of neck towards right side. On 10/24/19 Resident #1's clinical record revealed she was at high risk for development of pressure ulcers. MAR for (MONTH) 2019 revealed that Resident #1's weight on 3/20/19 was 78.8 lbs. MDS assessments completed for Resident #1 on 3/14/19, 6/12/19 and 8/6/19 all are coded to indicate she was always incontinent of bowel and bladder, was totally dependent upon staff for care, and had cognitive impairments; all which are factors in pressure ulcer development as per the facility policy. On 10/24/19 a request was made for all Braden scales completed for Resident #1. They are as follows: 10/21/15 score 21 (not at risk) 10/13/16 score 12 (high risk) 10/11/17 score 12 (high risk) 3/18/19 score 13 (moderate risk) On 10/24/19 at 1:50 PM an interview was conducted with Employee F, the wound care specialist physician and the DON in the conference room. Employee F was asked about Resident #1's wound to her shoulder, Employee F stated, it is starting to heal, it is an abscess and it is coming together. Employee F was asked, by Surveyor A you did a surgical debridement of the necrotic cap? It was not an incise and drain of an abscess, it was sharp debridement with a scalpel of dead, hard, black necrotic tissue, correct? Employee F stated, yes ma'am, a sharp bedside debridement was performed. On 10/24/19 at 4:29 PM an interview was conducted with LPN B asking about pressure relief and contracture management for Resident #1. LPN B stated Resident #1 has wedges between her legs when in and out of bed for pressure relief but nothing for her arms or neck that I know of. On 10/24/19 at approximately 4:35 PM an interview was conducted with CNA A and CNA B. Both CNA's stated they care for Resident #1. When asked about Resident #1 and wounds and contracture's CNA B stated, her arms and hands are contracted and one of her legs. Her hands have palm guards, we put pillows between her legs and turn her every 2 hours. When asked if Resident #1 can move her neck and head, CNA A stated, She moves her head some. On 10/24/19 at approximately 4:40 PM CNA C was observed in the room with Resident #1. She moved Resident #1's gown so that both shoulders could be observed by the surveyor. There was no evidence of any devices or positioning devices to prevent the pressure or resting of her head/chin on her neck area. Resident #1 did not move during the observation. Review of the facility policy titled skin risk assessment: skin prevention and treatment protocol read on page 3, Part one: risk assessment/prevention: a. each admission or readmission of the resident will have a thorough head to toe skin assessment. This also includes a Braden scale assessment on admission, followed by one per week for 4 weeks; then quarterly. c. Determination of risk assessment for pressure ulcers, using the Braden Scale; in addition to using the input from Nutrition Risk assessment. This scale ensures systematic evaluation of individual risk factors. Factors which place a resident at risk for pressure ulcers: general physical condition (including poor nutrition), mental status, activity, mobility, incontinence, braden scale. This same policy stated on page 5: Prevention Protocol: Rehab screening upon admission and yearly according to the MDS schedule; and as needed. Review of the MDS schedule for Resident #1 revealed that on 3/14/19 an annual MDS had been completed but therapy had not been consulted until 5/28/19 after the development of and progression of the wound to a stage IV. Guidance is provided for the staging of pressure ulcers by the National Pressure Ulcer Advisory Panel (NPUAP), and is as follows; NPUAP announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury FOR IMMEDIATE RELEASE (MONTH) 13, (YEAR). Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant (fat) adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. Stage 4 Pressure Injury: If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness stage 4 pressure injury. Do not use (deep tissue pressure injury) DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. 10/24/19 at 5:14 PM during an end of day meeting, the facility administrator and DON were made aware of the facility staff's failure to provide care and treatment to prevent the development in pressure ulcers for Resident #1, resulting in HARM. No further information was provided. COMPLAINT DEFICIENCY.

Based on observation, staff interview, physician interview, facility documentation review, clinical record review, hospital record review, and in the course of a complaint investigation, the facility failed to provide timely notification to the Responsible party of pressure sores, and failed to notify the doctor timely of a worsening condition for one Resident (Resident #3) in a survey sample of 5 residents. The findings included: 1. For Resident #3 the facility staff failed to notify the Responsible party timely of pressure sores, and failed to notify the doctor timely of the Resident's change in condition on 10-23-19. Resident #3 was originally admitted to the facility on [DATE], and most recently readmitted [DATE]. [DIAGNOSES REDACTED]. Resident #3's most recent Minimum Data Set (MDS) assessment was a significant change full assessment for deterioration in cognitive status with an Assessment Reference Date (ARD) of 8-2-19. The MDS revealed that Resident #3 was coded on the most recent MDS with a Brief Interview of Mental Status score of 3 points out of 15 points possible, indicating severe cognitive impairment. The Resident required extensive to total assistance of one to two staff members with all activities of daily living (ADL's) including bed mobility and transferring. Resident #3 was coded as always incontinent of bowel and bladder. A clinical record review revealed Resident #3 had the following pressure sores: #1. One pressure ulcer identified at a stage 3, Right buttock/ Ischium, with tunneling and significant slough. #2. An unstageable wound was found with 80% necrotic tissue on 6-20-19, which was identified in the wound physician notes to the Right buttocks. The 2 wounds were distinctly different in location, description, and measurement. Physicians orders, Wound Specialist Physician's notes, and Primary care physician's notes, were reviewed on 10-23-19 and revealed the progression of the 2 (current to survey) pressure ulcers which were as follows, and are dated in chronological order; (Right buttock (site 1) ) 1. 5-30-19 (site 1) Right buttock pressure ulcer was first identified (ID) by Wound doctor shear wound right buttock for duration of at least 20 days, 100% thick adherent devitalized necrotic tissue. 4.7 cm (centimeters) long (L) x 3.8 cm wide (W) x 0.1 cm deep (D). The wound was surgically debrided at that time by cutting out 17.86 cm squared of dead tissue and dead subcutaneous fat to a depth of 0.2 cm. The treatment plan was for Santyl ointment (enzyme [MEDICATION NAME] ointment) and discontinue zinc moisture barrier ointment, then cover with a dry dressing, and the notes went on to state re-evaluation would occur in 7 days and the procedure was explained to the resident on this day. 2. 6-13-19 (site 1) was the next evaluation date, 2 weeks later. The wound was described as 4.6 cm (L) x 3.4 cm (W) x 0.1 cm (D) with 65% thick adherent devitalized necrotic tissue, and 35% granulation tissue. The wound doctor again debrided the wound surgically removing another 10.17cm squared of dead tissue and dead subcutaneous fat to a depth of 0.2 cm. and the note documented that the procedure was explained to the resident on 5-30-19. 3. 6-20-19 (site 1) was the next evaluation date, 1 week later. The wound was described as 7.2 cm (L) x 5.6 cm (W) x 0.1 cm (D) with 35% thick adherent devitalized necrotic tissue, and 35% granulation tissue, and 30% skin. The wound doctor again debrided the wound surgically removing another 14.11cm squared of dead tissue, dead subcutaneous fat, and surrounding connective tissues to a depth of 0.2 cm. and the note documented that the procedure was explained to the resident on 5-30-19. No changes were made to the treatment. At this evaluation on 6-20-19 a second wound on the right buttock (site 2) was identified as a shear wound first identified with 80% necrotic tissue. That wound will be described below. Right Buttock (re-classified as Right Ischium on 6-27-19 by wound doctor) Site 2 1. 6-20-19 first identification of the unstageable pressure sore. The wound was described as 5.5 cm (L) x 5.4 cm (W) x 2.5 cm (D) with 80% thick adherent devitalized necrotic tissue, and 20% granulation tissue. The wound doctor debrided the wound surgically removing 23.76 cm squared of dead tissue, dead muscle, and fascia fibers to a depth of 2.7 cm. and the note documented that the patient has been spending most of the day sitting up in his wheel chair while at PACE, now with stage 4 wound with odor, start Dakins (for 30 days) with crushed [MEDICATION NAME] (for 14 days)250 mg (milligrams) antibiotic. Cover with dry dressing. procedure was explained to the resident on 6-20-19. The Resident had not been to PACE since 5-31-19 (3 weeks) when this wound was identified. On 10-23-19 at 11:00 a.m., during wound care observation with LPN C and LPN D (Licensed Practical nurses, the Resident's brief was removed, and there was no dressing on the ischial wound. The brief was examined by the surveyor and nurses to be certain the dressing was not inside of it. They stated no, it's not there. The Resident's Right ischium measured 2.0 cm (L) x 2.3 cm (W) x 4.0 cm (D). The wound was a stage 4 ulcer with necrotic tissue and slough inside of the wound bed margins, and silver fascia and bone was visualized. There was also a 6.0 cm tunnel into the wound under the skin pointing toward the Resident's head at the 12 o'clock location. The wound had in it a moderate amount of foul smelling (spoiled milk odor) purulent (pus) drainage and stringy green and tan exudate. The second wound located on the upper right buttock resting just below the Iliac crest and lateral to the spine was an unstageable pressure ulcer measuring 7.0 cm (L) x 10.0 cm (W) with no depth able to be visualized. The wound bed could not be seen secondary to a yellow slough covered center, with the entire outer circumference of the wound being a complete border of 1.0 cm of hard black dead necrotic tissue. The nurse had just taken the Resident's vital signs to include temperature. The Resident was febrile (had a fever) with a temperature of 101.4. The Resident stated I don't feel good. in a soft panting voice. The nurse stated she had given the Resident Tylenol, and when she listened to the Resident's lungs, she could hear wheezing. When asked if she had contacted the Resident's doctor, she stated, No, they may come in and see him this evening, the Tylenol has not had time to work yet, I just gave it. The surveyor asked how an antibiotic or other treatment could be prescribed if a resident had an infected wound, which was indicated by some of the Resident's symptoms, and she responded I don't know. On 10-23-19 at 12:16 p.m., an interview was conducted with Resident #3's daughter. She stated that no one notified her of the wound until she started smelling a bad smell and called the PACE doctor to find out what the problem was. On 10-23-19 at 2:00 p.m., the nurse LPN C was asked again if the doctor had been contacted, and she stated no, but if they don't come in, I will have the next shift call them. 10-23-19 at 2:50 p.m., RN B (PACE nurse) was interviewed. RN B stated that she sees the Resident weekly, and he has had a significant decline since last week. The PACE nurse stated that the daughter was very involved with her father's care. RN B was asked if the Resident could be suffering from an infected wound, she stated no one had said anything to her about it, and that he didn't look bad like this last week. She went on to say that she only saw the Resident once per week, and if the staff had concerns they could call the doctor at PACE. She stated the only way they know what is going on with the Resident is if the facility calls them, as the Resident has not been to PACE in months, and she can't act as an intermediary between the facility and the doctor. That is for the facility to do. On 10-23-19 at 4:00 p.m., the DON was made aware of the Resident's symptoms and asked if the staff had notified the doctor. She stated she would look into it. At 6:00 p.m., the Resident was sent to the hospital at the request of the daughter. The facility staff did not notify the responsible party timely or fully of the numbers or severity of pressure ulcers for Resident #3. Further on 10-23-19 during an acute change in the Resident's condition, the facility staff failed to timely and fully notify the doctor of the fever and symptoms, and did not send the Resident to the hospital for evaluation until surveyors and the Responsible party insisted. On 10-24-19 at 5:14 p.m., during an end of day meeting, the facility administrator and DON were made aware of the facility staff's failure to timely notify the Responsible party and doctor of a worsening condition, and of pressure ulcer worsening for Resident #3. No further information was provided.

Based on observation, staff interview, physician interview, facility documentation review, clinical record review, hospital record review, and in the course of a complaint investigation, the facility failed to review and revise the care plan for the treatment of [REDACTED].#3, and #4) in a survey sample of 5 residents. The findings included: 1. For Resident #3 the facility staff failed to care plan treatments, supplements, assessment documentation for pressure ulcers. The 2 current pressure ulcers involved during survey were as follows; #1. One pressure ulcer identified at a stage 3, Right buttock/ Ischium, with tunneling and significant slough. #2. An unstageable wound was found with 80% necrotic tissue on 6-20-19, which was identified in the wound physician notes to the Right buttocks. The 2 wounds were distinctly different in location, description, and measurement. Resident #3 was originally admitted to the facility on [DATE], and most recently readmitted [DATE]. [DIAGNOSES REDACTED]. Resident #3's most recent Minimum Data Set (MDS) assessment was a significant change full assessment for deterioration in cognitive status with an Assessment Reference Date (ARD) of 8-2-19. The MDS revealed that Resident #3 was coded on the most recent MDS with a Brief Interview of Mental Status score of 3 points out of 15 points possible, indicating severe cognitive impairment. The Resident required extensive to total assistance of one to two staff members with all activities of daily living (ADL's) including bed mobility and transferring. Resident #3 was coded as always incontinent of bowel and bladder. General prevention orders prior to identification of the current 2 pressure ulcers remaining at the time of survey were as follows; 1. 1-23-19 - Air mattress for prevention. 2. 3-29-19 & 4-1-19 Triad [MEDICATION NAME] wound paste (ingredients; [MEDICATION NAME], cellulose gum, zinc oxide, dimethicone) to scrotum and right buttock topically every shift for wound care. Manufacturer instructions insist if no improvement or if condition worsens within 10 to 14 days, consult a physician or wound care specialist. The Resident's full care plan for 2019 was requested on 10-22-19, and received and reviewed on 10-23-19. The care plan revealed 4 torso wounds which healed, and were as follows; 1. Rash to groin & genitals - resolved - 1-21-19. 2. Shearing to right upper buttock - resolved on 3-26-19. (This was an old wound, and not the current upper right buttock identified later). 3. Wounds to scrotum - resolved - 5-29-19 4. Stage 3 pressure wound medial sacrum - resolved - 10-17-19 The care planned interventions for the 2 torso wounds which were acquired in the facility and did not resolve, were as follows; 1. Shearing right upper buttock - weekly skin assessments current/active added 3-29-19 (for old healed wound), and not removed. Wound to be followed by Vohra wound care current/active added late on 7-19-19. Administer medications as ordered current/active added for an earlier wound 4-26-19 and not removed. Keep skin clean and dry. Use lotion on dry skin (ordered for left leg). Apply barrier Zinc cream if needed current/active added 9-13-16 (for old healed wound) and not removed, even though the order was discontinued on 6-1-19. Check air pressure in air mattress current/active added 7-24-19 (after it was not functioning 7-9-19, and 7-10-19. The document reveals that it was revised on 10-22-19, however, there are no new interventions dated for this date. No treatments, assessments, or dressings were included nor updated in the care plan for this wound. Dakins solution, and normal saline were used to clean the wound, and santyl ointment was used as an enzymatic debridement agent. 2. Stage 3 pressure wound right ischium will show signs of resolve by the target date, Initiated late on 7-19-19. Initiated late on 7-19-19. Interventions were; - administer treatments as ordered and monitor for effectiveness. Assist to shift weight in wheel chair frequently when resident is up in wheel chair. The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. Wound to be followed by wound MD (doctor) until healed. And the final intervention was, resident has antibiotic therapy (crushed and sprinkled in the wound) initiated 10-11-19, and resolved 10-22-19. The antibiotic was ordered initially on 6-21-19, for 30 days, however, not added to the care plan until 10-11-19. No treatments, assessments, or dressings were included nor updated in the care plan for this wound. Dakins solution, and normal saline were used to clean the wound, and santyl ointment was used as an enzymatic debridement agent. There was no care planned interventions for the Sacrum identified 6-7-19, Left ischium identified 6-3-19, or the Inner right buttock identified 9-24-19. These 3 wounds received orders for treatment, however, no nursing wound assessments, or weekly skin evaluations were found for these wounds, and they were all healed by the time of survey. On 10-24-19 at 5:14 p.m., during an end of day meeting, the facility administrator and DON were made aware of the facility staff's failure to provide revised care planning to comprehensively prevent and treat the development of pressure ulcers for Resident #3. No further information was provided. 2. For Resident #4 the facility staff failed to review and revise care plan to reflect 3 pressure ulcers and an arterial ulcer that were identified and treated. Resident # 4, an [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/11/19 codes the Resident as having a BIMS (Brief Interview of Mental Status) score of 99 indicating unable complete the interview. The Resident is coded in Section C 1000 Cognitive skills for daily decision making as a 3 severely impaired - never/rarely made decisions. In section G the resident is coded as #4 Total Dependence on staff for bed mobility (turning and repositioning), transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene, with assistance of 2 person physical assist for any weight bearing activities and assist of 1 person physical assistance for eating, wheel chair mobility, and incontinence care. On 10/24/19 at 9:45 AM during clinical record review it was discovered that Resident #4 had 3 (three) pressure areas, excerpts from progress notes read: 6/15/19 10:11 AM - Open area was found by CNA this AM to L buttock. Triad Ointment applied per order until assessed by wound team RN supervisor was made aware. 6/17/19 14:29 (2:29 PM) - Skin reassessed r/t (related to) area to (L) buttock continue current TX (treatment) and interventions will continue to monitor. MD/RP (medical doctor/responsible party) updated. On 7/2/19 the Wound Evaluation Flow Sheet was initiated excerpts are as follows: Location: L (left) SACRUM - 7/2/19 - Wound status - Initial Assessment Current Preventative Measures Air Mattress - Current Treatment Santyl & Dry Dressing Stage-3 - Granulation Tissue 75% Slough 25% Measurements: L (length) 1.1cm (centimeters) x W (width) 1.1cm x D (depth) 0.1 cm A review of Resident #4's care plan revealed that for Focus Area of Risk for Pressure Ulcer development the Care plan was not updated to include the 3 pressure areas that developed in (MONTH) and (MONTH) of 2019 and the Arterial ulcer that developed on 9/12/19 and resolved on 9/19/19. Also according to the Nurses notes on 7/2/19 the resident had an air mattress however the care plan does not reflect the air mattress being initiated until 9/16/19. Excerpts from the care plan are as follows: F[NAME]US: (Resident name redacted) is at risk for pressure ulcer development r/t reduced physical function, left sided weakness. The resident requires extensive assistance of two staff members for bed mobility. Date Initiated 1/5/18 Revision on 2/22/19 GOAL: RESOLVED -Open area between 4th and 5th toe will heal- Initiated -6/18/18 resolved - 7/25/18 RESOLVED - Open area Right Great Toe - Date Initiated - 8/27/19 - Resolved 10/7/18 RESOLVED - The two open areas to the residents LEFT BUTT[NAME]K will resolve by target date. 12/11/19 DATE Initiated - 2/22/19 RESOLVED - 3/4/19 RESOLVED - Open area to Right Axilla - Date Initiated 5/19/19 Resolved - 6/18/19 RESOLVED - The resident will develop intact skin, free of redness, blisters, or discoloration through review date Date Initiated - 7/23/18 Resolved - 9/9/19 Air Mattress - Check for function every shift Date Initiated - 9/16/19 On 10/24/19 at approximately 11:00 AM the ADON was interviewed. The ADON was asked who updates the care plans with the new wounds and treatments? The ADON said, The MDS person updates the care plans, we take them the orders and they update the care plans based on the new orders. The ADON was asked how often should the care plan be updated she stated Quarterly and with any change in condition, or new treatment or new symptoms. On 9/24/19 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, resident interview, staff interview, facility documentation review, clinical record review and in the course of a complaint investigation, the facility failed to follow professional standards for 1 Resident (Resident #2) in a survey sample of 5 Residents. The findings included: 1. For Resident #2 the facility staff failed to follow professional nursing standards as evidenced by waiting extended periods of time, several days, before caring out physician orders. Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 9/3/19 was coded as a significant change assessment. Resident #2 was coded as having had a BIMS (brief interview for mental status) score of 3, which indicated severe cognitive impairments. Resident #2 was coded as total care with assistance of one staff members for ADL's (activities of daily living), which included transfers, locomotion, dressing, personal hygiene and bathing. On 10/23/19 and 10/24/19 during a review of the clinical record for Resident #2 it was revealed that in a wound evaluation & management summary note dated 8/29/19, the wound care specialist physician (Employee F) gave an order to discontinue [MEDICATION NAME] 250 mg. Review of Resident #2's Medication Administration Record [REDACTED]. Further review of the clinical record from 10/23/19-10/24/19 revealed that in a wound evaluation & management summary note dated 10/10/19, Employee F gave an order to discontinue Dakins Solution and Santyl, add [MEDICATION NAME] packing. Review of the Treatment Administration Record (TAR) for Resident #2 revealed that Resident #2 continued to receive the Dakins Solution and Santyl 12 occasions/days after the order had been discontinued (10/11-10/22) and the facility still had it listed as an active order at the time of survey. As of 10/23/19 the order for [MEDICATION NAME] had not been carried out. On 10/24/19 at 10:55 AM during an interview conducted in the conference room with surveyors B, C and D present, LPN A, (the wound nurse) and Employee C, (the assistant director of nursing (ADON) were asked if the wound care physician makes recommendations or gives orders. The ADON stated, he manages and drives the treatment of [REDACTED]. The ADON was asked if the wound care specialist gives an order does the Resident's attending physician have to approve the order before it is carried out, the ADON stated, no, when he gives an order we can implement it immediately. 10/24/19 at 1:50 PM the Director of Nursing (DON) and the wound care specialist physician (Employee F) came into conference room, in the presence of all surveyors (A, B C, and D) an interview was conducted. Employee F was asked if it is his expectation that wound care orders are to be followed, Employee F stated yes. The physician was asked in what time frame he expects his orders to be carried out and he stated, immediately if it is house stock or in the stat box, otherwise when it is available from the pharmacy. The DON stated the pharmacy has 2 hour turn around time. The facility DON cited Lippincott as their standard of nursing practice. Lippincott Manual of Nursing Practice eighth edition, states on page 18, box 2-3 Common Legal Claims for Departure from Standards of Care as failure to implement a physician order [REDACTED]. 10/24/19 at 5:14 PM during an end of day meeting, the facility administrator and DON were made aware of the facilities delay in carrying out physician orders. When asked about carrying out orders and the process, the facility Administrator stated, as soon as possible, the nurse transcribes order, orders the medication and when it is available they execute the order. No further information was provided.

Based on observation, staff interview, facility documentation, clinical record review, and in the course of a complaint investigation, the facility failed to prevent/identify, assess and treat pressure ulcers in a timely manner for three residents (Resident's #1, #28 and #15) in a survey sample of 32 residents, resulting in harm. 1. For Resident #1 the facility staff failed to identify timely, fully assess, and timely treat 2 pressure ulcers found at an unstageable state of development. They were the right hip found on [DATE], and the right heel found on [DATE]. 2. For Resident #28, the facility staff failed to implement preventative measures prior to and after the development of pressure ulcers. 3. For Resident #15, the facility staff failed to implement the use of a small pillow between the knees when in bed, a pressure reducing measure to prevent the development of pressure areas. The findings included: 1. Resident #1 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's most recent Minimum Data Set (MDS) assessment was a significant change full assessment with an Assessment Reference Date (ARD) of [DATE] revealed that Resident #1 was coded on the most recent MDS with a Brief Interview of Mental Status score of 0 points out of 15 points possible, indicating severe cognitive impairment. The Resident required extensive to total assistance of one staff member with all activities of daily living (ADL's) including bed mobility and transferring. The Resident was coded with no range of motion limitations on any of the four extremities. Resident #1 was always incontinent of bowel and bladder. This current assessment was compared to the former assessment with ARD of [DATE] which was also a significant change full assessment. Those assessments are as follows: The [DATE] assessment coded the Resident as at risk for development of pressure ulcers, and at area M0300 as having 1 current unstageable pressure ulcer described as suspected deep tissue injury in evolution. At area M0700 in the document, the wound was not described. No measurements of the wound dimensions was coded. This assessment was found to be coded incorrectly, as the Resident had 2 unstageable wounds identified as Right hip dark area sightly open deep tissue injury on [DATE], and Right heel grayish discoloration and blister deep tissue injury on [DATE]. At area M1200 No dressings or pressure ulcer care was coded, and no turning or repositioning program was coded. The [DATE] current MDS coded Resident #1 as at risk for development of pressure ulcers, and at area M0300 as having 2 current unstageable pressure ulcers slough and/or eschar: known but not stageable: Deep tissue. At area M0700 in the document, the wound was described as Eschar (black, brown, or tan necrotic, dead tissue) that adheres firmly to the wound bed or ulcer edges, and may be softer or harder than the surrounding skin. Measurements of the largest wound dimensions was coded and listed 2.2 cm (centimeters) in length x 3.0 cm in width, and no depth was recorded. At area M1200 No pressure ulcer care was coded, and no turning or repositioning program was coded. The application of dressings to feet was coded. The Resident's full care plan was reviewed on [DATE], and was dated [DATE]. The care plan had been reviewed and revised on [DATE], and [DATE]. No previous care plan could be found in the clinical record. LPN (Licensed Practical Nurse) A stated that she had taken part in the care planning process, and the care plans were written in the computer, and old care plans or copies of care plans were not at the nursing station and might be in the medical records department. The Don was asked to supply all care plans for Resident #1, and stated she would look into it. No further care plans were ever supplied during the survey for Resident #1. The care plan listed headings of "Problem": Ulcer/wound." included 2 pressure ulcer wounds listed as a stage 2 on right heel, and deep tissue injury right hip. The "Approaches" area, stated interventions and they are listed below; 1. Braden scale quarterly and as needed. 2. Provide wound care as ordered. 3. Overlay air mattress. Ordered [DATE] eleven days after the hip pressure sore was identified, and 1 day after the heel pressure ulcer was identified. 4. Heel protectors. 5. notify nurse of any skin changes. 6. Skin prep as ordered. Ordered [DATE] upon identification of right heel pressure ulcer. and Ordered [DATE] to right hip Deep tissue injury opened reddened area on the day of identification of the hip pressure ulcer and discontinued [DATE]. 7. Keep skin clean dry and moisturized, inspect skin every shift. 8. float heels off bed. 9. floater boot to right foot. 10. Provide ordered diet, RD consult, provide food supplement, encourage fluid intake, recommend supplements if needed. 11. check and change frequently, turn frequently. 12. pressure relieving device for chair. 13. Hipsters (padded pull up pants to protect hips) for added protection. Ordered [DATE]. 14. Barrier cream as needed. Ordered [DATE]. Physicians orders, Medication Administration Record [REDACTED] (General orders prior to identification of the two pressure ulcers) 1. [DATE] Skin assessment every Friday. 2. [DATE] Braden scale (skin breakdown risk assessment) Quarterly. To be done in May, August, November, and February, on the 4th Thursday, in the morning. 3. [DATE] Protective barrier cream to reddened buttocks daily in the morning. 4. [DATE] Multivitamin supplement had been ordered and was being administered. (Right Hip) 1. [DATE] Right hip pressure ulcer was first identified (ID) as deep tissue injury dark and slightly open with no drainage. 2. [DATE] Apply skin prep to right hip daily in the morning, discontinued [DATE]. 3. [DATE] Patient to use turning wedge in bed with position change every 2 hours. (ordered 2 days after ID) 4. [DATE] Overlay air mattress when in bed. (ordered 12 days after ID) 5. [DATE] Foam wedge when in chair for turning and repositioning. (ordered 12 days after ID) 6. [DATE] Foam wedge when in bed for turning and repositioning. (ordered 12 days after ID) 7. [DATE] Cleanse right hip with normal saline, apply santyl ointment & calcium alginate & cover with a dry dressing daily in the morning. This order was the only treatment order for the hip pressure ulcer, and had not been changed after this date and through survey [DATE]. 8. [DATE] Hipsters at all times for protection. (ordered 75 days after ID) 9. [DATE] Med pass supplement ensure plus 240 ml (milliliters) three times per day at 8:00 a.m., 1:00 p.m., and 6:00 p.m. (ordered 93 days after ID) (Right Heel) 1. [DATE] the Right Heel pressure ulcer was first identified as grayish color deep tissue injury with blister. Skin prep was ordered the same day to be applied every shift, three times per day. 2. [DATE] heel floater wedge when in bed. (ordered 1 day after ID) 3. [DATE] podus boot to right foot at all times. (ordered 1 day after ID) 4. [DATE] Float heels off of bed. (ordered 3 days after ID) 5. [DATE] Wear heel booties to float heels. (ordered 3 days after ID) 5. [DATE] Clean right inner heel with normal saline & Apply skin prep cover with calcium alginate dressing & dry dressing daily in the morning. Discontinued [DATE]. 6. [DATE] Clean right inner heel with normal saline & Apply skin prep cover with Silver alginate dressing & dry dressing daily in the morning. Discontinued [DATE]. 7. [DATE] Clean right inner heel with normal saline & Apply Santyl ointment cover with Silver alginate dressing & dry dressing daily in the morning. This order had not been changed after this date and through survey [DATE]. The Assessment, Treatment and Medication orders that were not documented as completed are as follows; 1. Full body & Skin Assessments weekly on Friday were not completed on the right hip ulcer on; [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 2. Full body & Skin Assessments weekly on Friday were not completed on the right heel ulcer on; [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 3. Braden scale (skin breakdown risk assessment) Quarterly. To be done in May, August, November, and February, on the 4th Thursday, in the morning, had only been completed after identification of the 2 pressure ulcers on [DATE], and was rated a "16" with ,[DATE] being at risk. None was found in the clinical record after the [DATE] assessment until the [DATE] assessment, and LPN A stated she could not find any others, and none had been completed in August. 4. The only preventive measures put into place to avoid skin breakdown were a protective cream once per day to the buttocks, skin assessments, Braden scales, and a multivitamin for nutrition. 5. Med pass supplement for healing ensure plus 240 ml (milliliters) three times per day at 8:00 a.m., 1:00 p.m., and 6:00 p.m., was not ordered until [DATE] . (ordered 93 days after identification, ID) 6. Treatments to the right hip and right heel ulcer, were not documented as completed on [DATE] (right hip), [DATE], [DATE], [DATE] (right heel), [DATE] (right heel and right hip), [DATE] (right heel and right hip), [DATE] (right heel), [DATE] right heel and right hip). 7. heel booties & podus boot, bed wedge, heel floater wedge, were not documented as completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and the heel booties, bed wedge, and heel floater wedge were absent prior to and during wound care observation on [DATE]. Weights were documented during this time and were; [DATE] - (148.6 lbs) pounds, [DATE] - (146.9 lbs), [DATE] - (134.7 lbs), [DATE] - (128 lbs) denoting significant weight loss during the time Resident #1's skin breakdown was occurring. RD notes from June, July, and [DATE], and care plan notes dated [DATE] stated that Resident #1 complains of hunger, likely dementia related, significant weight loss, and Med pass supplement for healing ensure plus 240 ml (milliliters) three times per day at 8:00 a.m., 1:00 p.m., and 6:00 p.m. This supplement was not ordered until [DATE] which was 93 days after identifying the pressure ulcers, and approximately 2 months after identifying significant weight loss, however the doctor and family did not want aggressive weight loss intervention. On [DATE] the Resident was seen by a wound specialty group who documented the wound at deep tissue injury to the right hip and dark purple/red, and recommended a mattress overlay to reduce pressure, was not received by the Resident until [DATE] and 11 days later. Resident #1 was seen again on [DATE] with no order changes, and again on [DATE] which noted a new area to the right heel. The Resident was seen again on [DATE], [DATE], and [DATE] for evaluation, and then no further records exist for specialty evaluation. Measurements from those visits are as follows; [DATE] DTI (deep tissue injury) Right hip 1.0 x 1.5 cm (centimeters) [DATE] DTI Right hip 1.3 x 1.0 cm [DATE] DTI Right hip 1.2 x 1.2 cm, and Brown/Red flat blister Right heel 4.5 x 4.5 cm. [DATE] DTI Right hip 1.0 x 1.0 cm, and Brown/Red flat blister Right heel 6.0 x 5.5 cm. [DATE] DTI Right hip 1.0 x 0.5 cm, and Brown/Red flat blister Right heel 6.0 x 5.5 cm. [DATE] No measurements given. The following measurements were documented in the weekly wound tracking record. [DATE] right heel 5.0 x 5.5 cm, right hip 1.5 x 1.7 cm. [DATE] right heel 4.8 x 4.0 cm, right hip 1.5 x 2.0 cm. [DATE] right heel 4.8 x 4.0 cm, right hip 2.2 x 2.4 cm. [DATE] right heel 1.5 x 2.5 cm, right hip 1.8 x 2.4 cm. [DATE] right heel 4.0 x 4.0 cm, right hip 1.5 x 2.0 cm. [DATE] right heel 5.5 x 5.0 cm, right hip 2.5 x 2.5 cm. [DATE] right heel 1.5 x 2.0 cm, right hip 2.0 x 3.0 cm. On [DATE] during wound care observation the right heel measured 1.5 x 2.5 cm x 0.5 cm deep, the right hip measured 2.3 x 3.3 cm x 1.0 cm deep. No depth of the wounds was recorded during any of the previous assessments, until this observation was made with RN A. On [DATE] Wound care observation was undertaken with the wound care nurse RN A, which included an interview with wound nurse during wound care observation. RN A stated that skin assessments are performed weekly on Fridays for full body and current wounds, and are documented in the nursing notes, and the weekly skin assessment document. She also stated she had been busy and sometimes had to do late entries, even if they were not done on Fridays, they usually get done once a week, and the CNA's (certified nursing assistants) see the residents every day. The observation revealed large black hard eschar dead tissue, around the center of the right interior aspect medial heel on the plantar surface with tan soft slough dead tissue around the edges and foul smelling, tan pus like drainage. The right hip wound was deep with silver fascia covering the bone visible at the joint, with slough and black necrotic tissue also visible around the inside of the wound which also exhibited foul smelling thick tan pus like drainage. RN A was asked if a culture of the wound had been obtained to diagnose infection, and the response was that the doctors did not do that very often. The surveyor asked how an antibiotic or other treatment could be prescribed if a resident had an infected wound without testing, and she responded "I don't know". RN A was asked what the wounds looked like when they were found, and the response was "I don't remember." The DON was asked for wound policies used for the facility, and she delivered a copy. On [DATE] a review was conducted of Facility policy and procedure guidelines for "Skin Risk Assessment: Skin Prevention and treatment Protocol" policy. Review of these documents revealed the facility followed guidelines that are according to and provided by the European Pressure Ulcer Advisory Panel & the National Pressure Ulcer Advisory Panel 2009 (NPUAP), with nursing best practice. On [DATE] at 4:00 p.m. The Director of Nursing (DON) stated during interview that nurses are expected to look at the staging information to make sure wounds are staged correctly and treated appropriately. She stated that the protocol guidelines are always available, that tell them how to stage. She further stated that if nurses did not document the assessments or treatments appropriately they were considered not done. The Director of Nursing and Administrator were asked for the pressure ulcer prevention care plan if any, and any other documents related to Resident #1's skin to show how these pressure ulcers were unavoidable at the end of day meeting on [DATE] at 4:30 p.m.. No further documents were provided on [DATE], and the Administrator and DON were made aware of the harm level findings on [DATE], and [DATE]. Guidance provided at www.NPUAP.com: The article "Prevention of ulcers in an orthopedic unit", from Nursing Times .net, [DATE], stated, "Although tissue breakdown is a complex multifactorial process, the focus with pressure ulcer development is on extrinsic factors such as pressure, shear and friction, with the most plausible explanation being the failure to relieve pressure. While many advances, such as pressure-relieving mattresses and beds, have greatly reduced the incidence of sacral ulcers (Blasczczyk et al, 1998). Krasner (1987) recognized that, even with pressure reduction, most support surfaces do not adequately relieve pressure. The NPUAP (National Pressure Ulcer Advisory Panel) advises "Use devices that eliminate pressure. The issues with Resident #1's right hip and right heel pressure wounds, include lack of an adequate measurable pressure ulcer prevention care plan, lack of preventive assessment and treatment, late identification, late timing and omission of interventions and treatments to the avoidable wounds. Assessment and treatment were instituted, only after development of un-stageable deep tissue injuries resulting in 2 pressure ulcers. The right hip pressure ulcer was identified on [DATE] and no preventive plan was put into place for further skin breakdown even after skin breakdown of the right hip had occurred, which resulted in a second pressure ulcer developing on the right heel on [DATE]. Findings were reviewed with The DON and Administrator at end of day debrief on [DATE], and [DATE], denoting a harm level finding and complaint deficiency. The administration presented no further information. 2. For Resident #28, the facility staff failed to implement preventative measures prior to and after the development of pressure ulcers. Resident #28, a female, was admitted to the facility [DATE]. Her [DIAGNOSES REDACTED]. Resident #28 expired at the facility [DATE]. Resident #28's most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] was coded as a quarterly assessment. She was coded as having short and long term memory deficits and required total assistance with making daily life decisions. Resident #28 was also coded as requiring total assistance of one staff member to perform her activities of daily living. Resident #28 was coded as having one stage II, one stage IV, and one unable to stage pressure ulcer. Additionally she was coded as having three DTI (deep tissue injuries). The NPUAP (National Pressure Ulcer Advisory Panel) defines pressure ulcers: "Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. Category/Stage IV: Full thickness tissue lossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Additional Categories/Stages for the USA Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as " the body ' s natural (biological) cover " and should not be removed. Suspected Deep Tissue Injury - depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment." Review of Resident #28's clinical record revealed she had required hospitalization after experiencing a fall at the facility. Upon returning to the facility [DATE], Resident #28 was documented as having a Stage II pressure ulcer on her coccyx. No new or updated care plan was developed until [DATE]. A Braden scale was completed on [DATE] which indicated Resident #28 was a high risk for the development of pressure ulcers. A Braden scale is a risk assessment tool utilized to determine if a Resident is at risk for the development of skin breakdown. At the time of her readmission to the facility, Resident #28 had a pressure reducing mattress on her bed. A pressure reducing mattress was the standard mattress utilized by all the Residents within the facility, with the exception of those Residents with specialty mattress such as a air mattress overlay or low loss air mattress. By [DATE] Resident #28's Stage II pressure ulcer on her sacrum had deteriorated to requiring a change of treatment that included the use of Santyl ointment for [MEDICATION NAME]. Review of the wound tracking documentation revealed that by [DATE] Resident #28 had developed an area on her right heel that was described: "right heel with a dry black eschar approx 3.0 cm (centimeter) oblong..no drainage..no redness to surrounding tissue. top of right toe with 2.0 fluid filled blister and reddened areas on both side of right foot. podus boots on in bed..right foot inward contracted...will assess again in am with wound team and rehab specialist about boots." The note was written by RN (Registered Nurse) A, the wound care specialist. On [DATE] Resident #28 was noted to have developed an area on her right great toe, with an "open area below the joint." On [DATE] an abrasion was noted below the right great toe, with darkened areas on right little and fourth toe. On [DATE], "the coccyx wound unable to stage was 2 x 1.5 cm (centimeters) yellow, shallow, with a dipped out appearance. Her left inner thigh DTI is scabbed and healed now, her right heel is 3 x 3 cm, dry black eschar, unable to stage and the side of right pinky toe is red stg (stage) 1 and measuring 1 x 0.3 cm., her right great toe (top) dry blister is 1 x 1.5 cm smaller, and the right side of her foot is 3.5 x 3.0 cm darker near 5th toe, unable to stage with dry black eschar, soft padded egg crate podus boot to be worn daily due to contraction in her foot, on air mattress (overlay), left hip surgical site was clean and healed, pressure relief is our goal for wound healing and encouraging po (by mouth) intake." Review of a care plan developed on [DATE], included the following interventions for the prevention of pressure ulcers: "Nurses-Weekly skin assessments and as needed, Assess nutrition, Refer to dietitian (as needed), Keep MD (Medical Doctor) informed, Follow medical plan for treatment, TEDs (socks used to prevent the development of blood clots), if ordered, special mattress if ordered, observe for signs of [MEDICAL CONDITION] ([MEDICAL CONDITION] such as continued [MEDICAL CONDITION], redness and or warmth of extremity, shortness of breath. Report to MD as needed. Nurse Aide-Keep skin clean and dry, Encourage and assist to reposition. Call System with in reach, Inspect skin every shift, Report changes, encourage at meal times." Resident #28 was referred to hospice services on [DATE]. A hospice referral was made and Resident #28 was opened to hospice care. While a recommendation from the wound team included the use of an air mattress on [DATE], no specialty mattress was implemented until [DATE] when an order was written for Resident #28 to utilize an "Over lay air mattress." An over lay air mattress is a vinyl air mattress that lies on top of the mattress, with alternating air pressure being pumped throughout the mattress. By the time the over lay air mattress was ordered, Resident #28 had been at the facility 6 weeks without any specialty mattress intervention. On [DATE] in addition to the previous documented areas, Resident #28 was documented as having an area "right side of her foot just beside and under the right pinky toe is 3.5 x 2.5 cm is black hard and unable to stage." The note included that Resident #28 was wearing soft crated bootie to right foot. While Resident #28's sacral wound had deteriorated from her admission on [DATE] to [DATE], to include the use of Santyl. After [DATE], no change in wound care occurred until [DATE] when her wound care changed to include, "cleanse sacral wound twice daily with ,[DATE] Dakins apply Santyl ointment, pack with Alginate, cover with dry dressing twice daily." [DATE], a physician's orders [REDACTED]." By the time the positioning devices were implemented, Resident #28 had been at the facility nine weeks with the deterioration of her sacral pressure from a Stage II (on admission) to an unable to stage. [DATE]. Resident #28's wound care team documented, "Noted sacral wound is 7.5 x 6.0 x 1.3 cm all clean red tissue with loose edges and undermining from 12 oclock 1.5 cm 9 oclock 2.5 and 6 oclock 2.0 and 3 oclock 2.5 cm" An order was initiated to apply a bed cradle to the bed. A bed cradle is a device that is designed to keep the bed covers from lying on the skin of the legs and feet. By this time Resident #28 had developed all the places on her feet and legs since her admission on [DATE]. [DATE], Resident #28 was noted to have a reddened area on her left hip and by [DATE] she was documented as having an open area on that let hip. A cushion dressing was applied to both hips for protection. Resident #28 continued to be treated for [REDACTED]. No low loss air mattress was recommended until an order was noted, [DATE], "Hospice to provide alternating mattress." By [DATE], Resident #28 had developed an area behind her left knee and thigh that required the use of skin prep. When interviewed, RN A, the wound care nurse, stated [DATE] at 11:06 a.m., an alternating air mattress was a "better" mattress than an overlay air mattress, providing more movement of the air. RN A stated that when a "decline" or Residents are determined to be "frail" an overlay mattress would be recommended. RN A further stated "Once hospice comes in, they provide an alternating air mattress." RN A was unable to state why an overlay air mattress was not recommended before [DATE] for Resident #28 after her sacral wound deteriorated. She also stated she did not know why an alternating air mattress was not recommended until February, 2014. Guidance was provided in "Pressure Ulcer Treatment, DHHS, p. 9: The goal of tissue load management is to create an environment that enhances soft tissue viability and promotes healing of the pressure ulcer(s). The term "tissue load" refers to the distribution of pressure, friction and shear on the tissue. The interventions are designed to decrease the magnitude of tissue load and provide levels of moisture and temperature that support tissue health and growth. Tissue load management can be achieved through the vigilant use of proper positioning techniques and support surfaces whether the individual is in in bed or sitting in a chair. While in Bed Positioning techniques and the support surfaces for patients in bed are important factors in the management of tissue loads. Staying off the ulcer. Avoid positioning patients on a pressure ulcer. Positioning devices. Use positioning devices to raise a pressure ulcer off the support surface. Positioning at-risk patients. Assess all patients to determine their risk of developing additional pressure ulcers. For those individuals who remain at risk, institute the following measures recommended in Pressure Ulcers in Adults... Avoid positioning immobile individuals directly on their trochanters and use devices such as pillows and foam wedges that totally relieve pressure on the heels, most commonly by raising the heels off the bed. Use positioning devices such as pillows or foam to prevent direct contact between bony prominences (such as knees or ankles). Maintain the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions. Support Services When one is selecting a support surface for a patient, the primary concern should be the therapeutic benefit associated with the product. A variety of support surfaces have been shown to provide an environment in which pressure ulcers improve, but there is no compelling evidence that one support surface consistently performs better than all others, under all circumstances. Therefore, the caregiver should consider a variety of factors when selecting a support surface, including the clinical condition of the patient, the characteristics of the care setting and the characteristics of the support service. The support surface should match the clinical condition and needs of the patient. Indications for dynamic support surfaces. Use a dynamic support surface if (1) the patient cannot assume a variety of position without bearing weight on a pressure ulcer, (2) the patient fully compresses the static support surface, or (3) the pressure ulcer does not show evidence of healing within 2 to 4 weeks. Indications for low-air-loss and air-fluidized beds. If a patient has large Stage III or Stage IV pressure ulcers on multiple turning surfaces, a low-air-loss bed or an air-fluidized bed may be indicated." While documentation was evident of Resident #28's decline from her admission on [DATE], no proactive preventative interventions were developed in a timely manner for the prevention of pressure ulcers on Resident #28's feet nor to enhance healing of her sacral pressure ulcer. The administrator and DON were informed of the failure of the staff to develop and provide preventative measures in an effort to prevent and assist with healing of pressure ulcers for Resident #28, [DATE] at 12:45 p.m. The administrator and DON (Director of Nursing) both stated they had not been at the facility during the time in question. COMPLAINT DEFICIENCY 3. For Resident #15, the facility staff failed to implement the use of small pillow between the knees when in bed, a pressure reducing measure to prevent the development of pressure areas. Resident #15, a female, was initially admitted to the facility [DATE] and readmitted after a hospitalization [DATE]. Her [DIAGNOSES REDACTED]. Resident #15's most recent MDS with an ARD of [DATE] was coded as a quarterly assessment. She was coded as having short and long term memory deficits and required total assistance with making daily life decisions. Resident #15 was coded as requiring extensive assistance of one person for her activities of daily living. Resident #15 was coded as being at risk for the development of pressure ulcers. Resident #15 was observed [DATE] at 8:06 a.m., 9:30 a.m., and 10:30 a.m., lying on her back in bed. Her bed was in the lowest position and a fall mat was observed beside her bed. An air overlay was observed on her bed, however was deflated. At all of the observations, Resident #15's right leg was observed to be contracted. No positioning devices or pillow was observed between her knees. Resident #15 was also observed ,[DATE] at 7:58 a.m. She was again lying on her back in bed. No pillow was observed between her knees. The air mattress overlay was noted to be functioning and was inflated. LPN (licensed practical nurse) C, the nurse assisting Resident #15 was informed of the lack of a pillow between her knees. LPN C said [DATE] at 8:02 a.m., a pillow was supposed to be between her knees at all times when she was in bed. LPN C and LPN B entered Resident #15's bedroom and looked for the pillow. No pillow was found and LPN B left the room, returning shortly with a pillow. LPN B and LPN C positioned a pillow between Resident #28's knees. Review of Resident #15's clinical record revealed a signed physician's orders [REDACTED].

Based on observation, staff interview, facility documentation review, family interview, and clinical record review, the facility staff failed to provide adequate supervision for two Residents (Residents' #15 and #18) in a survey sample of 32 Residents to prevent harm during a transfer. 1. The facility staff transferred Resident #15 with a one person manual lift resulting in a fractured thumb and tibia/fibula. She had been assessed as requiring two person extensive assistance to transfer; and 2. For Resident #18, the facility staff failed to use a two person transfer on two different occasions resulting in skin tears and abrasions to the lower legs. The findings included: 1. The facility staff transferred Resident #15 with a one person manual lift resulting in a fractured thumb and tibia/fibula. She had been assessed as requiring two person extensive assistance to transfer. According to http://emedicine.medscape.com/article/ 4 The Tibia and fibula are the the lower leg bones. Resident #15, a female, was initially admitted to the facility 6/7/06 and readmitted after a hospitalization [DATE]. Her [DIAGNOSES REDACTED]. Resident #15's most recent MDS (minimum data set) with an ARD (Assessment Reference Date) of 8/20/14 was coded as a quarterly assessment. She was coded as having short and long term memory deficits and required total assistance with making daily life decisions. Resident #15 was coded as requiring extensive assistance of one person for her activities of daily living. Review of the MDS assessment in effect during November, 2013 revealed Resident #15 was a two person extensive assist for bed mobility and transfers. Resident #15 did not walk. No falls were coded. Review of Resident #15's clinical record revealed nursing note entries: "11/26/13 13:37 (1:37 p.m.) bruise right thumb/also noted swelling right palm/thumb Physician notified orders received continue to observe. 11/26/13 15:03 (3:03 p.m.) Noted right thumb swollen and bruised-tender to touch. Noted at 11:00 sitting in wheelchair when noted, bruising right dorsal hand/thumb Physician notified, orders received. Family notified." Documentation revealed the clinician ordered an X-ray of Resident #15 right hand. The X-ray was obtained at 1:53 p.m. and Resident #15 was determined to have "right thumb fracture." After talking with the family, the physician ordered for Resident #15 to be evaluated by therapy for "thumb splint." At 4:25 p.m., same day 11/26/13, Resident #15 was observed to have a large bruise on her right leg. The physician was again contacted and ordered for an X-ray of her right leg to be obtained. The X-ray was obtained at 5:52 p.m. and the X-ray reading included, "Strong suspicion for nondisplaced proximal tibial metaphysis fracture within marked limits due to contraction as described." A repeat X-ray of Resident #15's right knee obtained 11/27/14 at 5:58 p.m. revealed "Right tibia fracture, as described, also suspect fibular neck fracture." Again Resident #15's family was contacted and the decision was made to treat Resident #15 conservatively due to her health and comorbidities. A referral was made to therapy for an assessment, and pain management was initiated. The facility began an investigation into the injuries of unknown origin, her fractured tibia, fibula, and thumb. Review of the investigation revealed the CNA (certified nursing assistant) that cared for Resident #15 during the early morning hours of 11/16/13 had showered her. Review of the statement of the CNA included: "11/26/13 I have Miss (name) on 11-7 yesterday nite, I change her and reposition her by 12 olock, this morning by 5:30 am I transfer her from bed to wheelchair took her for shower remove her gown and put on I sweater on her then transfer her back to bed. I didn't hurt her or cause any bruises on her." The CNA was reinterviewed: 11/27/13 At 5:30 am I took shower chair to her room and position the shower chair close to the foot of the bed to transfer her to shower chair. I dangling the resident to the edge of the bed then transfer her to shower chair. I cover her with sheet and took her to shower room then remove her hospital gown then shower her, after that I dry her with a towel and used lotion on her body. I put sweater on her from weak arm to strong arm, I took her back to her room, then position the shower chair toward the head of the bed. put my arm under her armpit and transfer her to bed." The CNA was suspended and subsequently terminated when it was determined she had transferred Resident #15 by herself and not with another staff member as Resident #15 had been assessed as needing. Review of the care plan in effect at the time of the injuries indicated, "Is comfort care. She requires max assist with ADLs Bed Mobility transfers, eating toilet use-She is now DNR and no hospitalization . Nurses-Reorient as able, Note changes in functional level, comfort care no hospitalization Oral Care: dependent, Grooming Dependent, Bathing: dependent, Eating: Dependent, Toileting: Dependent, incontinence care Locomotion:Dependent, Transferring Dependent 1 assist 2 or more assist. Nurse Aide-Position correctly at meals. Call System within reach assist with all care and mobility, assist with feeding. Assist with turning & positioning as needed..." When interviewed, 10/1/14 at 3:15 p.m., the DON stated she would research and decide what the assistance level needed meant for transferring (Dependent 1 assist or 2 or more assist.) As of the end of the survey no further information was provided regarding Resident #15's assistance during November, 2013. The DON stated the CNAs have a sheet for each Resident that provides guidance for their needs, however the guidance that would have been in place during November, 2013 would have been updated since then. She said there was no way to know what guidance had been provided to the CNAs regarding Resident #15 needs during that period of time. During a family interview, Resident #15's daughter stated 10/1/14 at 11:50 a.m., she had been informed at the time of the injuries. Resident #15's daughter stated she had been informed that Resident #15 had been dropped by the CNA during her shower. A thorough review of the investigation done at the time revealed no information Resident #15 had been dropped by the CNA. The investigation did indicate the CNA had transferred Resident #15 from the bed to either her wheelchair or shower chair prior to the shower and back to bed after the shower by herself. Review of the nursing notes revealed no other injuries, falls, or unusual occupancies had occurred in the time period just before the identification of the tib/fib and thumb fracture. The administrator and DON were informed of the failure of the staff to perform a two person transfer for Resident #15, instead using one person transfer resulting in a tib/fib and thumb fracture, 10/2/14 at 12:45 p.m. The DON (director of nursing) nor administrator that were at the facility during the time of the injuries were no longer at the facility. The current DON provided the investigation and some educational sheets indicating after the injuries due to improper transferring technique, the staff received education for proper transferring of Residents. The sign in sheets indicated the education occurred in December, 2013. No further follow up, assessment of compliance or further Resident injuries had taken place. 2. For Resident #18, the facility staff failed to use a two person transfer on two different occasions resulting in skin tears and abrasions to the lower legs. Resident #18, a [AGE] year old, was most recently admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She used a motorized wheelchair. Resident #18's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 9/7/14. She was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. She required extensive assistance with her activities of daily living. For bed mobility and transfers, Resident #18 was coded as "3/3" meaning she required extensive assistance with a 2+ person physical assist. Resident #18's MDS with an ARD of 12/27/14 coded her bed mobility and transfer as "3/3" meaning she required extensive assistance with a 2+ person physical assist. A review of Resident #18's nursing notes revealed that she was improperly transferred on 3/3/14 and 8/6/14. The 3/3/14 note read "INCIDENT TYPE: skin tear resident sitting DATE OF INCIDENT: 3/2/14 TIME OF INCIDENT: 22:30 (10:30 p.m.) LOCATION: resident's room MENTAL STATE: normal for resident ACTIVITY AT THE TIME: in wheelchair: turning to go to bed with CNA assistance and bumped left chin EQUIPMENT INVOLVED: mechanical lift INJURY: skin tear (95) left anterior lower leg re-opened old skin tear FIRST AID: immediately applied, 2x2 area was cleaned with normal saline and bandaged POSSIBLE CAUSE: other: bumped lift while transferring to bed. STAFF INVOLVED: CNA (name) WITNESSES: (name) " The 8/6/14 note read : INCIDENT TYPE: abrasion left leg DATE OF INCIDENT: 8/6/14 TIME OF INCIDENT: 22:30 (10:30 p.m.) LOCATION: resident's room MENTAL STATE: normal for resident ACTIVITY AT THE TIME: transferring: to bed hit left leg on tray over wheelchair EQUIPMENT INVOLVED: other: tray over wheelchair INJURY: abrasion (91) left anterior lower FIRST AID: area was cleaned with normal saline and bandaged POSSIBLE CAUSE: during transfer to bed wheelchair tray hit left leg STAFF INVOLVED: none WITNESSES: staff (name)" On 10/2/14 at the end of day meeting, the transfers were reviewed with the Administrator and Director of Nursing (DON). They were notified that Resident #18 required a two person transfer and it appeared from the nursing notes that she was transferred by one staff during both incidents. They were asked to provide any investigation or incident reports regarding Resident #18's transfers. Resident #18 attended the group meeting held on 10/1/14. She felt that the facility did not have enough staff but did not indicate that she had any issues with transferring to and from her wheelchair. She was not available for interview on 10/2/14. No further information was provided from the facility regarding Resident #18's transfers.

Based on resident observation, staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed to provide staff supervision and an appropriate wander guard system which resulted in an elopement of one resident (Resident #3) of 32 residents in the survey sample. The elopement out of the facility resulted in a fall and a fracture of Resident #3's left upper arm (humerus). The findings included: Resident #3, a [AGE] year old female, was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #3's MDS assessment with an Assessment reference date of 12/29/2010 coded her with a Bim score of "03" which indicated severe cognitive impairment. She was coded at E0900 "Wandering - Presence and Frequency" with 1 (Behavior of this type occurred 1 to 3 days) of the look back period. For ambulation in her room she was coded as a 1/1 (requires supervision when walking with set up help only. For ambulation in the corridor on the unit, she was coded as a 3/2 indicating extensive assistance with one person physical assist. Before Resident #3 fell on [DATE], her MDS with an ARD date of 3/22/11 indicated that her Bim score was "04" meaning she had severe cognitive impairment. For ambulation in her room she was coded as a 1/1 indicating that she required supervision when walking with set up help only. Walking In the corridor she was coded as 3/3 requiring extensive assistance with two plus persons to assist. She was not coded with wandering behaviors during this look back period. Resident #3's most recent minimum data set (MDS) was a quarterly assessment with an assessment reference date of 9/1/11. She was coded with a Brief Interview of Mental Status (BIMS) score of "00" indicating severe cognitive impairment. She required assistance with her activities of daily living. For ambulation in her room she was coded as a 3/2 indicating that she required extensive assistance with a one person physical assist. For ambulation in corridor she was coded as 8/8 (activity did not occur). For locomotion on and off the unit, she was coded as 4/2, which is total dependence with one person assist. It was documented on the facility's form titled "The Facility Self Report Investigation" that Resident #3 eloped from the facility and fell outside on 6/4/11. The report does not indicate the time that the incident occurred. The facility was notified by a resident at the apartment building located behind the nursing facility that she had witnessed Resident #3 walking outside with her walker and fall on the sidewalk. The report read that a nursing supervisor responded to the Resident and 911 was called. Resident #3 was transferred to (Name of ) hospital via 911. It was documented in the facility's computerized incident tracking system that the incident occurred at 18:50 (6:50 P.M.). Resident #3 was discharged from the hospital with a left proximal humerus (upper arm) fracture on 6/9/11. Hospital orders included physical therapy and occupational therapy for two to three weeks to increase range of motion and medication to manage pain. LPN L, supervisor on shift at the time of the elopement, was interviewed on 10/13/11 at 5:57 p.m. After the call was received that Resident #3 was outside and had fallen, LPN L stated that she went outside to find Resident #3. LPN L stated that Resident #3 was on the ground when she got to her. She stated that Resident #3 would not speak to her but she did complain of pain. LPN L had staff call 911 at this time. LPN L stated that she remembered that the incident took place after dinner because Resident #3 was holding her dinner diet slip in her hand. LPN L stated that the Certified Nursing Assistants (CNAs) were cleaning dinner trays from the resident rooms during this time. LPN L completed a "Supervisor Investigation Form of Accident/ Incident" for Resident #3. LPN L documented that Resident #3 was last seen at 6:30 P.M. When asked if staffing was short handed that evening, LPN L stated that she felt staffing was normal that evening. When asked how she knew that Resident #3 wore a wander guard, LPN L stated that there was a list of Residents who wore wander guards located on the unit. The surveyor received information (QA Investigation/Root Cause form) from the facility concerning Resident #3 which had written that Resident #3 had a wander guard since 4/2010. On 10/13/11 at 10:04 a.m. ADM A, Director of Nursing, retraced Resident #3's possible elopement pathways with members of the survey team. ADM A stated that there were two paths that Resident #3 could have taken to get outside and end up at the place where she was found. The first was through the hallway doors located outside of Resident #3's room. Resident #3 lived in the last room at the end of one of the hallways on the Bermuda unit. When exiting Resident #3's room, a set of hallway doors was located on the left. These doors were operated by a large blue push button and were armed with wander guard sensors. Immediately to the left, past this set of doors was an exit door that lead to an outdoor courtyard. Because the exit door was very heavy and the courtyard was under construction on the date that Resident #3 eloped, ADM A did not believe that Resident #3 exited through this path. ADM A also stated that if Resident #3 exited into this courtyard she would have fallen there rather than in the spot where she was found. The second path was the one believed by ADM A to be the actual path that Resident #3 used to exit the facility. ADM A stated that Resident #3 was last observed by staff in the common area at the nursing station on Bermuda unit. This area was located at the other end of Resident #3's hallway, farthest away from her room. From the nursing station it was believed that Resident #3 passed through a set of open double doors that lead to another hallway on the Bermuda unit. Resident #3 was not observed leaving the unit and this doorway was not armed with wander guard sensors. This hallway led to an intersection of hallways joining the Cloverhill unit, Dale unit, the rehab department and the Bermuda unit. When Resident #3 reached this intersection, ADM A believed Resident #3 turned right and entered the rehab department through a set of open double doors. This doorway was not armed with wander guard sensors. ADM A believed that Resident #3 continued through the Rehab department to the unlocked emergency door at the left rear of the room. It was believed that she left the building through this door and followed the sidewalk until she fell . In total, Resident #3 would have passed through three doorways on this path, none of which were equipped with the wander guard sensors. ADM A stated that she also believed that this was the path that Resident #3 took because the resident at the apartment building that reported the fall stated that she observed Resident #3 walking from the direction of the rehab door. If Resident #3 had exited through the other set of doors near her room, the direction she would have walked would have been opposite from how it was reported from the witness. Other D, Certified Occupational Therapist Assistant, was working in the rehab department on the day that Resident #3 exited the facility. Other D was interviewed on 10/13/11 at 11:05 a.m. Other D stated that she had worked on Saturdays at the facility for about two years. She stated that on the Saturday of Resident #3's incident, there was also a restorative aide working in the Rehab department. Other D stated that on the weekend days it was common for her to provide therapy on the unit or in the Resident ' s room rather than bringing the Residents down to the therapy room. She stated that the restorative aide did the same. Other D stated that it was standard practice to leave the double doors to the rehab department open, even on the weekend when there was not always staff in the rehab room. She said the doors were left open because they were very heavy and hard for the Residents to open. She stated that there had never been any previous problem with the rehab doors open on the weekend. Other D stated that the door at the rear of the rehab room cannot lock from the inside as it is a fire door. It automatically locks from the outside. On the day that Resident #3 exited, Other D stated that she was working on the Bermuda unit (Resident #3's unit on the 1st floor) and on the 2nd floor. She stated that she never saw Resident #3 in the hallway or in the rehab room. She stated that it was possible that she was in a Resident room or on the 2nd floor when Resident #3 exited. Other D stated that she thought the incident occurred between 4 and 5 p.m. Other D stated that since Resident #3's incident the rehab entrance doors were kept closed and locked on the weekends. When asked how Resident #3 was walking prior to her fall, Other D stated that she was ambulating pretty good. The facility completed a review of Resident #3's elopement incident using the "QA Investigation/ Root Cause Form." It was documented on the form under the section labeled "Why?, Equipment" that the "wander guard system had also been malfunctioning this particular evening. The nursing supervisor and maintenance were notified. However, the doorway __________(Resident #3) exited was not alarmed anyhow." On 10/13/11 at 10:04 a.m., Other C, Maintenance Tech, tested the wander guard system in the presence of surveyors. The system functioned properly when tested . When asked how often the facility tested the wander guard system, Other C stated that it used to be tested weekly and now it was tested daily. When asked for the date on which testing went from weekly to daily, Other C stated that they started to test daily on 6/4/11, the day of Resident #3's incident. When asked how the wander guard bracelets were monitored once put on the Resident, Other C stated that checks were not performed once the bracelet was activated. Other C demonstrated how the bracelet was activated and the red light on the device that indicated activation. The wander guard service records were reviewed with Other B, Director of Plant Operations, on 10/13/11 at 10:45 a.m. The wander guard system was serviced by (name of company) . Other B provided service records. The system was serviced on 6/7/11 after the elopement of Resident #3 occurred. The 6/7/11 wander guard service receipt read as follows: "Wander guard in Bermuda- Bad panel- wiring." Other B stated that this was related to a device above the door rather than the actual sensors on the sides of the hallway. When asked if the system had any maintenance instructions, Other B flipped through the wander guard manual and stated no. On 10/13/11 at 10:04 a.m. ADM A stated that Resident #3 should be wearing her wander guard at all times. ADM A stated that Resident #3 wore the wander guard prior to her elopement on 6/4/11. When asked if Resident #3 was assessed for elopement or the use of a wander guard, ADM A stated that she must have been since she was wearing a wander guard. ADM A was asked to provide the assessment information. Two nursing notes were provided by ADM A regarding " why a wander guard was placed/ used." The first note dated 7/1/10 read, "abnormal behavior, resident anxious and confused. Walking the halls." The second note dated 8/26/10 read, "abnormal behavior, resident walking to exit door repeatedly and cursing the aids when they try to redirect resident." It was unclear when Resident #3 began wearing a wander guard. On 10/12/11 at 8:22 a.m. Resident #3 was observed in her room. She was in her night gown sitting in her wheel chair eating breakfast from a tray on the bedside table. She was not wearing her wander guard. It was on the night stand next to her bed. A review of Resident #3's clinical record revealed no documentation that she should or should not wear a wander guard. Her care plan prior to her elopement on 6/4/11 did not address elopement or the wander guard. Her care plan that was written after she returned to the facility from the hospital on [DATE] did not address elopement or the wander guard. On 10/13/11 at 10:03 a.m. ADM A was notified that Resident #3 was observed on 10/12/11 without wearing her wander guard. ADM A checked with LPN O, Bermuda unit nurse, regarding Resident #3's wander guard. On 10/13/11 at 10:24 a.m. LPN O stated that she changed the bracelet type on Resident #3's wander guard the previous evening (10/12/11) because she got it off at dinner. On 10/13/11 at 4:23 p.m. Resident #3's elopement and wander guard were discussed with ADM A and ADM B, Administrator. At this time ADM B was informed that Resident #3 was observed by surveyors not wearing her wander guard, that there was no evidence from her chart that she was or was not supposed to be wearing a wander guard and that elopement was not care planned prior to or after Resident #3's elopement. ADM A stated that the elopement should have been cared planned but it was not care planned. It was also reviewed with ADM A and ADM B at this time that Resident #3 obtained a fractured humerus (upper arm) as a result of her elopement. During the interview, ADM A and ADM B were asked how staff knew which Residents were supposed to be wearing wander guards. ADM A stated that the nursing staff pass this information to each other verbally because there was no way to document wander guard use in the electronic nurse charting system. ADM B stated that the units kept a paper wander guard record of the Residents who use wander guards. This surveyor stated that no nurse had provided a copy of the paper wander guard record or had mentioned the paper wander guard record existed. After the interview ADM B went out to the units to find the paper wander guard record. She found that the paper wander guard record was not being used on the Bermuda unit where Resident #3 resided. On 10/14/11 at 12:32 p.m. a copy of the paper wander guard record was reviewed with ADM A and ADM B. It was titled "Wander Guard Audit. " ADM A stated that the form was not being used for Resident #3. After Resident #3 returned to the facility, an order was written by the Nurse Practitioner on 6/10/11 to evaluate Resident #3 for placement on the Cloverhill unit, the locked unit at the facility, due to her history of exiting the facility. ADM D, Assistant Director of Nursing, stated that the assessment was not done because Resident #3 was discharged from the hospital and could not walk. She stated that Resident #3 will be assessed for the locked unit when she can walk again. The facility presented the following documentation: 1. Employees were inserviced regarding regulations and facility policies concerning elopement. 2. The facility's wander guard system would be tested daily to ensure all sensors were functioning properly. 3. The Rehabilitation Department would keep the internal entrance doors to the rehab department closed and locked on weekends unless a staff member was in the immediate area. Resident #3 was observed with the wander guard not applied. The resident's care plan was not updated concerning the wanderguard nor was there any documentation to determine if Resident #3 needed or should continue to wear the wanderguard. Also, the facility had no system of checking and then documenting to ensure that residents with wanderguards had functional wanderguards. Complaint Deficiency

Based on observation, facility record review, clinical record review, and staff interview, the facility staff failed to prevent an accident for 1 of 18 residents in the survey sample (Resident # 106). Facility staff failed to return Resident # 106's bed to the lowest position prior to leaving the resident's room. Subsequently, Resident #106 fell out of bed to the floor. The findings included: Resident # 106 was an [AGE] year old, originally admitted to the facility on [DATE]. The Minimum Data Set, with an Assessment Reference Date of 8/8/10, coded Resident # 106 as being severely cognitively impaired, in addition to having both short-term and long-term memory impairment. Resident # 106's [DIAGNOSES REDACTED]. A review was completed of Resident #106's clinical records on 11/10/10. A nurse's note dated 11/6/10 read "fall - observed on floor lying on right side facing bed, resident's head was bleeding. Time of incident: 11:30 A.M. She had fallen out of bed, the resident's bed was in the up position. First aid applied, transferred to the emergency room . Possible Cause: Climbed over side rail, staff involved- CNA #1." Resident #106 was transferred to (name of hospital). According to the Medical Center Report, no stitches were required, resident was given a "Tetanus vaccine and Bacitracin ointment was applied to posterior head laceration. No evidence of acute trauma." On 11/10/10 at 2:20 P.M., an interview was conducted with RN #1 - The Manager of Matocaca Unit. RN #1 stated, "CNA #1 was giving Resident #106 care, and left the bed in the highest position when she left the room for a few minutes. The CNA is being counseled, she was supposed to put the bed in the lowest position before leaving the resident's room." On 11/10/10 at 3:30 P.M. Resident #106 was observed lying in her bed on her right side, facing the wall. The bed was in the lowest position, and a floor mat was on the floor alongside the bed. On 11/10/10 at 3:30 P.M., an interview was conducted with the Director of Nursing (Admin. #1) who stated, "It is the best practice to put a bed in the lowest position when care is not being given at the time."