Every finding on record at Hebron Oaks

Based on interview, record review, and facility document and policy review, the facility failed to protect residents from potential further abuse by allowing an alleged abuser to return to the facility during an ongoing investigation of staff-to-resident abuse involving 1 (Resident #1) of 3 residents reviewed for abuse prohibition. On 10/09/2025 around 5:00 PM, Resident #1 was subjected to verbal and physical abuse from Registered Nurse (RN) A. RN A re-entered the facility on 10/11/2025, 10/12/2025, and 10/13/2025 during an ongoing investigation. This failure resulted in RN A having access to all residents of the facility during an ongoing investigation of an allegation of abuse. Findings included: A facility policy titled, Abuse, Neglect, Misappropriation, Mistreatment, and Exploitation Preventing, Investigating, and Mandatory Reporting Policy, updated on 08/25/2023, revealed, Residents will not be abused by anyone, including but not limited to [facility name] staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The policy continued, The first responsibility of the facility is to assure resident safety. In the event of an allegation of abuse, neglect, mistreatment, misappropriation of resident property, and exploitation made against a staff member, visitor, contractor, and/or family member, the facility shall take immediate steps to ensure the safety of the resident(s) and prevent the risk of future or further harm. Such steps shall minimally include: Suspension of the staff member until an investigation of the allegation is complete. An admission Record revealed the facility admitted Resident #1 on 10/02/2025. According to the admission Record, the resident had a medical history that included diagnoses of osteomyelitis of the vertebra of the lumbar region, discitis of the lumbar region, anxiety disorders, muscle weakness, and pain in the right thigh. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/08/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident rejected care one to three days during the assessment period. The MDS indicated the resident was dependent on staff assistance for toileting hygiene and for rolling to their left or right side. The MDS indicated that Resident #1 experienced frequent pain over the previous five days of the assessment period, which frequently affected sleep, frequently limited participation in therapy activities, and frequently limited day-to-day activities. Resident #1's Care Plan Report included a focus area initiated 10/10/2025 that indicated the resident had chronic pain to the bilateral hips related to arthritis and acute pain to the back related to lumbar osteomyelitis. Interventions directed staff to anticipate the resident's need for pain relief and respond immediately to any complaint of pain (initiated 10/15/2025). The Care Plan Report also included a focus area initiated 10/02/2025 that indicated the resident had activities of daily living (ADL) self-care deficit related to activity intolerance, limited mobility, and hospice services. Interventions directed staff to check and change the resident frequently (initiated 10/02/2025). An Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, submitted on 10/10/2025 at 11:00 AM by the Administrator (ADM), revealed that an allegation of abuse occurred on 10/09/2025 at 5:00 PM. Per the Report, Registered Nurse (RN) A was observed by the Interim Director of Nursing (IDON), telling Resident #1 you just need to knock it off or therapy will cut you and we will throw you out. The Report indicated that RN A had completed her shift, left the facility, and was suspended. An untitled, undated document provided by the facility revealed documented evidence that RN A clocked in at the facility after the alleged allegation of abuse, on 10/11/2025 from 5:55 AM to 11:55 AM; 10/12/2025 from 5:49 AM to 10:47 AM; and 10/13/2025 from 5:20 AM to 9:01 AM. During a telephone interview on 01/07/2026 at 11:42 PM, RN A stated she could not remember assisting Resident #1 with care on 10/09/2025 at any time during the shift. RN A stated the facility's Former Director of Nursing (FDON) left a message on her answering machine on 10/10/2025, and she tried to call the FDON back but was unable to reach her. RN A stated facility management never told her that she was suspended until 10/13/2025 around 9:00 AM while she was working on the 3rd floor. RN A stated she was called on 10/13/2025 around 3:00 AM by a night shift nurse and asked if she could come in to work, so she picked up a shift on that day from about 5:20 AM to 9:00 AM. RN A stated she saw the IDON and the ADM by the nurses' station on the 3rd floor, and the ADM told her that she was not supposed to be at the facility because she was suspended. RN A stated she was also at the facility on 10/11/2025 to return some keys and complete online computer training and came to the facility on [DATE] to complete online computer training. RN A stated she did not have contact with Resident #1 on 10/13/2025 because the resident was sent to the hospital on the prior shift. During a telephone interview on 01/08/2026 at 2:07 PM, the FDON stated the ADM would have typically been the person who informed the staff member that they were suspended, and RN A was difficult to reach because she did not have a cell phone or email. During an interview on 01/08/2026 at 9:58 AM, the IDON confirmed that RN A came to the facility the weekend following the incident to complete online computer training. During an interview on 01/08/2026 at 10:03 AM, the IDON stated that RN A was removed from the schedule following the incident on 10/09/2025, but RN A was not aware that she had been removed from the schedule. During a telephone interview on 01/08/2026 at 9:59 AM, the ADM stated he was not aware that RN A came to the facility to complete online computer training on 10/11/2025 and 10/12/2025. The ADM stated RN A was not authorized to come into the facility on [DATE] and work a shift. The ADM stated that he saw RN A on the 3rd floor on 10/13/2025 and told her she was suspended. The ADM stated that when a staff member was suspended, they did not have a way to suspend the staff member's timecard, and the rest of the facility staff would not be aware of the staff member's suspension. Facility did not put protections in place to after an allegation of abuse occurred with RN A involving R1.

Based on interview, record review and policy review, the facility failed to protect the resident's right to be free from verbal and physical abuse by a Registered Nurse (RN A). This failure affected 1 of 3 residents (R1) reviewed for abuse.Resident #1 was subjected to verbal and physical abuse on 10/09/2025, when Registered Nurse (RN) A verbally berated the resident and turned the resident onto their side against their will. This failure resulted in unnecessary pain and anxiety for the resident. Findings included: A facility policy titled, Abuse, Neglect, Misappropriation, Mistreatment, and Exploitation, Preventing, Investigating, and Mandatory Reporting Policy, updated on 08/25/2023, revealed, Residents will not be abused by anyone, including but not limited to [facility name] staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The policy revealed, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy continued, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled using technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. An admission Record revealed the facility admitted Resident #1 on 10/02/2025. According to the admission Record, the resident had a medical history that included diagnoses of osteomyelitis of the vertebra of the lumbar region, discitis of the lumbar region, anxiety disorders, muscle weakness, and pain in the right thigh. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/08/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident rejected care one to three days during the assessment period. The MDS indicated the resident was dependent on staff assistance for toileting hygiene and for rolling to their left or right side. The MDS indicated that Resident #1 experienced frequent pain over the previous five days of the assessment period, which frequently affected sleep, frequently limited participation in therapy activities, and frequently limited day-to-day activities. Resident #1's Care Plan Report included a focus area initiated 10/10/2025 that indicated the resident had chronic pain to the bilateral hips related to arthritis and acute pain to the back related to lumbar osteomyelitis. Interventions directed staff to anticipate the resident's need for pain relief and respond immediately to any complaint of pain (initiated 10/15/2025). The Care Plan Report also included a focus area initiated 10/02/2025 that indicated the resident had activities of daily living (ADL) self-care deficit related to activity intolerance, limited mobility, and hospice services. Interventions directed staff to check and change the resident frequently (initiated 10/02/2025). An Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, submitted on 10/10/2025 at 11:00 AM by the Administrator (ADM), revealed that an allegation of abuse occurred on 10/09/2025 at approximately 5:00 PM. Per the Report, RN A was observed by the Interim Director of Nursing (IDON), telling Resident #1 you just need to knock it off or therapy will cut you and we will throw you out. The Report indicated that RN A had completed her shift, left the facility, and was suspended. An email correspondence, titled Incident Report PM Shift 10/09/2025, dated 10/09/2025, sent to the former Director of Nursing (FDON) and IDON (interim Director of Nursing) from Certified Nursing Assistant (CNA) B revealed CNA B and CNA C entered the resident's room around 4:00 PM to assist Resident #1 with incontinence care and to change the resident's bedding. The document indicated Resident #1 was joking and laughing with the staff as they were washing the resident. CNA B informed Resident #1 that they needed to roll the resident over to change the resident's bedding and to clean the resident's back and buttocks. Per the document, CNA B and CNA C began to roll Resident #1, but Resident #1's back began to spasm, and the resident yelled out. The document revealed Resident #1 did not want to continue care at that time and needed a minute to recover. CNA B and CNA C reattempted to roll Resident #1, but the resident screamed again when the staff members touched the resident. The document revealed CNA B left to get the IDON for assistance in calming the resident down. CNA B spoke to the IDON and requested assistance. The document revealed RN A overheard the conversation between CNA B and the IDON and that RN A said Resident #1 could not refuse anymore and needed changed. Per the document, CNA B told RN A that she understood but could not force the resident to be changed. The document revealed RN A walked to Resident #1's room with CNA B following, and when they arrived in the resident's room, RN A started to lecture Resident #1. Per the document, RN A said, I am not doing this with you anymore, You need to be changed, repositioned, and up in your chair at least twice a day, and This isn't an option. Then RN A pulled Resident #1 over on their side and told CNA C to clean the resident. Resident #1 was pushing and screaming, and CNA B was holding the resident so the resident would not fall out of the bed, while CNA C assisted with cleaning Resident #1. Per the statement, Resident #1 continued to scream and push, while RN A continued to lecture the resident. The document revealed at that time, the IDON entered Resident #1's room and the staff members repositioned Resident #1 on their back but still needed to roll the resident to the other side to change the resident's bedding, absorbent pad, and incontinence brief. The document revealed that RN A pushed the resident to their other side and at that point stood over the resident and started pointing at the resident, stating, You need to knock this off or you are going to get cut from therapy and kicked out next week. An email correspondence, titled Incident 10/09/2025 PM Shift, dated 10/09/2025, sent to the former FDON and IDON from CNA C, revealed that around 4:00 PM, CNA B asked CNA C to assist her in changing Resident #1's incontinence brief and bedding. The document revealed that when CNA C entered Resident #1's room, CNA B had everything set up to perform incontinence care on the resident. They rolled Resident #1 toward CNA C, and the resident started to yell, Please put me back down. The document revealed CNA B and CNA C returned Resident #1 to a back lying position, and the resident did not want to roll again. After talking with the resident, CNA B and CNA C attempted to roll Resident #1 again, but when they touched the resident, she started to have another back spasm and yelled for the staff members not to touch the resident. The document revealed CNA B left Resident #1's room to get the IDON. Per the document, about a minute later, RN A entered the room yelling that the staff needed to change Resident #1, or the resident would never get better if the resident continued lying in bed. Per the document, RN A rolled Resident #1 to one side, at which point the IDON entered the room. The document indicated RN A rolled Resident #1 to their other side while CNA C placed a new fitted sheet and new brief under the resident and then they rolled the resident back onto their back. Per the document, RN A was leaning over the resident and pointing, stating I'm not going to keep doing this with you, you need to be getting out of the bed at least twice a day, and you need to knock this off or you're going to be cut from therapy and kicked out next week. Per the document, Resident #1 was crying, upset, and in pain the entire time. A typed employee statement from the IDON, dated 10/10/2025, revealed that on 10/9/2025 around 4:30 PM, CNA B and CNA C asked for assistance to convince Resident #1 that the resident needed incontinence care as the resident's brief was saturated. Per the statement, RN A entered the resident's room first, and the IDON followed a couple of minutes later. Per the statement, RN A told the resident, You need to knock it off. If you don't participate in therapy, they are going to cut you, and you'll be kicked out of here next week. The statement revealed Resident #1 was screaming and crying in pain, begging staff to leave them alone. The statement revealed that Resident #1 was changed and cleaned by staff and, after the staff left the room, the IDON stayed in the room and reassured Resident #1 that they would not be kicked out of the facility. During an interview on 01/05/2026 at 11:43 AM, CNA B stated she had worked at the facility for almost four years and was familiar with Resident #1's care. CNA B stated Resident #1 was dependent on staff assistance with most care and was incontinent of bowel and bladder. CNA B stated that Resident #1 was not physically resistive to care but verbally refused care often and required education and encouragement to have incontinence care provided. CNA B stated Resident #1 had a lot of anxiety and lower back pain and normally refused care due to concerns with pain. CNA B stated that on 10/09/2025, she approached Resident #1 and encouraged the resident to allow them to provide incontinence care to prevent further skin breakdown. CNA B stated she asked Resident #1 if they could get another staff member to speak to them, and the resident agreed. CNA B stated she went to get the IDON, who was familiar with Resident #1. CNA B stated that when she went to speak to the IDON, RN A stood up from a chair and told CNA B that Resident #1 needed to be changed and went to Resident #1's room. CNA B stated she followed RN A into Resident #1's room. She stated RN A yelled at Resident #1 and threatened to kick the resident out of the facility if they did not agree to be changed. CNA B stated the IDON entered the room at that time and RN A, without explaining anything to the resident, forcibly pulled Resident #1 onto their side, and the resident began screaming. CNA B stated RN A then told CNA C to clean the resident. CNA B stated that while Resident #1 was positioned on their side, RN A lectured the resident and told the resident she was sick of the resident refusing care. CNA B stated Resident #1 asked RN A to let the resident go, but RN A ignored the request and continued to yell at the resident. CNA B stated that Resident #1 was positioned on their side for eight to ten minutes while the IDON stood on the other side of the room. CNA B stated RN A forcibly rolled Resident #1 to the other side, and she and CNA C cleaned the resident, applied ointment, and applied a clean brief to the resident before positioning the resident on their back. CNA B stated that she, CNA C, and RN A left the room while the IDON stayed in the room to talk to the resident. CNA B stated she checked back in with Resident #1 three or four more times during the remainder of the shift, and the resident refused to allow staff to provide care for the rest of the shift. CNA B stated she left the facility at 10:30 PM when her shift ended. During an interview on 01/05/2026 at 3:26 PM, CNA C stated she had worked at the facility since July 2025 and was familiar with Resident #1. CNA C stated Resident #1 was in terrible pain when the resident first arrived at the facility and did not like rolling in the bed, so the resident usually allowed staff to provide incontinence care once a shift. CNA C stated that on 10/09/2025 around 4:00 PM, CNA B asked her to assist in encouraging Resident #1 to allow them to provide incontinence care. CNA C stated she entered Resident #1's room with CNA B, and the resident agreed to allow them to provide incontinence care, but when they attempted to roll the resident, the resident started screaming and wanted to be put down. CNA C stated that CNA B exited the resident's room to get the IDON while she stayed in the room and talked with the resident. CNA C stated RN A ran into Resident #1's room and started screaming at the resident, telling the resident that they were going to be kicked out of the facility if they did not allow staff to provide incontinence care. CNA C stated that CNA B entered the room while RN A continued to yell at the resident. CNA C stated that RN A rolled Resident #1 onto their side without getting the resident's permission to do so, while CNA B ran to the other side of the bed to ensure the resident was not rolled out of the bed. CNA C stated that RN A told her to hurry up and clean the resident, while the IDON stood in the room and observed the interaction. CNA C stated she left the resident's room after providing incontinence care to the resident. During an interview on 01/05/2026 at 4:28 PM, the IDON stated that Resident #1 was dependent on staff for most care, and the resident refused care often due to having a lot of anxiety and bilateral hip and back pain. The IDON stated Resident #1 was very fearful of rolling over in bed and always had to have someone to hold them during care. The IDON stated that on 10/09/2025 around 3:00 PM, she heard Resident #1 screaming. The IDON stated she remembered RN A was still at the facility and went to Resident #1's room. The IDON stated she went to Resident #1's room a couple of minutes later, and CNA B and CNA C were trying to convince Resident #1 to allow them to provide incontinence care. The IDON stated RN A, was bullying Resident #1 and told the resident they were going to get kicked out of the facility if they did not cooperate, and therapy would kick them out if the resident did not do what she (RN A) said. The IDON stated Resident #1 appeared very anxious at the time and later told her they did not like being told that they were going to be kicked out of the facility. The IDON stated she remembered seeing CNA B and CNA C on either side of the resident while RN A was in the resident's face and yelling at the resident but could not recall any other details regarding the incident. The IDON stated she left the room when the staff were turning the resident onto their side but went into the room following the incident to reassure the resident that they were not being kicked out of the facility. During a telephone interview on 01/07/2026 at 11:42 PM, RN A stated she had been working at the facility since August of 2022 and was familiar with Resident #1. RN A stated Resident #1 had bone pain due to an infection and was receiving intravenous antibiotic therapy. RN A stated Resident #1 was often resistant to care due to pain and did not like getting into the full body mechanical lift. RN A stated that pain was a major issue for Resident #1, and the resident cried in pain when staff had to turn them to provide care. RN A stated she had conversations with Resident #1 and the resident's family member regarding therapy services and the resident's progress with physical therapy because the resident refused to get out of bed and therapy was not progressing. RN A stated her goal was to keep Resident #1 motivated to participate in physical therapy because the resident's Medicare would only pay so much before the benefit ran out, and she was afraid that the resident wouldn't improve. RN A stated that on 10/09/2025 around 3:30 PM or 4:00 PM, a physical therapist told her that they were going to have a care conference the following day to discuss Resident #1's progress with physical therapy, and they were going to recommend that the resident's therapy be stopped due to lack of progress. RN A stated she was afraid that physical therapy was going to stop therapy, and she went into Resident #1's room to speak to the resident and try to motivate them to participate in therapy. RN A stated that no other staff members were in Resident #1's room when she went to speak with the resident. RN A stated that she explained to Resident #1 that a physical therapist spoke to her and explained that they might stop the resident's therapy due to lack of progress. RN A stated she could not remember if the resident responded, and she did not tell the resident that they had to participate in therapy to stay in the facility. RN A said she did not tell the resident they would be thrown out of the facility and reiterated to the resident what the physical therapist told her. RN A stated that she returned to the nurse's station, finished charting, and left the facility without any further conversation with the resident. RN A stated she could not remember assisting Resident #1 with care on 10/09/2025 at any time during the shift. RN A stated she left the faciity on [DATE] and did not think she did anything wrong. During a telephone interview on 01/08/2026 at 9:00 AM, the ADM stated that on 10/09/2025, RN A was attempting to assist with Resident #1 because the resident was resisting therapy, and RN A spoke very harshly to the resident, The ADM stated RN A then left Resident #1's room and the facility because her shift was over. The ADM stated they tried to notify RN A that she was suspended pending investigation, but the staff member did not have a cell phone or voicemail. The ADM stated that RN A was removed from the schedule, and a police report was filed. The ADM stated they discovered during the investigation that staff were trying to provide incontinence care for Resident #1 and the resident was crying out during the care, which alerted RN A to enter the room. The ADM stated that according to statements gathered from facility staff, RN A forced Resident #1 to receive incontinence care. During an interview on 01/08/2026 at 9:47 AM, the facility's Executive Director (ED) stated RN A should not have lectured Resident #1 or forced the resident to receive incontinence care against their will. During a telephone interview on 01/08/2026 at 9:50 AM, the ADM stated that RN A was terminated following the investigation. During an interview on 01/08/2026 at 9:58 AM, the ED stated that the facility substantiated the allegation of abuse.

Based on interview, record review, and facility document and policy review, the facility failed to report an allegation of abuse within the required timeframe for 1 (Resident #1) of 3 residents reviewed for abuse prohibition. Findings included: A facility policy titled, Abuse, Neglect, Misappropriation, Mistreatment, and Exploitation Preventing, Investigating, and Mandatory Reporting Policy, updated on 08/25/2023, revealed, All personnel, residents, family members, visitors, etc., are expected to report incidents of, or suspected incidents of, abuse, neglect, mistreatment, misappropriation of resident property, and exploitation. Such reports must be made immediately to the Administrator and may be made without fear of retaliation from the facility or its staff. If such incidents occur or are discovered after hours, the Administrator must still be notified. The facility will ensure that all allegations of abuse, including injuries of unknown source, neglect, mistreatment, misappropriation of resident property, and exploitation, are reported to DQA [The Department of Quality Assurance]. For allegations of abuse or serious bodily injury, immediately, but not later than 2 hours after the allegation is made. An admission Record revealed the facility admitted Resident #1 on 10/02/2025. According to the admission Record, the resident had a medical history that included diagnoses of osteomyelitis of the vertebra of the lumbar region, discitis of the lumbar region, anxiety disorders, muscle weakness, and pain in the right thigh. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/08/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident rejected care one to three days during the assessment period. The MDS indicated the resident was dependent on staff assistance for toileting hygiene and for rolling to their left or right side. The MDS indicated that Resident #1 experienced frequent pain over the previous five days of the assessment period, which frequently affected sleep, frequently limited participation in therapy activities, and frequently limited day-to-day activities. Resident #1's Care Plan Report included a focus area initiated 10/10/2025 that indicated the resident had chronic pain to the bilateral hips related to arthritis and acute pain to the back related to lumbar osteomyelitis. Interventions directed staff to anticipate the resident's need for pain relief and respond immediately to any complaint of pain (initiated 10/15/2025). The Care Plan Report also included a focus area initiated 10/02/2025 that indicated the resident had activities of daily living (ADL) self-care deficit related to activity intolerance, limited mobility, and hospice services. Interventions directed staff to check and change the resident frequently (initiated 10/02/2025). An Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, revealed that an allegation of abuse occurred on 10/09/2025 at 5:00 PM. The Report was signed as submitted by the Administrator (ADM) on 10/10/2025 at 11:00 AM (18 hours after the allegation of abuse). Per the Report, Registered Nurse (RN) A was observed by the Interim Director of Nursing (IDON), telling Resident #1 you just need to knock it off or therapy will cut you and we will throw you out. The Report indicated that RN A had completed her shift, left the facility, and was suspended. During a telephone interview on 01/08/2026 at 9:00 AM, the ADM stated that when made aware of an allegation of abuse, he reported the allegation immediately. The ADM stated that on 10/09/2025, RN A was attempting to assist with Resident #1 because the resident was resisting therapy, and RN A stated very harshly to the resident, You just need to knock it off or therapy will cut you and throw you out, which was upsetting to the resident. The ADM stated that RN A was removed from the schedule, and a police report was filed. The ADM stated they discovered during the investigation that staff were trying to provide incontinence care for Resident #1 and the resident was crying out during the care, which alerted RN A to enter the room. The ADM stated that according to statements gathered from facility staff, RN A forced Resident #1 to receive incontinence care. During a telephone interview on 01/08/2026 at 10:17 AM, the ADM stated he was informed of the allegation of abuse on 10/09/2025 and submitted the initial report on 10/10/2025. The ADM stated that since the allegation did not involve physical bodily injury, they reported the allegation within the 24-hour timeframe. The ADM stated the initial report for the allegation of abuse was not filed within two hours, and he was not aware that it was part of the facility's policy. During a telephone interview on 01/08/2026 at 2:07 PM, the facility's Former Director of Nursing (FDON) stated she was familiar with the incident that occurred involving Resident #1 on 10/09/2025. The FDON stated she could not remember all the details of the allegation, but she and the ADM were made aware of it during the morning meeting on 10/10/2025. The FDON stated she conducted verbal education with the IDON on the importance of reporting allegations of abuse immediately. During a telephone interview on 01/08/2026 at 2:39 PM, the ADM stated he expected facility staff to report any allegations of abuse to him right away.

Based on observation, interview, and record review, the facility did not ensure food was stored, prepared, and served in a safe and sanitary manner. This practice has the potential to affect all 42 residents who reside at the facility. Surveyor observed left over food items not properly covered, labeled, and expired. Surveyor observed walk in freezer to have a large puddle of water outside freezer, door sticking, and to the front left side of the freezer large chunks of ice covering boxes of food and left over food item. Surveyor observed cleanliness concerns in main kitchen. Surveyor observed staff in kitchen and kitchenette not wearing beard restraints.Surveyor observed staff wearing gloves, touching cabinets and door handles, and then directly touching food with same pair of gloves. During dishwashing Surveyor observed staff going from dirty to clean with no handwashing in between. Evidenced by: The facility policy, Food Storage, dated 3/22, states: . Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded.a. All freezer units will be kept clean and in good working conditions at all times.The facility policy, Oakwood Dining Appearance & Dress Code Policy, dated 1/25, states, in part: .All supervisors are charged with monitoring adherence to dress code for their department's staff.hair restraint when in kitchens.Beard or mustache restraint, if applicable.The facility policy, General Food Preparation and Handling, dated 3/25, states, in part: .The kitchen will be kept neat and orderly.Bare hands should never touch ready to eat raw food directly.Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods.The facility policy, Cleaning Dishes/ Dish Machine, dated 4/10, states, in part: .The person loading dirty dishes will not handle the clean dishes unless they wash hands thoroughly before moving from dirty to clean dishes. On 7/15/25 at 8:51AM, during initial walk through of kitchen, Surveyor observed left over food not properly stored. Surveyor observed left over rice uncovered, noodles uncovered, tuna salad use by 7/13/25, and chicken salad use by 7/14/25. Dining Service Manager C (DSM) indicated leftovers will be thrown out. DSM C indicated everyone is responsible for checking dates and throwing out items. On 7/15/25 at 8:51 AM, during initial walk through of kitchen, Surveyor observed a puddle of water outside of walk-in freezer. Surveyor observed door difficult to open, curtains of freezer to have ice chunks, ice on the floor of the freezer, and large chunks of ice on boxes of food to the front left of the freezer. Storeroom [NAME] E (SP) indicated she has reported this to maintenance a couple times now and this is an ongoing issue. DSM C indicated the boxes of food will be thrown out and food should not be served if it is covered in ice. On 7/15/25 at 8:51 AM, during initial walk through of kitchen, Surveyor observed food wrappers, food, and splatters of red substance in the walk-in refrigerator floor. SP E indicated all floors need to be swept and mopped daily. On 7/15/25 at 8:51 AM in main kitchen and 11:18 AM in kitchenette Surveyor observed kitchen staff to not be wearing beard restraints. On 7/15/25 at 11:14 AM, Surveyor observed Dietary Aid G (DA) prepping for lunch. Surveyor observed DA G wearing gloves, opening cabinets and refrigerator door, and then directly touching food with same pair of gloves on. On 7/16/25 at 9:31 AM, SP E indicated the walk-in freezer has been an issue for the last couple of months. SP E indicated she threw out some boxes of food because the food has ice on it. On 7/16/25 at 9:53 AM, Certified Dietary Manager D (CDM) indicated the walk-in freezer has been an ongoing issue. CDM D indicated they have put in a work order with maintenance, moved all boxes, and threw out some food items. CDM D indicated beard restraints should be worn in the kitchen and kitchenettes. CDM D indicated staff should not directly touch food with dirty gloves. CDM D indicated all left over food items should be covered, labeled and dated. CDM D indicated the kitchen does have cleaning schedules and expectations.On 7/16/25 at 2:03 PM, Surveyor observed dishwashing observation on 2nd floor. Surveyor observed Dietary Aide F (DA) loading dirty dishes, taking off gloves, and going directly to clean dishes without any handwashing. Surveyor observed this twice. Surveyor reviewed concern with DSM C. DSM C indicated staff should wash their hands when going from dirty to clean and typically there are two staff in the kitchen. DSM C translated this concern to Dietary Aide F (DA). Surveyor reviewed kitchen concerns with DSM C at 2:15 PM. DSM C indicated understanding. On 7/17/25 at 9:18 AM, Facilities Services Supervisor H (FSS) indicated he found out about the walk-in freezer this week. FSS H indicated the kitchen could have submitted a work order, but the person who reviews work orders has been out on vacation this week. FSS H indicated he does not recall knowing about the freezer prior to this week. Surveyor asked if FSS H would expect a phone call or to be notified immediately about freezer concerns. FSS H indicated his experience is with construction so he would consult with kitchen staff to determine the importance of freezer concerns. On 7/17/25 at 10:15 AM, Surveyor reviewed above concerns with Nursing Home Administrator A (NHA). NHA A indicated understanding. The facility did not ensure food was stored, prepared, and serviced in a safe and sanitary manner.

Based on interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. RN J‘s (Registered Nurse) background check information did not include an out of state criminal background check. Findings include:The facility policy, Abuse, Neglect, Misappropriation, Mistreatment, and Exploitation, Preventing, Investigating, and Mandatory Reporting Policy, updated 8/25/23, indicates, in part: .Procedure: (1) Screening Components: It is the policy of Oakwood Village to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license, and criminal background check. 1. Employee screening and training. a.iii. A complete caregiver background check always consists of the following documents: i. A completed F-82064 Background Information Disclosure (BID) form and Appendix F-82069: ii. A response from the Department of Justice (DOJ) Wisconsin Criminal History Record Request.iii. A Response to Caregiver Background Check letter from the Department of Health Services (DHS) that reports the person's administrative finding or licensing restriction status.v. Other documentation must be obtained by [Facility Name] when information is needed to complete the background check, such as other states' conviction records.d. A criminal background check will be conducted on all prospective employees as provided by [Facility Name] policy on criminal background checks.On 7/16/25, Surveyor reviewed RN J's (Registered Nurse) background check information provided by the facility. RN J's date of hire was 4/29/25. RN J's BID (Background Information Disclosure), completed on 4/28/25, indicated RN J had resided outside of Wisconsin within the last three years and listed an address in California. Surveyors were unable to find evidence in the information provided that an out-of-state criminal background check was completed for RN J.On 7/17/25 at 12:04 PM, Surveyor interviewed HRBP I (Human Resources Business Partner) who indicated the facility did not have the California background check and should have run it prior to RN J starting patient care.

Based on observation, interview, and record review, the facility did not ensure each resident receives cares, consistent with professional standards of practice to promote healing, prevent infection, and prevent new injuries from developing for 2 of 3 residents (R1 & R3) reviewed with pressure injuries or at risk for developing pressure injuries. R1 was admitted on [DATE], without a pressure injury. R1 developed three pressure injuries - two identified as Deep Tissue Injuries (DTIs; a type of pressure injury that occurs when prolonged pressure or shear forces damage the underlying soft tissues, such as muscle, fat, and tendons) and one Unstageable (a full thickness wound where the base of the injury is obscured by a layer of dead tissue called slough or eschar). R1 did not have all weekly wound assessments completed, wound vac treatments were not completely correctly, robust pressure injury preventions were not implemented until after development of the pressure injuries, R1 and wound deterioration occurred. When interviewed in February 2025, R1 stated, What I've had to live with since (the development of the PI's) has not been a pleasant experience. I wish it would never have happened. R3 admitted to the facility with a stage 4 pressure injury (a full thickness wound that exposes bone, muscle, or tendon) with osteomyelitis (a bone infection characterized by inflammation of the bone tissue). The facility did not complete weekly assessments and ensure that skin interventions were followed per standards of practice. R3's developed multiple wounds on his lower extremities and R3's sacral wound deteriorated and became infected. The facility's failure to ensure R1 and R3 received the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing created a finding of immediate jeopardy that began on 10/31/24. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 2/6/25 at 2:05 PM. The immediate jeopardy was removed on 2/10/25; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: The facility policy Skin Injury Prevention and Management Program Guidelines, dated 10/17/23, indicates, in part: Residents admitted to Oakwood Village without pressure injuries will not develop pressure injuries unless the resident's clinical condition demonstrates that it was clinically unavoidable. Staff will provide care and services to: Promote the prevention of pressure injury development. Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible). Prevent the development of additional pressure injuries. Prevent the reoccurrence of healed pressure injuries. General Information: Pressure injuries occur when tissue is compressed between a bony prominence and an external surface. In addition to pressure, shear force and friction are important contributors to pressure injury development .Skin and soft tissue changes associated with aging, illness, small blood vessel disease, and malnutrition increase vulnerability to pressure injuries. Additional external factors, such as excess moisture and tissue exposure to urine or feces, can increase risk. Procedure: 1. Each resident, upon admission, readmission, and/or discharge to/from the facility, will have head-to-toe skin evaluation completed by a licensed nurse. The nurse will document the findings in the EMR (Electronic Medical Record). 2. The licensed nurse will complete a weekly skin observation and sing the Body Check form for each week on bath day. 3. Direct care givers for the resident will observe daily for any skin changes and report their findings to the Licensed Nurse. 4. When evaluating the resident's skin, note the condition, if the skin is intact, color, and temperature, and any abnormal findings such as .red areas .blisters .pressure wounds, etc. 5. Risk factor examples that increase a resident's susceptibility to develop or not to heal pressure injuries include, but are not limited to: *Impaired/decreased mobility and decreased functional ability . *Drugs such as steroids that may affect wound healing . *Resident refusal of some aspects of care and treatment. *Exposure of skin to urinary or fecal incontinence *Undernutrition, malnutrition, and hydration deficits . 7. It is the responsibility of the Interdisciplinary Care Plan team to review each risk factor and potential cause(s) individually to: a. Identify those that increase the potential for the resident to develop pressure injuries. b. Decide whether and to what extent the factor(s) can be modified, reduced, stabilized, removed, etc. Policy Explanation and Compliance Guidelines: .2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate.3. Assessment of Pressure Injury Risk: .c. Licensed nurses will conduct a whole-body skin assessment on all residents .after any newly identified pressure injury. Findings will be documented in the medical record .4. Interventions for Prevention and to Promote Healing: .c. Evidenced-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. iii. Provide appropriate, pressure-redistributing support surfaces. iv. Provide non-irritating surfaces. v. Maintain or improve nutrition and hydration status, where feasible .e. The goals and preferences of the resident and/or authorized representative will be included in the plan of care .ii. Compliance with interventions will be documented in the weekly summary charting. 5. Monitoring: a. Weekly, a RN (Registered Nurse) will review all relevant documentation regarding skin assessments, pressure injury risks, progression toward healing, and compliance at least weekly, and document a summary of findings in the medical record. b. The attending physician will be notified of i. The presence of a new pressure injury upon identification. ii. Any complications (such as infection, sinus tract development, etc.) as needed .6. Modifications of Interventions: .b. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include i. Changes in resident's degree of risk for developing a pressure injury .iii. Lack of progression towards healing. iv. Resident's non-compliance . Example 1 R1 was admitted to the facility on [DATE] with diagnoses that include, in part: age-related osteoporosis with current pathological fracture of left femur (long bone in the thigh) and superior/inferior pubic rami (two branches of the pubic bone that make up the front of the pelvis); chronic congestive heart failure (a long-term condition where the heart can't pump blood as well as it should); rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints and causes inflammation, pain, stiffness, and damage to the joints, leading to loss of function and disability); difficulty in walking; and need for assistance with personal cares. R1's admission Minimum Data Set (MDS) dated [DATE] indicates a Brief Interview of Mental Status (BIMS) of 15, indicating R1 is cognitively intact. Section GG Functional Abilities and Goals, indicates, in part: Functional limitation: lower extremity one side. Roll Left to Right: dependent (Helper does all of the effort. Resident does none of the effort to complete the activity). Lying to Sitting: dependent R1's Care Plan includes, in part: 9/18/24: ADL's (Activities of Daily Living) Potential for Alteration in ADL's Related to: Left Femur IMN (Intramedullary nailing (IMN) is a surgical procedure used to treat fractures of the femur, the long bone in the thigh). Approach: Transfers: 2 assist; Mobility: 2 assist; Toileting: 2 assist; Bilateral Assist handles to assist with bed mobility. Urinary .Foley catheter (removed 10/8/24 - need for assistance with toileting) 11/13/24 - Foley placed for wound healing. Enhanced barrier precautions skin. (Date is incomplete at top of this portion of the care plan) Nutrition Potential for Alteration in Nutrition related to: Increased needs for healing. Additional Information: .Juven TID (Three Times a Day) (a nutritional supplement), Boost BID (Twice a Day) (nutritional supplement), Thrive Ice Cream PRN (as needed) (nutritional supplement), Gelatine pro Jello BID (High Protein Gelatin). There is a hand written date of 11/13/24. 9/18/24: Skin Potential for Alteration in Skin Integrity related to Left hip incision, Left hip hematoma. Approach, in part: Complete skin assessments. Provide treatment as ordered (see TAR (Treatment Administration Record). Reposition per turn schedule: encourage every 2 hours and PRN (Of note, this item is crossed off and discontinued 11/15/24 with initials is written in). Refer to Dietician/designee .Barrier cream with cares .Mattress: air (Of note, this item is crossed off and discontinue 11/15/24 is written in). chair cushion: wc (wheelchair) (does not indicate what type of cushion). Educate on causes of skin breakdown. Confer with wound care specialist PRN (as needed). Measure wound(s) weekly. Additional information and/or updated (date): 10/17/24 use wedges for repositioning (discontinued 11/15/24) 10/16/24 I have a DTI (deep tissue injury) to my R (right) & L (left) buttock, stage 3 to my L buttock. 11/13/24: wound vac (a negative pressure device that helps to heal a PI (pressure injury) placed - L buttock PI. 11/14/24 air mattress (standard) changed to United Mattress (combination of memory foam and air cells allow for patients eight to be equally distributed. No electricity or electric pump needed.) 11/21/24: heel boots on at HS (bedtime) float heels in bed during day when in bed . On 9/18/24, R1's Braden scale for predicting pressure sore risk, indicates a score of 15, which indicates R1 is at risk. On 9/18/24, R1's Certified Nursing Assistant (CNA) Kardex report indicates the following: Toileting use 2A (two staff to assist) foley/incontinent of bowel offer to toilet Q 3 (every 3) hours and PRN (as needed). Foley cares Q shift. Monitors - monitor alert & oriented times 4, w/c cushion, enhanced barrier precautions r/t (related to) foley catheter. Mobility - transferring 2A Hoyer (full body lift). Bed mobility 2A encourage/assist to reposition Q 2 hours and PRN. On 9/18/24, R1's Skin monitoring CNA/Nurse shower review form indicates R1 does not have any skin impairment to her buttocks. On 9/20/24, R1's CNA Kardex report indicates R1 transferring 2A (two assist) Hoyer WBAT (weight barring as tolerated) to LLE (left lower extremity) and bed mobility L (left) assist rails for bed mobility. On 9/21/24, R1's Braden scale indicates a score of 17, indicating R1 is at risk. On 9/21/24, R1's Skin monitoring CNA/Nurse Shower review form indicates R1 does not have any skin impairment to her bottom/buttocks. On 9/25/24, R1's CNA Kardex report indicates R1 transferring/toileting with EZ stand lift and assist of 2 and Bathing to use EZ stand for transfers with assist of 2. Bed mobility remains 2 A (assist) On 9/27/24 at 2:45 PM, R1's Nurses note states in part: sheared areas on buttocks with discoloration [sic] surrounding, informed NP (nurse practitioner). Orders to be sent, staff will continue to monitor. On 2/5/25 at 9:40 AM, Surveyor spoke with RN J (Registered Nurse). Surveyor asked RN J what the process is when you find an open area on a resident's skin. RN J stated, she would notify the NP (Nurse Practitioner) and obtain orders. RN J stated, she's not sure if she notified RN D (Registered Nurse), who is the Wound Care Nurse, or if she needs to notify RN D. RN J stated, I'm honestly not sure. Surveyor asked RN J, how does RN D find out there's an open area. RN J stated, they (management) read our documentation every day. RN J stated, all Progress Notes are read by management. Surveyor asked RN J, when you observed and documented a PI to R1's buttock, which buttock was it. RN J stated, she does not recall which buttock, however, she stated it was an upper buttock. RN J added, it was higher on the hip versus a true gluteal (buttock). Surveyor asked RN J, did you document anywhere else. RN J stated, no. Surveyor asked RN J, did you measure and describe the wound. RN J stated, no. Surveyor asked RN J, when you discover a PI, should you measure, assess and document a description of the PI. RN J stated, yes. RN J stated, she verbally reported it to the NP (Nurse Practitioner) face to face when she was in the facility. Surveyor asked RN J, did you get an order. RN J stated, she noted that she reported it to the NP but does not recall getting an order. RN J stated, It would have been documented had I gotten the order. RN J stated the interim treatment was barrier cream (already using prior to development). Surveyor asked RN J, did you put a dressing on the PI. RN J stated, no, not without an order. Surveyor asked RN J, did the NP look at R1's wound. RN J stated, I can't say. Surveyor asked RN J, how often are residents turned and repositioned. RN J stated, it depends on the care plan and if there are any wounds present. RN J stated it's individualized for each resident. Surveyor asked RN J, how often was R1 turned and repositioned. RN J stated she is unsure. Surveyor asked RN J, do staff document turning and repositioning. RN J stated, yes, the nurses (Registered Nurses and Licensed Practical Nurses) document in the TAR (Treatment Administration Record). Surveyor asked RN J, do staff document refusals. RN J stated yes, nurses enter a note to document the refusal. Surveyor asked RN J, what stage is R1's PI. RN J stated, it's a shearing, her skin was sheared off. Surveyor asked RN J, was R1's wound open. RN J stated, yes. Note, there was no documentation of a measurement, stage or description of the PI when it was first discovered. On 9/28/24, R1's Braden scale indicates a score of 17, indicating R1 is at risk. On 9/28/24 R1's Skin monitoring CNA/Nurse Shower review form indicates R1 does not have any skin impairment to her bottom/buttocks. On 9/29/24, the facility's 24-hour board indicates for R1, 9/28/24 monitor open areas to buttocks. On 10/2/24, R1's Telephone order indicates, buttock treatment: cleanse area with soap and water, pat dry, apply foam dressing to affected areas. Change every three days or PRN. May d/c when healed. Foley removal discontinue foley on 10/8/24 at 0600 (6:00 AM). On 10/3/24, R1's CNA Kardex report indicates R1 is dependent of assist of two for lower body with use of [NAME] steady (mechanical stand lift device to assist with standing) for standing. Mobility: [NAME] steady transfers with moderate assist of 2, WBAT to LLE. On 10/5/24, R1's Braden scale indicates a score of 16, indicating R1 is at risk. On 10/6/24, R1's Skin monitoring CNA/Nurse Shower review form indicates R1 has three areas to her left buttock, two areas indicated as scabbed, and one area indicated as open. On 10/7/24, R1's NP Nursing Facility acute visit note, states in part: .seen today for chief complaint of new skin concerns as reported by patient and staff. chief complaint: I have new sores.new skin concern under bilateral breasts .exam: Back: tenderness noted, limited range of motion due to stiffness and pain .skin: abrasions under bilateral breasts. Of note: There is no mention of R1 having open areas to her left and right buttock. On 10/12/24, R1's Braden scale indicates a score of 17, indicating R1 is at risk. On 10/12/24, R1's Skin monitoring CNA/Nurse Shower review form indicates R1 does not have any skin impairment to her bottom/buttocks. Had shower with therapy refused today. On 10/15/24 at 9:51 AM, R1's Nursing Advance Skilled evaluation note, states in part: .Skin: skin warm & dry, skin color WNL (within normal limits) and turgor normal.Skin note: .buttocks with superficial open areas MASD (Moisture associated skin damage), treatment applied as ordered . Of note, there is no description of what the skin tissue looks like or how big the MASD area is. On 10/16/24, R1 has no documentation of her skin for this day. On 10/17/24, R1's CNA Kardex report indicates R1's mobility is maximum assist of 1 for sit to stand transfers with 2ww (two wheeled walker). Bed mobility is 1 assist to reposition Q 2 hours and PRN with wedges, air mattress, Right and left assist rails for bed mobility. On 10/17/24, R1's Telephone order indicates Left buttock cleanse area with soap and water, pat dry, apply Santyl to slough bed, cover with foam dressing, perform daily or PRN. Right buttock cleanse area with soap and water, pat dry, cover wound with vitamin AD, cover with foam dressing, change daily or PRN. On 10/17/24 at 9:51 AM, R1's Nursing Advance Skilled evaluation note, states in part: Skin: .Skin note: .bilateral buttocks with wounds treatment applied. On 10/17/24 at 12:02 PM, R1's Skin/wound note, states in part: Writer assessed area to R buttock at request of floor RN. Upon assessment, dark purple wound, indicative of a DTI, present to superior portion of R buttock. Discolored area measures 1.5cmx1.5cm with irregular edges. Appears to be open in center of wound, with small amount of scattered yellow slough present. Sanguineous drainage noted on dressing. Periwound pink, but blanchable. No odor. Resident did state area is tender. NP updated with assessment and recommendations . On 10/17/24 at 12:04 PM, R1's Skin/wound note, states in part: Writer assessed area to L buttock at request of floor RN. Upon assessment open area present to superior portion of L buttock, with linear DTI (deep tissue injury) just inferior to it. Open area measures 1cm x 0.7cm and is 100% slough. Based on presence of slough, wound would be classified as unstageable PI. Not currently draining. DTI just inferior to open area, appearing dark purple and measuring 0.5cm x 4cm. periwound of both areas pink, but blanchable. No odor. Resident did state area is tender. NP updated with assessment and recommendation [sic] for the following treatment to be done daily and PRN .Other interventions: offer repositioning Q 2 hrs. and PRN with foam wedges, air mattress, Roho cushion. Will monitor during weekly wound rounds to ensure proper healing. On 2/5/25 at 11:45 AM, Surveyor spoke with RN M (Registered Nurse) and asked what the process is when you find an open area on a resident's skin. RN M stated, staff measure and assess the wound (e.g. granulation, slough, describe the wound), identify risk factors, update MD/NP (Medical Doctor/Nurse Practitioner) to request orders, alert Nurse Manager and Wound Care nurse for follow up. Document all of this in a Progress Note. RN M stated, when she receives the order, she implements the order. Surveyor asked RN M, if unable to obtain the order on the first attempt how soon do you try again. RN M stated, if it's in the morning she would call back after lunch. RN M stated, if it's near the end of her shift she will report it to the next shift and let the Nurse Manager know so they can coordinate. Surveyor asked RN M, how often are residents repositioned. RN M stated, every 1 1/2 to 2 hours or follow care plan if there are specific instructions for a resident. Surveyor asked RN M, how often was R1 repositioned. RN M stated, she believes it was every 2 hours. RN M stated, for CNAs (Certified Nursing Assistants) she believes it was a documented in POC (point of care) charting and in the TAR (Treatment Administration Record) for nurses. Surveyor asked RN M, what do you do if a resident refuses repositioning. RN M stated, she expects CNAs to report to the nurse. The nurse will approach the resident to ask why they are refusing, provide education, document and if still declining, provide education regarding risks and benefits of not having repositioning done. Surveyor asked RN M, if she is familiar with the United Mattress. RN M stated, yes. RN M stated, R1 was the first resident to have the United Mattress in the facility. RN M stated, the vendor provided an in-service regarding the United Mattress to the facility. RN M stated, the in-service topics included the following: Hand pump like a Roho cushion; a Chux can be used with this mattress; May not be necessary to elevate heels or use heel boots; Set-up. RN M stated, she saw R1's wounds on occasion but not consistently. RN M added, R1 had a wound to her right buttock. Surveyor asked RN M, what caused R1's PI's. RN M stated, a poor appetite her nutrition was not well, limited mobility issues, slept a lot, not a lot of motivation, sat in wheelchair for long periods of time with a regular cushion before the Roho cushion was put in place. RN M added, R1 slept a lot, was fatigued and took lots of encouragement to eat. Surveyor asked RN M, how often PI's should be assessed and measured. RN M stated, weekly or if there's a change and it's worsening. Surveyor asked RN M, if you note that a resident's PI is worsening, what should you do. RN M stated, she would measure and assess the PI noting a description, let MD/NP/resident know that it's worsening and may need a different treatment, update Nurse Manager and Wound Care Nurse, document in Progress Notes. On 10/17/24, R1's NP nursing facility acute visit note, states in part: .seen today for follow up for worsening buttock wounds as reported by patient and staff. Chief complaint: I hear they are getting worse.staff and patient are reporting they are getting worse. I had assisted (R1) to the restroom to take a peek. See photos and descriptions below.Skin: left buttock with area of slough, sero-sanguinous [sic] drainage noted, no odor with deep tissue injury below. Right buttock with open area with surrounding erythema, no drainage, tender to touch.A. 1. Unstageable pressure ulcer of left buttock .cleanse with soap and water, pat dry apply Santyl to slough bed. Cover with foam dressing. offer repositioning q 2 hrs. and PRN with foam wedges, air mattress, Roho cushion. 2.pressure ulcer of right buttock, stage 2 .cleanse with soap and water, pat dry, cover wound with vitamin AD cover with foam dressing . Of note, the NP stages this PI as a stage 2 however, mentions the PI has slough; this would make the PI at least a stage 3. On 10/17/24, Maintenance work log indicates, air mattress needed. Air mattress to bed, for skin concerns/wounds present. Assigned on [DATE]. [DATE] at 1:05 PM Standard mattress has been removed in the [sic] primer has been put on. Of note: The facility's standard mattress is a Geo-mattress ultra max. The manufacturer guidelines indication for use states in part: prevention of stage 1-4 pressure injuries .early intervention for multiple stage 1-2 and treatment of single stage 3 pressure injuries .reposition frequently by self or caregiver . The Air mattress that was placed on R1's bed is indicated as a Panacea Air advance mattress. The manufacturer information indication for use, states in part: .provides pressure management to assist in the prevention and treatment of up to Stage IV pressure ulcers. The alternating pressure and low air loss mode provided with the panacea air advance mattress is indicated for use as a preventative tool against further complications associated with critically ill residents or immobility. On 10/19/24, R1's Skin monitoring CNA/Nurse Shower review form indicates R1 does not have any skin impairment to her bottom/buttocks. On 10/23/24, R1's NP Nursing Facility acute visit note, states in part: .seen today for follow up for wounds as reported by patient. Chief complaint: my back hurts.follow up on her buttock wounds. Unfortunately, on appearance they are worsening .both wounds are drainage [sic]. Wound RN (RN D's name) also assessed with me today .A: 1. Unstageable pressure ulcer of left buttock (HCC) comments: .unfortunately worsening. Worry this wound may progress due to underlying hardness felt. Plan: wound care left buttock: cleanse area with soap and water, pat dry apply Santyl to slough bed. Cover with foam dressing. Change daily and PRN. Cushion in wheelchair, air mattress, reposition every 2 hours. Educated staff to provide Roho cushion to recliner. start ProStat (high protein drink to help with wound healing) 30ml daily. 2.Pressure injury of right buttock, unstageable. Comment: .unfortunately worsening. Worry this would [sic] may also progress due to underlying hardness felt. Plan: wound care: Right buttock cleanse with soap and water, pat dry cover apply Santyl to eschar/slough cover with foam dressing. Change daily and PRN. Of note: NP provided education to staff to provide a Roho cushion in her recliner. On 10/23/24 at 2:34 PM, R1's skin/wound note, states in part: weekly assessment of DTI to R buttock, first noted on 10/16/2024, with assessment completed on 10/23/2024 in presence of NP. DTI is now open, presenting as an unstageable PI. Open area measures 1.8cm x 1.4cm with undeterminable depth due to 100% black eschar within wound bed. Moderate serosanguineous drainage noted on previous dressing .periwound pink blanchable. Hard area noted inferior to open area upon palpation. No odor. Resident did state area is tender . treatment order changed .other interventions: offer repositioning Q2 hrs. and PRN with foam wedges, air mattress, Roho cushion . On 10/23/24 at 2:34 PM, R1's Skin/wound note, states in part: weekly assessment of PI and DTI to L buttock, first noted on 10/16/2024, with assessment completed on 10/23/2024 in presence of NP. Two open areas present on L buttock. Superior open area measures 0.7cm x 0.8cm x <0.1cm. DTI just inferior to open area is now open with a linear scab to the right, presenting of stage 2 PI. Area measures 0.6cm x 1.1cm x <0.1cm. Wound beds of both ~ 80% (approximately 80 percent) yellow slough. Scant light-yellow drainage noted upon cleansing .hard area noted [sic] inferior to open areas upon palpation. No odor. Resident did state area is tender . inferior unstageable PI has improved. Presenting as a healing unstageable PI based on smaller measurements. DTI has deteriorated as it is now open. Will continue to monitor during weekly wound rounds to ensure proper healing. Of note: R1's wounds are indicated as being noted on 10/16/24, but there are no notes in R1's record related to skin on 10/16/24. R1 was noted to have MASD on 10/15/24 - no further assessment was charted on 10/15 or 10/16 of R1's skin. On 10/23/24, R1's Telephone order indicates: Discontinue current right buttock treatment order. Right buttock treatment order cleanse area daily with wound cleanser, pat dry, apply Santyl to eschar/slough wound, cover with foam dressing. Change daily or PRN. On 10/26/24, R1's Skin monitoring CNA/Nurse Shower review form indicates R1 has an open area to her left and right buttock. On 10/28/24, R1's NP Nursing facility acute visit note, states in part: .nurse also tells me patient with scab to buttock, nicker [sic] size, that is starting to pull away from skin. Nurse notes what appears to be some tunneling under the scab. NP noted wounds at appointment on 10/17/24. She reports some discomfort with the wounds. She is concerned they are getting worse also patient tells me she sits I [sic] wheelchair most of the time. She does have a cushion in her chair. She is a 1 assist for transfers . Right buttock wound: there is about 3-4cm of undermining/tunneling of this wound. There is moist slough noted in wound bed. There is some odor. There is no erythema or warmth. (of note, left buttock wound was noted, but no description with photo given) .A right buttock, stage 3 .some undermining noted .pressure injury of left buttock, stage2 .seems stable from previous photo .encourage lying in bed with side-side positioning to encourage pressure relief . On 10/28/24 at 12:49 PM, R1's Health status note, states in part: .NP and writer assessed resident wound to right buttock at approximately 1130 today. Wound measures 2cm x1cm with a black scab partially intact held by slough tissue. Black scab has separated from skin partially and wound has a depth of 4.5cm at 6 o'clock and 4.5cm at 10 o'clock. Moderate amount of light red serious drainage noted. New orders received for new dressing change to be completed this evening. On 10/28/24 at 12:54 PM, R1's health status note, states in part: Correction: wound depth at 10 o'clock is 3cm. On 10/28/24, R1's Telephone order indicates cleanse/flush right buttock wound with wound cleanser, pat dry, pack with iodoform, cover with gauze, then Mepilex daily and PRN. On 10/30/24, R1's CNA Kardex report indicates R1 has a wheel chair Roho cushion to seat and Roho to w/c back. On 10/30/24 at 10:04 AM, R1's Skin/wound note, states in part: . weekly assessment of DTI to right buttock, first noted on 10/16/24. Open area measures 2.3 cm x 1.4 cm, with a depth of 4 cm. no eschar noted .resident states that pain of wound is 9/10.(R1) answers that she has had boils on her bottom previously, but it has been many years. Of note: there is no facility measurement or assessment for the L buttock wound. On 10/30/24 at 1:32 PM, R1's Skin/wound note, states in part: .met with resident and daughter to discuss wound status and current interventions Resident shared personal goal of more independent repositioning and offloading more frequently. Care plan clarification requested by resident to utilize lift sheet as primary tool to assist with repositioning in bed Daughter shared she had been providing a firm lumbar support device in resident's w/c and that after evaluating, she will be taking this device home as it rubs to the wounded area. Request for Roho style cushion to be provided for w/c back support surface . On 2/5/25 at 8:35 AM, Surveyor spoke with FM I (Family Member). Surveyor asked FM I, when did R1 start using a lumbar support. FM I stated, R1 had the lumbar support before R1 fell and fractured prior to admission. FM I stated, the lumbar support was used for musculoskeletal back pain. FM I stated, the lumbar support was used intermittently not all the time. FM I added, it was not particularly helpful for R1. FM I stated, R1 used the lumbar support at the facility when she was still having pain from pelvic fractures when sitting in her wheelchair. FM I stated, R1 did not tolerate time in the wheelchair for the first 2-3 weeks. FM I added, R1 spent a lot of time in bed flat on her back. Surveyor asked FM I, did you speak with anybody at the facility regarding the lumbar support. FM I stated, she spoke with PTA K (Physical Therapy Assistant). FM I stated, when she visited R1, she observed staff, Dragging her bare hind end (while assisting her in bed). FM I stated, due to shear forces this put R1 at risk for injury. FM I further stated, when staff would reposition R1 they would do so without a draw sheet. FM I added, she also observed R1 sitting on a Hoyer sling while up in her wheelchair or recliner. FM I stated, she doubts staff was repositioning R1 every 2 hours at night. FM I stated, Staff didn't offload (pressure) like they needed to. FM I added, a nurse (name unknown) told her we don't know what we are doing with the wound vac. FM I stated, the facility lacks general oversight and training of staff. A supervisor told staff, here's a video to watch (related to wound vacs). On 2/5/25 at 9:30 AM, Surveyor spoke with PTA K (Physical Therapy Assistant). Surveyor asked PTA K, when R1 was admitted to the facility was she able to turn and r [TRUNCATED]

Based on record review and staff interviews, the facility did not complete a performance review of every nurse aide at least every 12 months for 5 of 5 Certified Nursing Assistants (CNAs) reviewed for in-service training. The survey team randomly selected five (5) facility CNAs who have been employed at the facility for longer than one (1) year. CNA/MT O (Certified Nursing Assistant/Medication Technician), CNA/MT P (Certified Nursing Assistant/Medication Technician), CNA Q (Certified Nursing Assistant), CNA R (Certified Nursing Assistant), and CNA S (Certified Nursing Assistant) did not have a performance review at least every 12 months. Findings include: Surveyor provided NHA A (Nursing Home Administrator) with a list of five CNA names the Surveyor had randomly selected and requested their performance review for the past 12 months. Surveyor reviewed performance review records and noted the following: Surveyor reviewed performance reviews from 2/18/24 -2/18/25. During this time, CNA/MT O, CNA/MT P, CNA Q, CNA R, and CNA S had no performance reviews completed. On 2/18/25 at 2:40 PM, Surveyor spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A, do you expect CNAs to have a performance review at least every 12 months. NHA A stated, yes. NHA A stated, RN's (Registered Nurses) and LPN's (Licensed Practical Nurses) had a performance evaluation completed. NHA A stated, the facility was confused with what to do with their CNAs that are in a union and have not been completing performance reviews for any CNAs. NHA A stated, moving forward, yes, there will be a performance review of CNA at least every 12 months.

Based on observation, interview and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 32 residents. Hood vents with visible clumps of dust. Kitchen staff with facial hair were not wearing beard restraints. Findings include Example 1 On 3/7/23 at 10:32 AM, Surveyor observed hood vents with visible clumps of dust in the main kitchen. The dust appeared to be separating from the hood vents. These hood vents were directly above a large [NAME] of soup that was uncovered and actively being prepared and mixed by facility staff. EC C (Executive Chef) stated to Surveyor at this time that the hood vents were dirty and needed to be cleaned. Example 2 The facility's Appearance & Dress Code policy outlines expectations for dining staff and lists beard restraints as necessary for staff who require them. The policy also states, All supervisors are charged with monitoring adherence to dress code for their department's staff. On 3/8/23 at 1:27 PM, Surveyor observed DA E (Dietary Aide/Cook) plating up individual pieces of cake without a beard restraint. DA E had a visible beard. Surveyor asked DS D (Dining Supervisor) if DA E should be wearing a beard restraint and DS D stated yes.

Based on observation, interview and record review, the facility did not ensure that residents with a pressure ulcer or at risk for pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure ulcers and to promote healing for 3 (R21, R16, and R25) of 5 residents reviewed for pressure ulcers and 1 (R6) of 1 supplement. R21's heels resting directly on Broda chair and sling left behind R21 while sitting in Broda chair. -R16's heels directly on mattress while lying in bed. -R6's heels resting directly on Broda chair and sling left behind R6 while sitting in Broda chair. -Surveyor observed wound care for R25 performed where hand hygiene and aseptic technique were not completed per current professional standards of practice. The facility policy, titled, Gloves - Use Guidelines, dated, 1/28/22, indicates, in part: It is the practice of this facility that gloves be worn when it can be reasonably anticipated that the employee may have hand contact with blood and other body fluids . Guidelines: I. Selection of Gloves. A .4. Failure to change gloves and disinfect hands between resident contacts or after contact with a known contaminated area will be considered a breach of infection control practice .II. Replacement of Gloves. A. Conditions. 1. Disposable gloves will be replaced as soon as practical when contaminated .Hands are to be sanitized after glove removal. 2. Disposable gloves will be changed after contact with each resident . The facility policy, titled, Infection Control-Hand Hygiene, dated, 6/11/22, indicates, in part: Procedure: 1. The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed: . H. Before and after changing a dressing. I. Upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse or blood pressure, and lifting a resident) . M. After handling soiled or used .dressing . O. After removing gloves or aprons .3. Alcohol-based hand rub may be used for all other hand hygiene opportunities (e.g., when soap and water is not indicated per #1 above) .C. When moving from a contaminated body site to a clean body site such as when changing a brief or wound dressing; D. After caring for a resident including after removing gloves; and E. After contact with a resident environment . The facility policy titled Skin Program Guidelines dated 6/15/22, states in part, .residents admitted without pressure injuries will not develop pressure injuries unless the resident's clinical condition demonstrates that it was clinically unavoidable. Staff will provide care and services to: Promote the prevention of pressure injury development .8. Possible care planning intervention for resident with actual skin problem and/or potential skin problem: The interventions listed are not all-inclusive. BED .off-loading of heels. FRICTION/SHEAR .Pillows positioned under calves to float heels off of surfaces .position devices (pillows, wedges, padding devices; OT and/or PT will be consulted as necessary if any special positioning and/or seating is required. Example 1 R21 was admitted to the facility on [DATE] with diagnoses including vascular dementia, palliative care, fracture, pressure ulcer of sacral region stage 1, rash/other nonspecific skin eruption, and squamous cell carcinoma of skin. R21's daughter is the activated health care power of attorney (AHCPOA). R21's Visual/Bedside Kardex indicates, as of 3/8/23, TRANSFER: The resident requires a Hoyer lift with 2 staff assistance for transfers. RESIDENT CARE: .BLE (bilateral lower extremities) Tubigrips on AM/off at HS (night). DRESSING: The resident requires assist of 1 by staff to dress .Reposition Q (every) 2-3 hours and check for incontinence. MOBILITY: W/C (wheelchair) mobility 1 assist, dependent on staff to propel Broda Chair. R21's Comprehensive Care Plan indicates, Focus: The resident has potential for pressure ulcer development/alteration to skin integrity r/t (Related to) incontinence. Goal: The resident will have intact skin, free of redness, blisters, or discoloration by/through review date. Interventions: Administer treatments as ordered and monitored for effectiveness 5/8/22. Apply barrier cream after each incontinence episode 3/2/22. Complete skin assessments per protocol 3/2/22. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning 5/8/22 Ensure socks are on for all transfers 2/14/23. Follow facility policies/protocols for the prevention/treatment of skin breakdown 5/8/22 Reposition Q 2-3 hours and check for incontinence 3/2/22. R21's current order indicates, please apply heel protectors to bilateral LE (lower extremity) to offload heels (may use substitute) every shift for offload heels; skin maintenance started 4/4/22 . On 3/7/23 at 10:56 AM, Surveyor observed R21 in bedroom with Activated Healthcare Power of Attorney H (AHCPOA). Surveyor observed R21 sitting in Broda chair with a sling behind her and feet resting on the footrest with gripper socks on. Surveyor observed two boot heel protectors to be sitting behind R21 on a chair. AHCPOA H indicated that R21 should not have the sling left behind her when she is in her Broda chair. AHCPOA H indicated heel protectors should be on when she is sitting in her Broda chair as well. AHCPOA H indicated it all depends on what staff are working, if these things are done correctly. AHCPOA H indicated she has brought up these concerns to the facility in the past. On 3/8/23 at 9:15 AM, Surveyor observed R21 sitting in Broda chair with the sling directly under her. On 3/8/23 at 4:21 PM, Surveyor observed R21 sitting in Broda chair with the sling directly under her. On 3/8/23 at 2:43 PM, CNA I (Certified Nursing Assistant) indicated R21's sling should come out from under R21 once she is positioned and in Broda chair. CNA I indicated it is easy to get out from under her. CNA I indicated R21 should have heel boots on or heel riser to elevate her heels. CNA I indicated staff are trained that less layers underneath a person the better. CNA I indicated if the resident has to have the sling left under them, it should be care planned. Example 2 R16 was admitted to the facility on [DATE] with diagnoses including palliative care, retention of urine, major depressive disorder, unsteadiness on feet, dementia, anxiety, and muscle weakness. R16 has an activated health care power of attorney. R16's Visual/Bedside Kardex indicates, as of 3/8/23, TRANSFERRING Hoyer lift with 2A (two assist) for all transfers W/C (wheelchair) mobility 1 assist, dependent on staff to propel Broda chair .TOILETING incontinent check and change Q2 (every two) hours and PRN (as needed). R16's Comprehensive Care Plan indicates, Focus Resident is at risk for impaired skin integrity/pressure injury development r/t (related to) incontinence, decreased mobility, pain and history of pressure ulcer 6/30/22. Goal Resident skin will remain intact 9/14/22. Interventions Assist with repositioning Q2 hours and PRN, barrier cream with cares, w/c cushion and air mattress, padding to my tray table, check and change Q2 hours and PRN, provide treatments as ordered 6/30/22. R16's current order indicates, apply skin prep to bilateral heels BID (twice a day) for blanchable redness and check placement of foam wedge to keep resident feet off the bed. Two times a day for redness [sic] skin 7/20/22. On 3/8/23 at 2:50 PM, Surveyor observed R16's heels resting directly on mattress. On 3/9/23 at 8:45AM, Surveyor observed R16 lying in bed with breakfast tray next to R16. R16 had eyes closed. Surveyor observed R16's heels to be resting directly on the mattress. CNA J (Certified Nursing Assistant) indicated R16's feet should be elevated while in bed. CNA J indicated R16 uses a heel riser while in bed and/or pillows to ensure heels are off-loaded. Example 3 R6 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, rash, and other nonspecific skin eruption. R6's son is the activated healthcare power of attorney. R6's Visual/Bedside Kardex indicates as of 3/9/23, TRANSFERRING 2A Hoyer (two assist full body lift) with small sling, socks on during transfers-pillows between resident and sling. RESIDENT CARE: Pillow under legs while in Broda chair, padding to beside table, apply lotion to BLE (bilateral lower extremities) and BUE (bilateral upper extremities) BID (two times a day) with cares, pillow between head and wall when boosting resident in bed, geri sleeves on BUE on at all times, except for cares, place bedside table to the side of resident except when eating, monitor extremities with transfers, monitor placement of BLE when placing me at the dining table, place pillows between resident and Hoyer sling during transfers encourage and assist reposition Q2 (every two) hours and PRN (as needed) while in bed. Encourage/assist weight shift while sitting up in chair .elevate BLE as often as I tolerate, encourage, and assist me to float my heels as often as I tolerate. MOBILITY The resident is totally dependent on staff for locomotion using Broda chair R6's Comprehensive Care Plan indicates, Focus The resident has potential for pressure ulcer development r/t fall history, incontinence, depression with use of psychotropic medication, Alzheimer's disease, weakness abnormality of gait and mobility 5/6/22. Goal The resident will have intact skin, free of redness, blisters, or discoloration by/through review date 5/6/22. Interventions Gel cushion to my Broda chair, Specialty mattress to my bed, Pillow under legs while in Broda chair, padding to bedside table, .Elevate BLE as often as I tolerate, encourage, and assist me to float my heels as often as I tolerate, .follow facility policies/protocols for the prevention/treatment of skin breakdown On 3/7/23 at 11:16 AM, Surveyor observed R6 sitting in Broda chair with sling directly under her. On 3/8/23 at 9:23 AM, Surveyor observed R6 sitting in Broda with sling directly under her. Surveyor observed R6 heels resting directly on Broda chair with no pillow underneath to off-load. On 3/8/23 at 2:20PM, CNA K indicated slings should come out from behind the person after they are in their Broda chair. CNA K indicated it might get a little tricky, but it needs to be done. CNA K indicated R21 should have heel protectors on when sitting in Broda chair. CNA K indicated R16's heels should not be directly on the mattress while in bed. On 3/9/23 at 10:39AM, DON B (Director of Nursing) indicated the expectation for slings is it should be identified in the person's care plan if they can be left behind them while up in wheelchair/Broda chair. DON B indicated R6 and R21's slings should be removed from behind them once they are positioned comfortably in their Broda chairs. DON B indicated R21's heel protectors should be on when in the Broda chair. DON B indicated R16's heels should not be resting directly on mattress when R16 is lying in bed. DON B indicated she does not see R16's heel protector care planned and that it should be. DON B indicated someone probably thought it would be a good idea and it's working but didn't update care plan. 39849 Example 3 R25 was admitted to the facility on [DATE] with diagnoses that include, in part: Pneumothorax; Pressure Ulcer of Sacral Region, Stage III; and Muscle Weakness . R25's most recent Minimum Data Set (MDS) with a target date of 1/16/23, documents a Brief Interview for Mental Status (BIMS) score of 13, which indicates, cognitively intact. On 3/8/23 at 9:42AM, Surveyor observed R25's wound care to sacral/coccyx region with LPN G (Licensed Practical Nurse). After removing dressing, LPN G performed hang hygiene and put on clean gloves, wet the gauze 4x4's and set them on the outside of the packaging. LPN G then utilized those 4x4's to clean the wound. LPN G changed gloves and performed hand hygiene. LPN G removed the new Opti foam dressing from the package and set aside. LPN G then opened two gauze 2x2 packages by tearing the package down the side and removing the 2x2's. This caused the gauze and LPN G's gloves to touch the outer portion of the package. LPN G also removed a cotton tipped swab from the packaging with the same gloves on, touching the outer portion of the package. LPN G then held a 2x2 in her hand, still wearing the contaminated gloves, and poured Normal Saline over the 2x2 gauze, squeezed out the excess, and used the cotton tipped swab to place the 2x2 on the wound bed. LPN G then changed gloves, sanitized hands in between and placed the other 2x2 over the wet 2x2, that was placed on the wound bed, and applied the Opti foam dressing. On 3/8/23 at approximately 10:00AM, Surveyor interviewed LPN G and asked what type of wound care training she has had at the facility. LPN G indicated, overview of dressing types, barriers for set up, wiping tables, clean and dirty, changing gloves, and keeping trash can near. Surveyor asked LPN G if the outer part of the dressing supply packages is considered clean or dirty. LPN G indicated, dirty. Reviewed observation of gauze and gloved hands touching the outer portion of the packages, setting wet gauze on outer part of package, holding the 2x2 while applying normal saline after the gloves and gauze had touched the outer part of the packaging and then were applied to the wound. Surveyor asked if this would be clean technique. LPN G indicated it would not. On 3/9/23 at 10:23AM Surveyor interviewed DON B (Director of Nursing) and asked what the expectation is with wound care. DON B indicated; staff should perform hand hygiene when entering the room. Set up supplies, then perform hand hygiene and change gloves again if they have them on when setting up supplies. Remove dirty dressing and then remove gloves, perform hand hygiene, put on a fresh pair of gloves to put on clean dressing and then remove, and perform hand hygiene and as needed in between. Surveyor asked DON B if after cleansing the wound and prior to clean dressing, should a glove change and hand hygiene be completed. DON B indicated, I would expect them to change their gloves and perform hand hygiene. Hand Hygiene between all glove changes. Surveyor asked DON B what the expectation is for setting up supplies. DON B indicated, they should be within reach, ideally in the order they are going to use it, place barrier, chux pad or wash clothes. Surveyor asked DON B if she would expect staff to have all the packages open so they can get items out of packaging without touching the package. DON B indicated if it stays within eyesight once open. Surveyor reviewed wound care observation with DON B. Surveyor asked DON B if she would expect the staff member not to touch the outer package of the supplies and then touch the gauze and apply to the wound with the same gloves on and not to set wet gauze on the outer portion of the package. DON B indicated, yes. Surveyor asked DON B, how she would have expected staff to wet the 2x2 with normal saline. DON B indicated, I would have expected her to open the 2x2 package and pour saline over it.

Based on observation, interview, and record review, the facility did not ensure that parenteral medications were administered consistent with professional standards of nursing practice for 1 of 1 (R133) of 12 residents reviewed. R133 was admitted to the facility on [DATE], with a Peripherally Inserted Central Catheter (PICC) line, which is a soft, thin, flexible tube in a vein used to administer IV medications and fluids. Staff did not complete appropriate hand hygiene and glove changes during administration of IV antibiotics. The facility policy, titled, Gloves - Use Guidelines, dated, 1/28/22, indicates, in part: It is the practice of this facility that gloves be worn .when performing vascular access procedures including starting intravenous lines, drawing blood, and doing finger sticks. Guidelines: I. Selection of Gloves. A .4. Failure to change gloves and disinfect hands between resident contacts or after contact with a known contaminated area will be considered a breach of infection control practice .II. Replacement of Gloves. A. Conditions. 1. Disposable gloves will be replaced as soon as practical when contaminated .Hands are to be sanitized after glove removal. 2. Disposable gloves will be changed after contact with each resident . The facility policy, titled, Infection Control-Hand Hygiene, dated, 6/11/22, indicates, in part: Procedure: 1. The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed: .F. Before and after handling peripheral vascular catheters and other invasive devices; .I. Upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse or blood pressure, and lifting a resident) .O. After removing gloves or aprons .3. Alcohol-based hand rub may be used for all other hand hygiene opportunities (e.g., when soap and water is not indicated per #1 above) .C. When moving from a contaminated body site to a clean body site such as when changing a brief or wound dressing; D. After caring for a resident including after removing gloves; and E. After contact with a resident environment . R133 was admitted to the facility on [DATE], with diagnoses that include, in part: Infection following a procedure, other surgical site; Pathological fracture, right femur; Encounter for adjustment and management of vascular access device; Long term use of antibiotics . R133's most recent Minimum Data Set (MDS) with a target date of 3/3/23, documents a Brief Interview for Mental Status (BIMS) score of 13, which indicates, cognitively intact. On 3/9/23 at 9:02AM, Surveyor observed RN F (Registered Nurse) during the set up and connection of the IV (Intravenous, by vein) antibiotic, Ceftriaxone, for R133. Surveyor observed RN F perform hand hygiene and place a new pair of gloves. RN F set up supplies for the antibiotic administration; set up IV pump; and touched resident's sleeve to push it upward to gain access to the port for connection of IV tubing. RN F then proceeded to clean the port and attach the IV tubing to the port. RN F did not complete a glove change after touching outer packages of supplies and touching items in the resident's environment, including clothing and IV pump, prior to opening the port and attaching the IV tubing to the port. This presented a potential for contamination. After the tubing was connected, RN F removed her gloves and then placed a new pair of gloves without performing hand hygiene. RN F then picked up remaining supplies and packages from R133's bed and over the bed table for disposal. On 3/9/23 at approximately 9:20AM, Surveyor interviewed RN F and asked when hand hygiene should be performed. RN F indicated, when entering and exiting the room and between glove changes. Surveyor reviewed the observation with RN F and asked if she should have changed gloves and performed hang hygiene after setting up equipment and touching resident sleeve, and prior to connecting IV tubing to port. RN F indicated she should have. Surveyor asked RN F if after she connected the IV tubing, when she then changed gloves if she should have performed hang hygiene between changing gloves. RN F indicated she should have. On 3/9/23 at 10:35AM, Surveyor interviewed DON B (Director of Nursing) and reviewed the antibiotic administration observation with her. Surveyor asked when she would expect glove changes and hand hygiene to be performed. DON B indicated, she would expect a change of gloves, hand hygiene, and new gloves prior to connecting the IV after set-up of supplies. Surveyor asked DON B if she would expect hand hygiene to be performed between glove changes. DON B indicated, yes.

Based on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R1) reviewed for fall concerns. R1 had a care plan intervention for anti-rollbacks to the wheelchair. R1's wheelchair did not have the anti-rollbacks in place and R1 fell out of the wheelchair and fractured his left ankle. Evidenced by: The facility's Fall Prevention Program policy dated 3/23/22 states in part: .Due to this fragile population, all residents will be considered at risk for fall . 2. Evaluation, care planning and monitoring of residents related to fall issues will be initiated by the primary nursing staff along with input from Fall Team Meetings, observation and/or staff report. 3. Care plan interventions will be reviewed and updated after each fall . Findings: R1 was admitted to the facility on [DATE] with diagnoses including in part: Type 2 Diabetes Mellitus, Repeated falls, Cognitive communication deficit, RBKA (right below the knee amputation,) and [CONDITION(S)]. R1 was transferred to the hospital on 10/24/22 following a fall on 10/23/22, resulting in a diagnosis of Left Ankle Fracture. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] notes R1 had a Brief Interview for Mental Status (BIMS) score of 13 indicating R1 is cognitively intact. MDS section G notes R1 is assist of two with transfers. R1's quarterly Fall Risk evaluation score on 7/11/22 was 10, R1's Fall Risk evaluation score on 10/11/22 was 13, a score of 10 or greater indicates R1 was at high risk for falls. R1's record shows R1 had a witnessed fall on 8/11/22 without injuries. Review of R1's Fall Care Plan that was in place on 10/23/22 notes in part: Initiated date of 5/31/19: Focus: The resident is High Risk for falls r/t (related to) Deconditioning, Incontinence, right BKA. Goal: The resident will be free of falls through the review date. Interventions: (dated 5/9/22) . Call, don't fall sign in place, anti-rollback brakes to wheelchair, Do not leave in bathroom alone, Vertical grab bar near toilet. Ask about pain prior to transferring and notify nurse if needed. Non-skid strips placed in front of toilet, bed and recliner . (initiated on 12/16/21) Remind resident to apply brakes to WC (wheelchair) before changing position . Review of R1's Certified Nursing Assistant (CNA) Care Assignment Sheet dated 8/16/22 includes: Safety/Devices: Bed against the wall, non-slip strip . anti-rollback brakes on w/c (wheelchair), 2 assist with transfers with 2 wheeled walker . Review of R1's Fall Report includes in part: On 10/23/22 at 3:49 PM, Resident found on floor in his room on his back. He was alert and moving all extremities with purpose. This happened at 12:00 PM (noon). Abraded area to right (sic) medial ankle found that are 1 cm. (centimeter) and 0.5 cm. in size. No injury to his head, he denied hitting it. Wheelchair found to have one wheel locked. Resident stated that he was trying to maneuver or adjust himself in his wheelchair and the wheelchair gave way and rolled backwards. Resident denied hitting his head. Said that he hit his left ankle. Used Hoyer lift to assist the resident back into wheelchair and he was told not to put any pressure on the left leg/foot MD on call notified but did not want an x-ray at this time . Other info: Resident did not lock both wheels on the wheelchair and according to resident it rolled backwards on him when he was trying to maneuver himself in the wheelchair . R1's Nurse Progress notes show R1's ankle became more swollen through out the PM shift; the physician was notified and an X-ray was ordered, staff noted the X-ray was not able to be obtained and the physician was not notified. On 10/24/22 at 1:55 PM, notes R1 was sent to the emergency department by ambulance at 9:55 AM for evaluation of his left ankle by orthopedic department for left ankle pain, swelling, and bruising. On 10/24/22, R1's hospital emergency department note includes in part: R1 had a fall from his wheelchair resulting in a left ankle fracture and was admitted to the hospital for treatment. On 10/27/22 at 8:50 AM, Surveyor observed R1's room (R1 was at the hospital). Surveyor observed R1's wide wheelchair without anti-roll brakes in place. Surveyor observed other fall prevention interventions in place as noted on R1's Care Plan. On 10/27/22 at 1:00 PM, Surveyor interviewed CNA F (Certified Nursing Assistant) who cared for R1 on 10/23/22. Surveyor asked CNA F how she knew what safety interventions were in place for R1 on 10/23/22. CNA F stated the interventions are noted on the CNA Care Assignment Sheet. Surveyor reviewed the interventions asking about the anti-rollback brakes. CNA F stated I don't know about the anti-rollback brakes. On 10/27/22 at 1:15 PM, Surveyor interviewed NM C (Nurse Manager) about R1's fall and care plan intervention of anti-rollback brakes. NM C stated on Monday, 10/24/22, she was reviewing R1's fall and noted the anti-rollback brakes were not in place on R1's wheelchair. NM C stated at some point R1 had anti-rollback brakes on his wheelchair, but R1 had gotten a new wheelchair sometime after that, and the anti-rollback brakes had not been placed on R1's new wheelchair. NM C did not know when R1 had received a new wheelchair. On 10/27/22 at 1:30 PM, Surveyor interviewed RN D (Registered Nurse) about R1's fall on 10/23/22. RN D stated R1 had not locked both wheelchair brakes on his wheelchair before trying to reposition himself. RN D stated she was not aware of the anti-rollback brakes being on his wheelchair or being part of R1's care plan interventions at the time of the fall. On 10/27/22 at 2:30 PM, Surveyor interviewed DON B (Director of Nursing) about R1's fall on 10/23/22, resulting in a left ankle fracture. Surveyor reviewed R1's fall Care Plan in place on 10/23/22, with DON B noting anti-rollback brakes to wheelchair had been added as an intervention on 5/9/22. DON B stated the facility had an IDT (Interdisciplinary Team) meeting on Monday (10/24/22), and noted anti-rollback brakes were already an intervention on R1's care plan, but through the discussion it was noted R1's wheelchair got changed; DON B did not know when this occurred. Surveyor asked what the facility did in response to this event. DON B stated on 10/24/22, DON B had sent out an email to staff, posted education for staff on the units regarding Anti-Rollback Bars and staying up to date on resident's care plan, but did not have documentation of which staff had received this education. DON B said in hindsight, she should have made sure documentation of education was received by all staff. DON B stated on Monday 10/24/22, staff had completed a sweep of all residents with fall interventions to assure care plan interventions were in place. DON B stated the facility had done education with Maintenance staff and special anti-roll bars are being ordered for R1's new wheelchair. DON B stated the staff should review resident's care plan interventions daily, report if the interventions are not in place and this did not occur for R1. R1 was known to be at risk for falls. The facility did not ensure all appropriate care plan interventions were in place to minimize the risk of falls on 10/23/22, resulting in R1 falling and fracturing his left ankle. Cross reference F580.

Based on interview and record review, the facility did not immediately consult with the resident's physician when there is need to alter treatment for 1 of 3 residents (R1) reviewed. R1's physician was not immediately notified when facility was unable to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: The facility's Change in Resident's Condition/Status Policy dated 6/14/22 states in part: (facility name) will notify the resident, his or her Attending Physician/provider . of changes in the resident's medical / mental condition and / or status . 1. Nursing will notify the resident's Attending Physician or On-Call Physician, utilizing the Physician Notification Guidelines, when there has been: . e. A need to alter the resident's medical treatment significantly . Findings: R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was transferred to the hospital on 10/24/22 at 9:50 AM following a fall on 10/23/22, resulting in a fracture to R1's left ankle. Review of R1's Physician notes includes in part: On 10/23/22 at 10:22 PM, Reason for call: Fall at 12:00 PM, recommended to monitor, now ankle turning deep purple . patient notes some mild pain, Tylenol available .Assessment /Plan: OK for L (left) foot XR (X-RAY). Worrisome signs and symptoms requiring further evaluation were discussed with the RN (Registered Nurse). No ED (Emergency Department) visit at this time, RN states they are able to obtain XR at facility. Worrisome signs and sx (symptoms) reviewed. RN indicates full understanding of the issues and agrees with the plan. Review of R1's Skilled Nursing Progress Notes includes in part: On 10/23/22 at 11:07 PM, Skin check done at HS (hour of sleep). Noted blister to left ankle as well as two small open area. Foam dressing applied for protection at this time until order received. No s/sx (signs/symptoms) of infection noted. Noted dark purple discoloration to left ankle and an abrasion to right back from fall today. Reported findings to (name), nurse manager at 2141 (9:41 PM) and Dr. (on-call Doctor name) returned page was notified at 2154 (9:54 PM). Received new orders for an X-ray to right (sic) ankle/foot and to send patient to ED if any change of condition. Writer attempted to and order X-ray and tech taking the call state she was unable to place order due to needing more information including NPI (National Provider Identifier) from primary provider. Endorsed information to noc (night) nurses for am. Patient declined further pain meds at this time. He received scheduled Tylenol at 2200 (10:00 PM). He (R1) continues on neuro checks and they remain WNLs (within normal limits) at this time. Patient had no complaints this shift and is sleeping at this time. (Of note, Surveyor requested copy of written physicians telephone order for X-ray on 10/23/22 and it was not provided.) On 10/27/22 at 2:15 PM, Surveyor interviewed RN E (Registered Nurse) about physician notification and orders RN E received for R1 on 10/23/22. RN E stated on 10/23/22, she noticed R1 left ankle was looking worse when R1 was put to bed. RN E contacted NM C and then called the on-call physician to report R1's condition. RN E received an order to obtain an X-Ray to R1's left ankle. RN E stated she stayed late on her shift to place the order with the facility's mobile X-Ray company and was told the company could not put forward the order because they did not have the NPI number and wouldn't be able to complete the X-Ray tonight anyway. RN E stated she reported this to the night shift nurses and they said they would handle it. On 10/27/22 at 2:30 PM, Surveyor interviewed DON B (Director of Nursing) about R1's fall on 10/23/22 and the documentation of care following the fall. DON B stated she was not aware of the X-Ray order given by the physician for R1 on the night of 10/23/22 and was not aware there had been a problem getting a portable X-Ray for R1. Surveyor asked DON B what she expect nursing staff to do if they were unable to carry out a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B stated she would want the nurse to call the physician back as it not the nurses call what to do if the order can not be carried out. On 10/27/22 at 3:20 PM, Surveyor attempted to reach night shift nurse caring for R1 on the night shift 10/23/22-10/24/22, left a message and no return call was received. Surveyor also attempted to reach the on-call physician for 10/23/22, no return call was received. There was no evidence the physician was updated and notified the facility was unable to obtain an X-Ray for R1 as ordered on 10/23/22. R1 was transferred to the hospital on 10/24/22 and found to have a fracture of his left ankle.

Based on observation, resident and staff interview, the facility did not ensure proper infection control practices were maintained related to resident hand hygiene for 7 Residents (R) (R96, R100, R28, R95, R5, R93, and R7) of 7 Residents observed at lunch delivery who were not offered hand hygiene prior to eating lunch. R96, R100, R28, R95, R5, R93, and R7 (300 wing) were not offered hand hygiene prior to the lunch meal. Findings include: The facility's policy, titled Infection Control-Hand Hygiene, dated June 11, 2020 states: Resident hand-hygiene should be offered before and after meals/snacks. On 11/8/21 at 12:03 PM, the Surveyor observed meal trays being passed to 7 of the 14 residents on the 300 wing. No hand hygiene was offered or encouraged to the 7 observed residents, R96, R100, R28, R95, R5, R93, and R7. Following the meal delivery, the Surveyor interviewed Certified Nursing Assistant (CNA)-F, who verified that staff did not always offer hand hygiene to the residents prior to eating. On 11/8/21 at 12:20 PM, the Surveyor interviewed R100 who had a BIMS (Brief Interview for Mental Status) score of 14 out of 15 indicating intact cognition, regarding whether the staff offered hand hygiene to R100 prior to meals. R100 stated R100 had been in the facility for about 3 weeks and that no one had offered to clean R100's hands prior to any of the meals. On 11/8/21 at 12:25 PM, the Surveyor interviewed R7 who had a BIMS score of 13 out of 15 indicating intact cognition, regarding whether the staff offered hand hygiene to R7 prior to meals. R7 stated they [the staff] had never offered hand hygiene prior to R7 eating. On 11/8/21 at 12:30 PM, the Surveyor interviewed R28 who had a BIMS score of 14 out of 15 indicating intact cognition, regarding whether the staff offered hand hygiene to R28 prior to meals. R28 stated R28 had not been offered hand hygiene prior to eating. On 11/8/21 at 12:32 PM, the Surveyor interviewed Registered Nurse (RN)-E regarding the staff not cleaning or offering to clean resident hands prior to meals. RN-E stated it is definitely an expectation that staff should offer hand hygiene prior to meals. RN-E went on to state that the residents previously were eating in the dining room and the hand sanitizer was located close by, but now that the residents are eating in their rooms, it's probably getting forgotten about. On 11/10/21 at 9:43 AM, the Surveyor interviewed Interim Nursing Home Administrator (INHA)-A regarding resident hand hygiene prior to meals. NHA-A stated the expectation is that staff would offer hand hygiene prior to meals.

Based on observation, interview and record review the facility did not provide pharmaceutical services to assure accurate administration of medications for 2 Residents (R) (R30 and R23) of 2 resident reviewed for self-administration of medication. R30 self-administered Refresh Tears eye drops (used to relieve dry eyes) without assessment for safe administration. R23 self-administered [MEDICATION(S)] (used to relieve mouth pain) without a physician's order and without assessment for safe administration. Findings include: Facility provided policy titled Medication Administration with no date stated, To ensure the safe, appropriate and accurate administration and handling of medications at all levels of care . Medications are stored, handled and accounted for in a safe manner complying with federal/state laws and standards of professional practice . E. Self-administration of medications is permitted when: - ordered by the physician. - Medication self-administration assessment is completed and resident demonstrates ability to self-administer medications and store safely and securely, and is documented appropriately. - Monitored by nursing and pharmacy . 1. On 11/8/21, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia (a group of symptoms associated with a decline in memory severe enough to reduce a person's ability to perform everyday activities) without behavior disturbance. R30's Minimum Data Set (MDS) assessment dated [DATE] stated R30's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated R30 had little to no cognitive impairment. On 11/8/21 at 10:25 AM, Surveyor interviewed R30. During interview, Surveyor observed a bottle of Refresh Tears eye drops in a clear bag labeled with a pharmacy label sitting on R30's over-bed table. When questioned, R30 stated, I have eye drops. I had shingles on my face at one time and now my eyelids itch from time to time. R30 indicated R30 put own eye drops in as needed. On 11/9/21, Surveyor reviewed R30's medical record. R30's care plan did not address self-administration of eye drops. R30's medical record contained the following physician orders: ~ Refresh Tears . drops; 0.5 % (percent); amt (amount): 1-2 drops; ophthalmic (eye) Special Instructions: Give one to two drops in each eye 4x/day (four times a day) as needed for dry eyes. ~ FYI (for your information) Special Instructions: Resident may have antifungal powder (used to treat skin irritation caused by fungus growth), [MEDICATION(S)] crm (cream) (used to treat a variety of skin conditions) and [MEDICATION(S)] cream (used to treat inflammation of the skin) at bedside & (and) may self administer. On 11/9/21 at 9:51 AM, Surveyor observed no eye drops in R30's in room. On 11/10/21 at 9:30 AM, Surveyor observed no eye drops in R30's in room. On 11/10/21 at 10:15 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated facility standing orders give facility permission to assess for self-administration of medication. NHA-A indicated facility had conducted self-administration of medication assessment for R30 last night. NHA-A indicated R30 was assessed as safe for self-administer R30's eye drops. On 11/10/21, Surveyor reviewed facility provided documents which included the following: ~ R30's Standing Orders dated 10/16/19 which under Treatments section stated, May self-administer medication & keep at bedside if deemed appropriate following RN assessment. ~ R30's original order for Refresh Tears (as stated above) dated 10/29/19 and did not specify whether or not R30 could self-administer. ~ Self-Administration of Medication assessment for R30 dated 11/9/21 which stated, Refresh eye drops able to self admin prn (as needed) eye drops at bedside. ~ Self-Administration of Medication assessment for R30 dated 1/23/20 which had a circle around Intact for resident to self-administer in cognition section. Plan section was not completed to indicate whether or not resident was able to self-administer meds at bedside. On 11/10/21 at 11:06 AM, Surveyor interviewed Director of Nursing (DON)-G, who was assisting the facility with this survey. DON-G verified R30's self-administration assessment dated [DATE] was incomplete and that R30's Refresh Tears eye drops should not have been left in R30's room without proper orders or assessments in place. 2. On 11/8/21, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] with diagnoses to include Spinal Stenosis (a narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine) of Lumbar (lower back) Region. R23's MDS assessment dated [DATE] stated R23's BIMS score was 15 out of 15 which indicated R23 had no cognitive impairment. On 11/8/21 at 10:43 AM, Surveyor interviewed R23. During interview, Surveyor observed a tube of [MEDICATION(S)] on R23's over-bed table. The [MEDICATION(S)] did not have a pharmacy label and was not in any bag or container. When questioned, R23 stated, It's ([MEDICATION(S)] is) for when I have a sore in my mouth. R23 indicated R23 used [MEDICATION(S)] per self as needed. On 11/9/21, Surveyor reviewed R23's medical record which contained no order for [MEDICATION(S)], no self-administration of medication assessment for R23 and R23's care plan did not address use of [MEDICATION(S)] for sores in R23's mouth. R23's care plan did state in Nutrition/Hydration Risk section, I have had dry mouth with interventions to include, I have an order for [MEDICATION(S)] (used to treat dry mouth) and for [MEDICATION(S)] toothpaste. On 11/9/21 at 11:26 AM, Surveyor observed tube of [MEDICATION(S)] on R23's over-bed table. On 11/9/21 at 1:47 PM, Surveyor interviewed NHA-A who indicated facility was unable to locate self-administration of medication assessment for R23. On 11/10/21 at 10:25 AM, Surveyor interviewed NHA-A who indicated R23 had an order for [MEDICATION(S)] which was discontinued on 6/8/21. NHA-A indicated facility conducted a self-administration for medications assessment yesterday. NHA-A indicated R23 was assessed as safe for self-administer R23's [MEDICATION(S)]. On 11/10/21, Surveyor reviewed facility provided documents which included the following: ~ Self-Administration of Medication dated 11/9/21 which indicated R23 was able to self-administer [MEDICATION(S)]. ~ Physician Order for R23 dated 11/9/21 and stated, [MEDICATION(S)] Oral Liquid: apply to sore tongue every hour as needed for discomfort. May self-administer and keep at bedside. ~ Nursing Progress Note dated 6/8/21 which stated, placed call left message with [named nurse practitioner] requesting order to d/c (discontinue) prn ambesol, RE (regarding) no use > (greater than) 90 days . On 11/10/21 at 11:04, Surveyor interviewed DON-G who indicated staff should have removed [MEDICATION(S)] from R23's room and assessed R23 for need. DON-G stated, Procedure should be followed.

Based on staff interviews and record review, the facility did not ensure required notifications of Medicare Part A non-coverage of services were provided to residents (R) who remained in the facility when Medicare Part A benefits ended for 2 (R1 and R37) of 3 residents reviewed for change of payer source notifications. The facility did not provide R1 with the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form which contained information to assist in making an informed decision when Medicare Part A coverage ended and R1 remained in the facility. The facility did not provide R37 with the SNF ABN form which contained information to assist in making an informed decision when Medicare Part A coverage ended and R37 remained in the facility. Findings include: On 11/9/21, the Surveyor reviewed R1 and R37's documents as part of a sample of residents whose Medicare Part A coverage ended. R1's Medicare Part A benefit ended 8/8/21 and R1 remained in the facility. Surveyor noted R1 or R1's representative did not receive a SNF ABN form. R37's Medicare Part A benefit ended 9/9/21 and R37 remained in the facility. R37 or R37's representative did not receive a SNF ABN form. On 11/9/21 at 11:22 AM, the Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed both R1 and R37 and/or their representatives should have received a SNF ABN form, but did not.

Based on staff interview and record review, the facility did not ensure 2 Residents (R) (R6 and R37) of 2 sampled residents reviewed for discharges and hospitalization s received the required written notice with the date of transfer, reason for transfer, location of transfer, appeal rights and contact information for the State Long-Term Care Ombudsman. R6 was transferred to the hospital on 10/27/21. R6 and/or the resident representative was not provided a transfer notice. R37 was transferred to the hospital on 9/13/21 and 8/20/21. R37 and/or the resident representative was not provided a transfer notice. Findings include: 1. The Surveyor reviewed R6's medical record and it included documentation that R6 was transferred to the hospital on 10/27/21. R6's medical record did not include documentation that a transfer notice was given to the resident and/or the resident representative. 2. The Surveyor reviewed R37's medical record and it included documentation that R37 was transfered to the hospital on 9/13/21 and on 8/20/21. R37's medical record did not include documentation that a transfer notice was given to R37 and/or R37's representative. On 11/20/21 at 11:47 AM, the Surveyor interviewed Director of Nursing (DON)- G, who was assisting the facility with this survey, and Nursing Home Administrator (NHA)-A. Both DON-G and NHA-A confirmed the facility does not have a written form or a process in place for notifying residents and/or resident representatives with notice of transfer.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the appropriate agencies for 1 of 3 residents reviewed (R1). When certified nursing asistant (CNA) D observed CNA C place his hand over R1's mouth and told her to shut up, CNA-D did not report the incident until 48 hours later. This reporting was done by e-mail, which was not received by the Director of Nurses (who was off duty) until another 5 days had elapsed. This is evidenced by: The facility's Abuse, Neglect, Misappropriation, Mistreatment and Exploitation Preventing, Investigating and Mandatory Reporting Policy dated 2/21/17, states in part: . Any nursing home employee or volunteer who becomes aware of mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator. The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements . Immediately: means as soon as possible, when the entity knew or should have known, but ought not to exceed 24 hours after discovery of the incident . 1 Employee Screening and Training . i. All new employees . will be oriented to the Abuse Policy and made aware of their responsibility to report any suspected maltreatment as defined and described in this policy . Training Components: It is the policy of (facility name) to train employee, through orientation and on-going sessions on issues related to abuse and prohibition practices . Findings: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Significant Change MDS (Minimum Data Set) assessment on 5/6/20 notes R1 has severe cognitive impairment. Review of R1's record notes monitoring and tracking of targeted behaviors including agitation and yelling out. R1's Care Plan dated 4/7/20 includes non-pharmacologic interventions to deal with R1's behaviors including in part: toileting, pain monitoring, music on CD player, T. V., aroma therapy, offering R1 space and re-approach if showing signs of agitation (calling out). On 7/2/20 at 9:20 AM and 11:00 AM, Surveyor observed staff providng care to R1, including implementation of appropriate interventions for R1 calling out behaviors. On 7/2/20, Surveyor reviewed facility's Self-report investigation noting an accusation of abuse toward R1 which occurred on evening of 6/8/20. Review of facility investigation notes in part, on 6/8/20 when CNA D (Certified Nursing Assistant) and CNA C were repositioning R1, R1 was calling out and yelling, CNA D witnessed CNA C place his hand over R1's mouth and stated shut up lady. CNA D did not immediately report this event to the facility in accordance to the facility Abuse Neglect, Misappropriation, Mistreatment and Exploitation Preventing, Investigating and Mandatory Reporting Policy. On 6/10/20 at 10:05 PM (48 hours after the event occurred), CNA D sent an email to DON B (Director of Nursing) describing what occurred with R1 and CNA C on 6/8/20. This email was not received by DON B until 6/15/20, as DON B was off duty from 6/11/20-6/15/20. DON B immediately reported this to NHA A (Nursing Home Administrator) on 6/15/20,who reported this to the State Agency and started the abuse investigation. Surveyor reviewed witness statements, interviews and education related to the 6/8/20 incident involving R1. Review of CNA D's interview and statement dated 6/15/20, notes after CNA D's shift on 6/8/20, CNA D reported this event with R1 to CNA E. CNA E told CNA D to report the incident. CNA E's interview and statement noted she heard about the event with R1 on 6/8/20 or 6/9/20 from CNA D, CNA E stated she told CNA D to report it. CNA E said she was not present and would let CNA D report it. It is important to note neither CNA D or CNA E reported the abuse incident for R1 immediately to the facility. On 6/15/20, CNA C and CNA D were immediately suspended from work, investigation notes CNA C was terminated from employment, and CNA D received disciplinary action for not reporting abuse immediately. Investigation notes show CNA D and CNA E received education on 6/15/20 to immediately report resident abuse to NHA A. On 7/2/20 at 2:00 PM, Surveyor interviewed NHA A asking about her expectations for staff reporting abuse. NHA A stated that staff are to immediately report any abuse to their supervisor and then this is to be immediately reported to NHA A. Surveyor asked if abuse should be reported by email, NHA A stated no, it should be reported verbally face to face or directly by phone. Surveyor asked when the facility was aware that an abuse event had not been reported, what the facility did to ensure all staff were educated on reporting abuse immediately. Surveyor asked NHA A why all staff had not received Abuse reporting education immediately? NHA A stated that she thought this was an isolated event and the staff involved had been educated or terminated. NHA A stated on 6/17/20 (2 days after being aware of the event with R1), she sent an email to all staff about abuse reporting and provided a copy of this email to Surveyor. Surveyor asked if NHA A had evidence that all staff had read this email, NHA A stated no, but staff were expected to read email daily. NHA A reported she besides sending the email, all staff had a laminated cards they carried daily which states If abuse is suspected the first thing you do is ensure the resident is safe, and then report to supervisor immediately. NHA A stated all nursing home staff were receiving education and a quiz on abuse reporting and were told they had to complete the education by 7/10/20. Review of abuse education to staff from 6/15/20-7/2/20 noted 22 of 87 nursing staff (25 percent) working in the nursing home had received the facility education and quiz on abuse reporting, 75 percent had not. It was noted that other ancillary staff, outside of the nursing department had received the abuse education before 7/2/20. The facility did not ensure staff reported abuse to NHA A immediately on 6/8/20 for R1. When the facility was notified of the abuse, and aware 2 staff had not immediately reported abuse, the facility did not ensure all staff were immediately re-educated on the facility's Abuse Policy reporting requirements to prevent a delay in reporting resident abuse.

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 53 residents residing in the facility. The following were observed during the survey: Three open bags of vegetables in walk-in freezer without labeling to indicate open or expiration date. Visible dust on oven hood pipes hanging over burners and cooking surface and dirty oven. Hobart mixer was covered and put away with visible food residue splatter from previous use. Two containers of ice cream in stand-up freezer which had evidence on top of container of thawing, leaking out on top, and refreezing. Visible grey dust observed on lights over food prep area. Visible layer of dust around ceiling vent above uncovered utensil storage/prep area. This is evidenced by the facility policy titled, Food Storage, from the Becky Dorner & Associates, Inc. Policy and Procedure Manual, dated (YEAR). This policy states that sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Within the procedures, the policy indicates that frozen foods must be maintained at a temperature to keep the food frozen solid and that all foods should be covered, labeled and dated. All foods will be consumed by their safe use by dates or discarded. On 11/5/19 at 9:38 AM, Surveyor made initial observation of kitchen, assisted by DSM P (Dietary Service Manager) and SC Q (Sous Chef). At this time, Surveyor observed three opened bags of frozen vegetables with no label to indicate open or use-by date. SC Q indicated these open bags were just used today for lunch and stated, Every bag that comes in is labeled. We'll get a label on these. We just used them today for lunch. Surveyor observed a sealed clear plastic bag of frozen cauliflower in the same location of the freezer which did not have a use-by or expiration date. SC Q indicated that the cauliflower they currently have is a substitute item and is in a different bag than normal. SC Q states the facility goes through frozen vegetables very quickly. During initial tour of kitchen, Surveyor observed dirty oven hoods and hood pipes, which DSM P stated are on a six month cleaning schedule and are due to be cleaned by the contracted provider this month. Surveyor observed visible layer of fuzzy dust on the pipes over the stove. No food was on the stove at that time. Ovens were also observed to have greasy build-up and debris. SC Q informed Surveyor that ovens were scheduled for weekly cleaning on Friday. Surveyor then observed Hobart Mixer in the baking area of the kitchen. The mixer was covered and sitting in a dark room. Surveyor asked if the mixer is cleaned each time after use and SC Q indicated that it is. Surveyor asked to remove cover and observed mixer with visible food spatter across the underside of the mixer. Surveyor asked SC Q and DSM P if they would say the mixer was clean. DSM P stated, No. I'll have someone do that. It didn't get cleaned after last use. Surveyor observed stand-up freezer which DSM P stated is the ice cream freezer. Two containers of ice cream in stand-up freezer had evidence on top of container of thawing, leaking out on top, and refreezing. DSM P removed the items at that time. On 11/7/19 at 10:22 AM, during a follow up visit to the kitchen, Surveyor observed lights over food prep area with visible grey dust hanging on surface. Directly below, was preparing pans of cooked honey chicken for the lunch meal. On 11/7/19 at 10:39 AM, Surveyor also observed a ceiling vent with a visible layer of dust in the middle area of the kitchen which was located above an uncovered utensil storage/prep area. Surveyor asked DSM P and SC Q if they would say the light and vent areas observed were clean, and both agreed they were not. The facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Based on interview and record review, the facility did not ensure prompt effort/resolution for a voiced grievance to the facility regarding a missing mouth guard for 1 of 2 residents (R102) out of a sample of 20 reviewed for grievances. R102's FM I (Family Member) voiced a grievance to the facility regarding R102's mouth guard (dental trays) not being in the proper case, knocked off the sink and flushed down the toilet. There is no documentation or follow up of this grievance. This is evidenced by: The facility's policy, Grievance Policy and Program, last updated 10/2/2018, includes, in part: 1. Right to file Grievances: a. Residents and visitors have the right to present grievances on behalf of himself or herself or others to the staff or administrator of (Facility name) either verbally or in writing, to government officials, or to any other persons. b. to receive a written decision related to the grievance filed. Then intent is to evaluate such matters for the purpose of resolution. Procedure: 1. any staff member can receive an initial verbal grievance and it needs to be reported to Nursing Home Administrator within 4 hours. The facility Admission packet includes, in part: (Facility name) Patient and Family Guide: Lost and Found: Please contact nursing supervisor at the nurse's station or social worker for assistance with missing items. The sooner the item is reported missing, the more likely it is to be found. On 11/5/19 at 1:11 PM, Surveyor reviewed the facility Grievance Log and noted there was not a grievance listed for R102's mouth guard. Surveyor asked DON B (Director of Nursing) if she had a grievance for R102's mouth guard. DON B indicated she would look for one as SW K (Social Worker) is on leave at this time. (Please note, no grievance was provided to Surveyor about FM I's concern regarding R102's missing mouth guard.) Review of R102's admission documentation, dated 6/10/19 at 5:23 PM, includes, in part: R102 has dental tray. Review of R102's TAR (Treatment Administration Record), dated 6/10/19 - 7/8/19, indicates, in part: Ensure that dental trays are put in AM and out at HS (bedtime). The TAR is initialed during this time frame. On 11/5/19 at 4:06 PM, DON B gave Surveyor a hand written note by RN [NAME] (Registered Nurse) that states: I recall R102's wife being upset that R102's mouth guard was on the sink and not in the correct container, so when R102 used the bathroom, he knocked it off the sink and it fell into the toilet. I do not recall it being broken or missing. DON B gave Surveyor the following statements: 11/6/19 at 10:20 AM, by previous NHA H (Nursing Hone Administrator), states: In regards to R102's missing or damaged mouth guard. From what I recall, I remember hearing the mouth guard was not secured in its container and that either the resident or the family member had knocked the mouth guard off the counter. I believe on the floor. Since the resident was on the 3rd floor, I can only assume that RN C would have been the initial person to begin the investigation, documenting and communicating with the resident, family and staff. I don't believe I was ever inquired to replace or purchase another mouth guard. 11/6/19, without a time stamp, RN C indicates that she was not aware that R102 was missing any personal belongings. 11/6/19 at 10:34 AM, by RN F, states: R102's wife notified Writer that her husband's mouth guard was on the bathroom counter and was knocked off the counter into the toilet. (Of note, DON B indicated RN F does not recall anything further regarding the mouth guard.) 11/6/19 at 11:53 AM, by SW K, states: I never received a written missing item form for R102 during his stay at (Facility name). On 11/6/19 at 3:26 PM, Surveyor interviewed RN C regarding R102's mouth guard. RN C indicated she does not recall being told about an issue with the mouth guard. On 11/7/19 at 8:04 AM, Surveyor interviewed FM J via telephone. Surveyor asked FM J if R102 had his mouth guard on the day of discharge. FM J indicated no, as it was flushed down the toilet and he did not have it upon discharge. Surveyor asked if they reported this to anyone. FM J indicated FM I filled out paperwork about this with the Social Worker. On 11/7/19 at 8:10 AM, Surveyor interviewed RN [NAME] regarding R102's mouth guard. RN [NAME] indicated R102 had a mouth guard and the facility was to sign it out to make sure it was by the sink in the right spot. RN [NAME] indicated that R102 self -transferred and he knocked the mouth guard off the sink and it fell into the toilet. RN [NAME] indicated it was not in the case, it was sitting on the sink. Surveyor asked RN [NAME] if she documented this. RN [NAME] indicated she did not document this. Surveyor asked RN [NAME] if she told anyone. RN [NAME] indicated she probably mentioned it to a nurse. Surveyor asked what happened to the mouth guard. RN [NAME] indicated, when she went back into the bathroom, it was on the sink. RN [NAME] was not sure if FM I or R102 took it out of the toilet. RN [NAME] indicated the mouth guard was not broken and FM I was upset. Surveyor asked RN [NAME] if she told anyone that FM I was upset. RN [NAME] indicated she didn't remember telling anyone. On 11/7/19 at 8:25 AM, Surveyor interviewed CNA/ MAA G (Certified Nursing Assistant/Medical Administration Assistant) regarding R102's mouth guard. CNA/MAA G indicated when he worked as a CNA he would see the mouth guard sitting on a Kleenex at times. Surveyor asked CNA/MAA G if R102 had the mouth guard on the day of discharge as CNA/MAA G initialed the box on the TAR. CNA/MAA G indicated he did not remember if R102 had it on the day of discharge. On 11/7/19 at 10:38 AM, Surveyor interviewed NHA A regarding R102's mouth guard and documentation of the grievance. NHA A indicated the previous NHA was not asked to replace it. Previous NHA did not fill out a grievance as no one at the facility thought it was a significant issue. This was not made into a big deal. NHA A indicated the facility does not have family fill out a bunch of paper work or forms if something is missing. NHA A indicated the facility was signing out the mouth guard BID (twice daily). NHA A indicated the facility would have known if it was flushed down the toilet. R102's FM I voiced a grievance regarding a dental tray that was not secured in the correct place and flushed down the toilet. The facility failed to have evidence they followed up on this grievance.

Based on observation, interview, and record review, the facility did not ensure residents were treated with dignity and respect in an environment that promotes an enhanced quality of life which affected 3 of 14 residents in 1 of 3 dining areas (R40, R10, and R37). R40 was observed waiting for meal assistance, with her food sitting in front of her, for 16 minutes at one meal and 8 minutes at another meal. R40 was also moved from her placement at the dining table three times during those two meals. R10 was observed to be moved from her placement at the dining table, with her meal sitting in front of her, three times. R37 was observed to be asked to move from his placement at the dining table three times. This is evidenced by: The facility policy titled Service Staff, dated 2013, states, Staff treats each individual as the focus during mealtime to create a person centered dining approach to the dining experience. Procedures include, in part: . 1. Create a welcome atmosphere for residents as they enter the dining room . 3. Keep distraction in the dining areas to a minimum and focus on the individual . 6. Notify appropriate individuals of issues . On 11/5/19 at 12:25 PM, in the East Dining location on the second floor of the facility, Surveyor observed R40 sitting at her table, with her lunch in front of her, with no assistance being provided. R40 was not eating. R40's most recent MDS (Minimum Data Set) assessment, a significant change dated 10/3/19, indicates she requires extensive assistance with eating - resident involved in activity, staff provide weight bearing support. R40 is coded as needing one person physical assist with eating. At 12:41 PM, Surveyor observed CNA O (Certified Nursing Assistant) move R40 away from the table and her food to make room for a kitchen staff member to push a cart through the dining area. R40 was returned to her spot at the table and CNA O then assisted R40 with her meal, after it had been sitting in front of her for at least 16 minutes. R40 did accept food and assistance provided. At 12:48 PM, Surveyor observed CNA O, who noticed a kitchen staff member starting to come out of the serving area with a cart, and asked if she needed to get through. The kitchen staff member said yes, and CNA O pulled R40 away from her table again to make room for staff to pass through with the cart. At 12:51 PM, Surveyor observed CNA N, who noticed another staff member was ready to take R12 out of the dining room and had no room to get through in any direction, move R10 away from her table to allow staff to assist R12 in leaving the dining room. R10 was then returned to her meal at the table. On 11/6/19, at 8:40 AM, Surveyor observed R40 sitting at a different table than the previous day for the breakfast meal. The dining room did not have assigned seating at any table. At this time, R42 entered the dining room. R40 had to be moved from her spot at the table she was sitting at in order for R42 to get to an open spot at another table. Surveyor observed R40's breakfast meal delivered to her and set up at 8:44 AM by LPN R (Licensed Practical Nurse), who then left to continue passing trays to other residents. At 8:52, another staff member sat down to assist R40 with eating her breakfast. At 8:58 AM, Surveyor observed R10 eating her breakfast when a kitchen cart was wheeled from the serving room through the dining area. R10 was pulled back from the table away from her breakfast by a staff member. R37, who was sitting at an adjacent table, was also asked to move in order to make room for staff to push the cart through. There was a delay in pushing the cart through the dining area and R10 sat approximately ten feet away from her table, with her breakfast plate, waiting to resume her meal. R10 pointed towards her food and leaned forward in her wheelchair as though she wanted to be pushed back to her meal at the table. Staff took the cart out of the dining area, and CNA N wheeled R10 back to her spot at 9:00 AM. At 9:02 AM, R10 was approached by staff to move her from her spot again to allow space for another cart to be wheeled through. R10 verbalized disgust and waved her arm. R37 was asked to move again at this time, also. At 9:03 AM, R10 was returned to her table to continue to eat her breakfast, at which time LPN M stated, This rearranging is not cool. I wouldn't want to be interrupted while I was eating. On 11/7/19 at 10:05, Surveyor discussed dining observations with DSM P (Dining Service Manager) and SC Q (Sous Chef). DSM P indicated they were moving residents to another dining location and would be looking into other set up options and/or waiting until the meal was over and residents had left the dining room before kitchen carts were removed from the serving area. DSM P and SC Q both acknowledged they would not want to be moved out of the way during a meal. The facility did not follow its policies and procedures for dining and meal service in making the dining room a welcome atmosphere, keeping distractions to a minimum, focusing on the individual, and providing eating assistance as necessary.

Based on observation, interview and record review, the facility did not ensure that 4 of 5 Residents reviewed (Residents 10, 7, 16 and 4) with pressure ulcers received the necessary treatment and services to promote healing and prevent new and recurrent pressure ulcers from developing. Resident 10 was admitted to the facility at risk for development of pressure ulcers. Resident 10 developed an in-house acquired stage 2 pressure ulcer. Once the pressure ulcer healed, the facility did not implement measures to prevent development of recurring pressure ulcers. The facility failed to provide Resident 10 with appropriate measures to prevent the development of further pressure ulcers. On 12/3/12, Resident 10 developed a recurrent stage 2 pressure ulcer. Resident 7 was assessed as being a high risk for pressure ulcers. The facility did not ensure that preventions were in place per their policy and Resident 7 developed a stage 2 pressure ulcer to her heel. Resident 16 had a pressure ulcer to her coccyx that the facility said was a stage 2. DON B stated it should have been staged as unstageable. Resident 4 was admitted to the facility without a pressure ulcer, Resident 4 developed a recurrent pressure ulcer and the facility did not stage the ulcer correctly. This is evidence by: The article 11/6/00 "Preventing Heel Breakdown" by Marilyn K. Graff, MSN, RN; Janet Bryant, MSN, RN, CNS, CWOCN; and Nancy Beinlich, RN, BSN, CWOCN indicates "the prevalence of heel pressure ulcers is a major health care problem. Heel ulcers develop as a result of pressure, shear, or friction concentrated on a small area over a bony prominence that lacks subcutaneous tissue. Significant risk factors for development of heel breakdown include immobility, age, mental status, nutrition and chronic illness... It is important for nurses to identify patients at risk for heel pressure ulcers and to initiate appropriate preventative interventions". The facility policy and procedure, titled pressure Ulcer Prevention, Assessment, and Treatment, dated November 2011, and revised September 2012, states: A. Policy Statement: A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual clinical condition demonstrates that they are unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infections, and prevent new ulcers from developing. B. Prevention:... 3. development of a temporary care plan with in the first 24 hours may include the following measures: support surfaces for bed and wheel chair, turning and repositioning schedule... heels elevated off the bed...Ongoing prevention Plan and Monitoring: 1. Braden scale Risk assessment to be completed at a minimum of a quarterly basis, with change in condition, or onset of a new wound discovered. Braden scale score of 12 or less indicates further assessment and evaluation to be completed... C. Assessment/Discovery of a Pressure Ulcer: 1. Measure the pressure ulcer... 2. Complete Wound Notification check list. These 2 documents were created to assist the Nurse through the documentation process when a Pressure Ulcer is discovered... a. Notify the Physician... c. Documentation of the pressure ulcer in the nursing progress notes: include category/stage of wound, describe location, measurements...f. Evaluate current interventions and document new interventions being implemented. g. Update/revise the Care Plan... h. Notify Dietician for nutritional consult... 4. Weekly assessment and documentation of a pressure ulcer completed by licensed nurse or wound certified nurse to include; a. date of assessment. b. location of pressure ulcer. c. stage of pressure ulcer. d. size and depth of pressure ulcer...l. Nursing progress notes to reflect progress of wound, risk factors, and care planning goals and interventions as indicated... 5. Wound Care Interdisciplinary Team (IDT) meeting:... d. Braden scale risk assessment score of High risk )12 or less) to review individual prevention plans that are current and to make recommendations to the prevention plan... According to the standards of practice outlined by the NPUAP (National Pressure Ulcer Advisory Panel), the US Department of Public Health's Agency for Health Care Policy and Research, and the "Nurses Clinical Guide to Wound Care" published in 1995, the assessment and documentation of a wound is to include: ~Location of the wound using the correct anatomical descriptors. ~Shape of the wound. ~Documentation of the anatomical position of the person during measuring as this can alter measurements. ~Measurements as Length x Width x Depth in centimeters. ~Measurements using the clock system with 12:00 the person's head and 6:00 the person's feet. ~Note any undermining. ~Note any tunneling. ~Asses and record the wound base and record the types of tissue using percentages. ~Drainage type and odor if applicable. ~The wound edges. ~The surrounding tissue at least 4 centimeters out. ~Presence of pain. The NPUAP also recommends that this documentation take place at least weekly and whenever the wound is visible as with a dressing change. According to the American Medical Directors Association (AMDA) clinical practice guidelines for Pressure Ulcers in the Long Term Care Setting (p. 22), "monitor and document the patients' overall progress and that of the ulcer healing at least weekly..." Example 1 On 1/7/13, at 9:30 AM during the initial tour, Surveyor was informed by RN (Registered Nurse) G according to the Matrix that Resident 10 has a pressure ulcer to her left foot toe. Resident 10 was observed lying in her bed. Resident 10's head of bed was elevated. Resident 10's breakfast tray was placed on the over bed table in front of Resident 10. Resident 10's black shoes were lying on the floor. Resident 10's bed covers were lying directly on top of Resident 10's toes and feet. Resident 10's foot of the bed was observed by Surveyor . Resident 10's foot of the bed did not have a device in place to keep Resident 10's covers from lying directly on Resident 10's toes and feet. Resident 10 was admitted to the facility on [DATE]. Resident 10 has the following diagnoses; Left Foot Hammertoe, Generalized weakness, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION] Resident 10's care plan titled, Potential for skin breakdown, dated 10/3/12, states: Problem: Potential for skin breakdown due to poor nutritional intakes, bowel and bladder incontinence, age, decreased physical activity. Goal: Resident 10 will be clean, dry and free from skin breakdown through next review, date set for 4/8/13. Approaches: 1. provide diet as ordered. Record food intake % at each meal. Report decline in intake to Physician. 2. Resident 10 use the top 1/2 side rails for positioning and mobility. 3. offer food substitutes if Resident 10 refuses to eat. 4. Dietician to evaluate Resident 10's nutritional status. 5. Assist Resident 10 with repositioning every 2 to 3 hours while in bed. 6. Resident 10 has pressure reducing mattress and wheel chair cushion in place. 7. Resident 10 requires assistance with toileting efforts, incontinence care, and incontinence product. Apply barrier cream as needed after incontinent episode. (Resident 10's care plan was not updated or changed when Resident 10 received a pressure ulcer to her left foot on 10/26/12 or when Resident 10 developed a second pressure ulcer to 2nd toe.) Resident 10's care plan titled, Nutrition and Hydration risk, dated 7/23/12, states Problem: Resident 10 is at nutrition and hydration risk related to need for mechanically altered diet. Resident 10 is at risk for abnormal electrolytes. Goal: Resident 10 has a goal weight of 100 to 120 # with no signs or symptoms of dehydration or abnormal electrolytes. Approaches: 1. Provide Resident 10 with verbal encouragement and cues. 2. Remind Resident 10 of swallowing precautions. 3. Monitor intake and output. 4. Monitor changes in condition that may warrant increase supervision/assistance... 5. Resident 10 eats in Restorative dining...7. Monitor for signs and symptoms of dehydration... 8. general Diet.. Consistency of fluid... 9. Laboratory test as ordered... 10. Monitor intakes and document.... Added on 10/18/12 Resident 10 would like oatmeal at breakfast. (It is important to note Resident 10's nutrition care plan has not been updated when Resident 10 developed a stage 2 pressure ulcer on 10/26/12 or when Resident 10 received a second pressure ulcer on 12/3/12.) Resident 10 Minimum Data Set (MDS), with a completion date of 10/17/12, states Resident 10 needs extensive assist with transferring, bed mobility, and personal hygiene. Resident 10 is at risk for skin breakdown and Resident 10 does not have current unhealed pressure ulcers. Resident 10's Care Area Assessment (CAAS), dated 5/1/12, states Resident 10 is at high risk for pressure ulcers due to her lengthy hospital stay... Resident 10 is alert but has some cognitive deficits noted. Resident 10 is frequently incontinent of bowel and bladder. no skin breakdown noted at this time. Resident 10 is requiring extensive assist of one with bed mobility and EZ stand (mechanical lift) for transfers. Resident 10 is weak and is working with therapy but is making slow progress. Weekly skin checks will be completed. Norton score on admission was 13... Will proceed to plan of care due to risk for pressure ulcers. Resident 10's Norton Plus Pressure ulcer scale, dated 10/10/12, states Resident 10's score is 13 placing Resident 10 at moderate risk for skin breakdown... Resident 10's wound assessment report, dated 1/4/13, states Resident 10 risk score is 17. Resident 10 is at moderate risk for skin breakdown... Resident 10's Quarterly Nutrition review, dated 10/18/12, states: Resident 10's current diet is Dysphasia (mechanical altered) with nectar thicken liquids... Skin integrity: Resident 10's skin is intact. At Risk for Pressure ulcers: Resident 10 is not at risk for pressure ulcers. Note written in 10/18/12, Care conference: Resident 10 and family present. Discussed Resident 10's stable weight and intakes. Resident 10's nutritional supplements will be removed related to Resident 10 is not consuming the supplements. No further Nutritional review was provided to Surveyor . Resident 10's physician order, dated 10/26/12, states; 1. Leave Resident 10's left shoe off over weekend. 2. Apply barrier cream to left foot toes pressure ulcer twice a day. 3. Have wound care nurse assess on Monday 10/29/12. Resident 10's nursing notes, dated 10/26/12, at 11:48 PM, states Aide reported to writer that Resident 10 had scant amount of serous drainage to TED ([MEDICAL CONDITION] Embolic Deterrent, compression stockings) hose noted upon removal. Small scabbed area to left foot, 2nd toe (hammer toe)... (Important to note measurements are not completed on Resident 10's 2nd toe pressure ulcer.) Resident 10's nursing notes, dated 10/28/12, at 7:49 AM, states... Very small yellow scab noted to base of left 2nd toe nail. Bilateral lower extremities remains elevated on pillows... (Important to note measurements are not completed on Resident 10's 2nd toe pressure ulcer.) Resident 10's nursing notes, dated 10/29/12, at 12:37 PM, states... Asked to assess left foot 2nd toe... complained of tenderness with touch... Resident 10 states she has had those old shoes forever "not sure if my (Resident 10) feet are old or the shoes?" Observed worn black shoes that have raised ridge where her 2nd toe would be in the shoe... Resident 10 currently wearing slippers... Resident 10's Weekly Summary, dated 10/30/12, shift AM, states... Skin condition: Resident 10's left foot 2nd toe with a stage 2 pressure ulcer... Preventative measures in place; wheel chair cushion, turn and reposition every 2 hours and protective skin barrier ointment... Resident 10's nursing notes, dated 10/30/12, at 10:28 PM, states Redness surrounding stage 2 is reddened, blanchable. Stage 2 has scab intact ... (Important to note measurements are not completed on Resident 10's 2nd toe pressure ulcer.) Resident 10's nursing notes, dated 10/31/12, at 7:31 PM, states ...Resident 10 is requesting a podiatry consult. Writer left message with unit secretary to make an appointment for a podiatrist consult for Resident 10... On 1/10/13, at 10:30 AM Surveyor 2904 requested the report for Resident 10's podiatry visit from 10/31/12 request. RN C stated Resident 10 did not see the podiatrist until 12/3/12. RN C stated the podiatrist comes only once a month and in November Resident 10 was not available when the podiatrist was in the facility. RN C stated Resident 10 was not sent to see a podiatrist when one was requested on 10/31/12, RN C stated the podiatrist comes to the facility on ce a month. On 1/10/13, at 10:30 AM Surveyor spoke with Director of Nursing (DON) B regarding Resident 10's ability to see a podiatrist. DON B stated the podiatrist only comes to the facility on ce a month. Resident 10 did not see the podiatrist upon her request. Resident 10 did not have changes to care plan made related to her shoes. DON B also stated an appointment should have been made for Resident 10 to go see a podiatrist after she was unable to see the podiatrist at the facility. On 1/10/13, at 1:30 PM, Surveyor was handed a one page hand written statement from RN C stating Resident 10 had requested to see (podiatrist after she left for the month (October). Resident 10 was then put on the November list and she was gone to her apartment with her husband that day. (It is important to note no alternative appointment was made for the podiatrist visit until 12/3/12 after Resident 10 developed the second left foot 2nd toe pressure ulcer.) Resident 10's nursing notes, dated 11/1/12, at 11:10 PM, states Dark grey color noted to 2nd toe. skin intact. (Important to note measurements are not completed on Resident 10's 2nd toe pressure ulcer.) Resident 10's nursing notes, dated 11/5/12, at 1:52 PM, states Left 2nd toe is no longer red. Problem resolved... Resident 10's Podiatry note, dated 12/3/12, states: Resident 10 was seen for at risk foot care and wound on 2nd toe (left foot). [MEDICAL CONDITION]: Ulcer noted dorsal left foot 2nd toe. Ulceration noted appears superficial, with slight surrounding [DIAGNOSES REDACTED]. Ulcer measures approximately 0.6 centimeters (cm) by 0.6 cm. Orthopedic: 2nd left toe presents with hammertoe deformity. Left shoe appears distended in this area... Plan... Apply triple antibiotic ointment, aperture pad, band aid to wound on 2nd toe. "At Patient (Resident 10's) request, left shoe was modified to better accommodate this toe." Recommend extra depth shoe for Resident 10. Resident 10's Physician order, dated 12/3/12, states: Apply triple antibiotic ointment to 2nd toe left foot and cover with a Band-Aid. Perform once per day until ulceration is healed. [DIAGNOSES REDACTED]. Resident 10's nursing notes, dated 12/3/12, at 6:46 PM, states Apply triple Antibiotic ointment to 2nd toe (hammer toe) left foot... (Important to note measurements were not completed on Resident 10's 2nd toe pressure ulcer.) Resident 10's nursing notes, dated 12/3/12, at 11:05 PM, states Resident 10's 2nd left toe has an open area to the top of it. Beefy red center with drainage noted... (Important to note measurements were not completed on Resident 10's 2nd toe pressure ulcer.) Resident 10's Wound Assessment report, dated 12/6/12, states: 1. Wound type: Pressure ulcer. 2. Wound location: Left foot 2nd toe. 3. Date wound identified 12/6/12. 4. Stage of pressure ulcer: Stage 2. 5. Measurements: Length -, Width -, Depth -. (It is important to note measurements were not completed for Resident 10's 2nd toe pressure ulcer.)... Notes: Pressure ulcer to left 2nd toe and Physician treatment order for the wound (pressure ulcer) on 12/3/12. Resident 10's Dining Service Communication form, dated 12/10/12, states; Resident 10 has decrease 1000 milliliters in the past 72 hours of fluid intake... (Resident 10's Dining Service Communication form does not state Resident 10 has a stage 2 pressure ulcer.) Resident 10's nursing notes, dated 12/13/12, at 1:31 PM, states weekly skin check on shower/bath day. No new changes noted. (It is important to note measurements were not completed for Resident 10's 2nd toe pressure ulcer.) Resident 10's nursing notes, dated 12/20/12, at 11:09 AM, states weekly skin check on shower/bath day. No new skin issues. (It is important to note measurements were not completed for Resident 10's 2nd toe pressure ulcer.) Resident 10's Wound Assessment report, dated 12/20/12, states: 1. Wound type: Pressure ulcer. 2. Wound location: Left foot 2nd toe. 3. Date wound identified 12/6/12. 4. Stage of pressure ulcer: Stage 2. 5. Measurements: Length -, Width -, Depth -. (It is important to note measurement were not completed for Resident 10's 2nd toe pressure ulcer.)... Wound edges: Border definition: Distinct, outline clearly visible. Description- Macerated... Notes: Pressure ulcer to left 2nd toe and Physician treatment order for the wound (pressure ulcer) on 12/3/12. Resident 10's nursing notes, dated 12/23/12, at 3:37 PM, states Left 2nd toe has red wound bed. Had small amount of serous drainage on Band-Aid... There are no measurements completed for Resident 10's left 2nd toe pressure ulcer. Resident 10's nursing notes, dated 12/26/12, at 10:36 AM, states Asked to assess left foot 2nd toe (hammer toe), observed band-aid, once removed base is pink and open approximately 0.5 cm by 0.5 cm peri-wound with in normal limits... staff nurse stated it looked sloughy the other day... suggested changing to [MEDICATION NAME] every 4 days, intervention ace wrap, shoe has "X" cut into top of shoe 2nd toe to relieve pressure. prepared by wound care certified RN (Registered Nurse) C. Resident 10's nursing notes, dated 12/26/12, at 2:53 PM, states Called Resident 10's Physician requesting new treatment for [REDACTED]. Left 2nd to has no S/S (signs or symptoms) of infection but is healing very slowly. Resident 10's Physician order, dated 12/26/12, 1. Discontinue [MEDICATION NAME] order left 2nd toe. 2. Apply [MEDICATION NAME] to left 2nd toe and change every 3 days. Resident 10's nursing notes, dated 12/27/12, at 9:00 AM, states weekly skin check on shower/bath day. No new skin issues. (It is important to note measurements were not completed for Resident 10's 2nd toe pressure ulcer.) Resident 10's Dining Service Communication form, dated 12/27/12, states; Resident 10 signed risk agreement for cold cereal... Resident 10's Dining Service Communication form does not state Resident 10 has a stage 2 pressure ulcer. Resident 10's Wound Assessment report, dated 12/27/12, states: 1. Wound type: Pressure ulcer. 2. Wound location: Left foot 2nd toe. 3. Date wound identified 12/6/12. 4. Stage of pressure ulcer: Stage 2. 5. Measurements: Length -, Width -, Depth -. (It is important to note measurements were not completed for Resident 10's 2nd toe pressure ulcer.)... Notes: Pressure ulcer to left 2nd toe and Physician treatment order for the wound (pressure ulcer) on 12/3/12. Changed to [MEDICATION NAME] on 12/27/12. Resident 10's nursing notes, dated 12/31/12, at 12:58 PM, states Left 2nd toe is without S/S of infection. Peri-wound is slightly pink...(It is important to note measurement were not completed for Resident 10's 2nd toe pressure ulcer.)... Resident 10's Wound Assessment report, dated 1/3/13, states: 1. Wound type: Pressure ulcer. 2. Wound location: Left foot 2nd toe. 3. Date wound identified 12/6/12. 4. Stage of pressure ulcer: Stage 2. 5. Measurements: Length -, Width -, Depth -. (It is important to note measurements were not completed for Resident 10's 2nd toe pressure ulcer.) Resident 10's nursing notes, dated 1/5/12, at 10:16 AM, states Left 2nd toe ulceration is with the scab intact... scant drainage to old dressing...(It is important to note measurement were not completed for Resident 10's 2nd toe pressure ulcer.) Resident 10's nursing notes, dated 1/7/12, at 10:47 AM, states scab intact Left 2nd toe...(It is important to note measurement were not completed for Resident 10's 2nd toe pressure ulcer.) On 1/10/13 at 8:05 AM Surveyor and RN (Registered Nurse) D observed Resident 10's left 2nd toe. Resident 10 lying on her bed. Resident 10's feet covered by a sheet. Resident 10's sheet was lying directly on top of Resident 10's open left 2nd foot pressure ulcer. Resident 10's Left 2nd toe pressure ulcer approximately measures 0.6 cm by 0.6 cm. Resident 10's left 2nd toe pressure ulcer was observed with a pink center and yellow slough appearance surrounding the wound bed. Surveyor asked RN D when the hole was placed in the top of Resident 10's shoe. RN D stated the hole was just recently placed after her left foot 2nd toe pressure ulcer developed on 12/3/12. Resident 10's black shoes were lying on the floor. Resident 10's foot of the bed was observed by Surveyor . Resident 10's foot of the bed did not have a device in place to keep Resident 10's covers from lying directly on Resident 10's toes and feet. On 1/10/13, at 8:05 AM, Surveyor asked RN D how Resident 10 received the open area to her left 2nd toe. RN D stated it was from pressure from Resident 10's shoe. RN D stated yes Resident 10's open area is a pressure ulcer. On 1/10/13, at 10:30 AM Surveyor spoke with DON (Director of Nursing) B and RN C regarding Resident 10's 2nd left foot pressure ulcer. Surveyor requested measurements for Resident 10's original left foot pressure ulcer on 10/26/12 and recurrent on 12/3/12. DON B stated Resident 10's original pressure ulcer was not measured. DON B also stated there are no current measurements for Resident 10's current left 2nd toe pressure ulcer. On 1/10/13, at 10:30 AM, Surveyor and DON B reviewed Resident 10's current Skin care plan. DON B stated Resident 10's care plan should have been revised with interventions to prevent reoccurrence of her pressure ulcer to her 2nd toe. DON B stated Resident 10's care plan has not been update or revised since 10/3/12 prior to Resident 10's original left 2nd toe pressure ulcer. On 1/10/13, at 10:30 AM Surveyor spoke with RN C regarding facility policy of pressure ulcer. RN C stated pressure ulcers are to be reported to RN C when the pressure ulcer occurs. RN C also stated pressure ulcers are to be measured weekly by RN C or the RN on the unit. In addition, RN C stated she was not aware of Resident 10's pressure ulcer, and Resident 10's pressure ulcer has not been measured. No further information was provided to Surveyor . On 1/10/13, at 10:30 AM Surveyor spoke with RN C regarding preventative items in place after Resident 10 received her first pressure ulcer. RN C stated the care plan was not changed to prevent Resident 10's recurrent pressure ulcer. RN C stated Resident 10 continued to wear her black shoes. RN C stated Resident 10 is to see a specialist to get fitted for new shoes in a couple of weeks. Resident 10 developed a pressure ulcer to her left 2nd toe (hammer toe) on 10/26/12. The facility did not implement preventative interventions to prevent a second pressure ulcer from developing on 12/3/12 to Resident 10's hammer toe. In addition, the facility did not complete measurements to Resident 10's previous or prior pressure ulcers to her left 2nd toe. Example 2 Resident 7 was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. Resident 7s annual Minimum Data Set ((MDS) dated [DATE] states Resident 7 has severe cognitive impairment. Section G indicates she is totally dependent on a minimum of 2 staff for bed mobility and transfers. Section M states she is at risk for pressure ulcers but did not have any at the time of the assessment. Resident 7s Braden Assessment completed by the facility on 10/16/12 states she has a score of 11 indicating she is a high risk for pressure ulcers. Resident 7s care plan dated 5/4/12 for skin indicates she is at risk for skin problems. It is important to note that it does not indicate an intervention to protect her heels from pressure, friction or shearing. Resident 7s Wound Assessment Report dated 11/14/12 states a stage 2 pressure ulcer was identified on 11/12/12 to her right heel. It measured 4.6 cm in length by 4.1 cm width and no depth. It was a intact clear fluid filled blister. A physician's orders [REDACTED]. On 1/10/13 at 10:15 AM Surveyor interviewed RN C, in charge of following the wounds in the facility, who stated that Resident 7s Braden score from 10/16/12 had not been relayed to her. RN C stated that heels should be floated as a standard of care but did not know if staff was floating Resident 7s heels prior to her acquiring the pressure ulcer on 11/12/12. RN C stated that Resident 7 should have had heel protection such as boots prior to Resident 7 obtaining the pressure ulcer. It is important to note that the facility did not follow their policy to review preventions for residents with a Braden score of 12 or less for Resident 7 on 10/16/12. Example 3 The facility Director of Nursing (DON) B identified the National Pressure Ulcer Advisory Panel (NPUAP) as a standard of practice the facility uses. Surveyor viewed the following on the NPUAP website on 1/14/12. NPUAP Pressure Ulcer Stages/Categories ...International NPUAP-EPUAP Pressure Ulcer Definition: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages/Categories ... Category/Stage II: Partial thickness: Partial 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 III: Full thickness skin loss: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable ... Additional Categories/Stages for the USA. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown: Full 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. Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 16s quarterly Minimum Data Set ((MDS) dated [DATE] states Resident 16 had moderate cognitive impairment. Section M indicated that Resident 16 had previous pressure ulcers and was at risk for pressure ulcers. Resident 16's care plan dated 1/16/12 for ADLs (activities of daily living) indicates she is on comfort care (end of life care). Resident 16's Wound Assessment Report dated 8/20/12 states she acquired a pressure ulcer to her coccyx on 3/28/12. The report states Resident 16s pressure ulcer is a stage 2 with Macerated surrounding skin, scant serous drainage, 50% granulation tissue, 50% slough, and measures 2.4 cm length, 2 cm width, and 0.1 depth. On 1/10/13 at 2:30 PM Surveyor interviewed Director of Nursing (DON) B who stated that Resident 16's pressure ulcer to her coccyx on 8/20/12. DON B stated that she was looking at the staging process. After reviewing with Surveyor DON B stated that on 8/20/12 Resident 16s pressure ulcer to her coccyx should have been staged as unstageable not a stage 2 pressure ulcer. Example 4 Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4s quarterly Minimum Data Set ((MDS) dated [DATE] states Resident 4 has moderate cognitive impairment. Section G indicates she transfers and ambulates independently. Section M states she is not at risk for pressure ulcers and does not have any at the time of the assessment. Resident 4s Braden Assessment completed by the facility on 1/8/13 states that Resident 4 has a score of 18 indicating she is low risk for pressure ulcers. Resident 4s care plan dated 8/17/12 for skin indicates she is at risk for skin problems. It is important to note that it does not indicate an intervention to relieve pressure from Resident 4's ankles and heels when Resident 4 sits in the stationery chair in her room, with her wheelchair in front of her and elevates her legs on the wheelchair. Resident 4s right foot falls to the right, putting pressure on her right lateral malleolus. On 1/6/13, it is first noted on a Wound Assessment Report that Resident 4 has a pressure ulcer on her right lateral malleolus. The report indicates "3.5cm outer aspect with black edge." This assessment was completed by LPN O. On 1/6/13, LPN O documents the following electronic Wound Assessment Report: "dr. (attending physician) here to see resident tomorrow on mon 1/7/13 will leave a note for him to see wound, this wound is old and was healed, bot (sic) appears to have a rolled dr brown edge around wound, unable to tell if there is tunneling, resident denies pin, no drainage present, is on abx (antibiotics) already but needs to be assessed by wound clinician or md. It is important to note that the Registered Nurse (RN) on duty was not notified, nor was the physician notified. These notifications were not made until the following day, 1/7/13, and a treatment was given with without an order. The treatment order was not received until 1/7/13. On 1/7/13, RN K documents the following electronic Wound Assessment Report: "Resident is alert but confused. Right lower extremity has brown staining to lower extremity. Trace [MEDICAL CONDITION] to right lower extremity. Stage II-base was 50% scab, 50% pink tissue, peri-wound is within normal limits. No drainage noted. No pain noted. Goal is to heal. Treatment order received from Medical Doctor (MD) [MEDICATION NAME] every 4 days/multi-vitamin every day /Hydration Program increased to 100cc three times a day. Resident states she sleeps on her right side. Will reposition off right side while in bed. Referred to Hospice. On 1/8/13, LPN O documents the following hand-written addendum to the electronic Wound Assessment Report dated 1/6/13. "Addendum - wound to right ankle is stage 2, 10% 6-9 o'clock, has black tissue and 12 to 2 o'clock presents with black tissue, 90% pink tissue in base, edges were rolled, no drainage, no discomfort, peri wound has brown staining and shiny, no [MEDICAL CONDITION], correction, this is not an old wound, but a new wound. Family is aware of wound; family has been here most of day. On 1/8/13 at 10:45 AM, RN K documents the following nursing note: Writer assessed new Stage II on right ankle on 1/7/13 at 0800. Resident is alert but confused. Right lower extremity has brown staining to lower extremity. Trace [MEDICAL CONDITION] to right lower extremity. Stage II-base 50% scab, 50% pink tissue, peri-

Based on interview and record review the facility did not ensure that a resident maintains acceptable parameters of nutritional status such as body weight and protein levels unless residents clinical condition demonstrates that this is not possible for 1 resident out of 9 reviewed (Resident 1). Resident 1 was admitted to the facility on [DATE] at a weight of 194 pounds. On 12/2/10 her weight dropped to 190 pounds. On 12/8/10 her weight dropped significantly to 180.9 pounds. The physician was not called and reweigh was not done. On 12/13/10 Resident 1's weight was 178 and on 12/14/10 her weight dropped again to 174 pounds for a total of 20 pounds in 15 days. Resident 1 received [MEDICATION NAME] for 6 days in error and the facility was doing a complete head to toe assessment on Resident 1 on 12/14/10 and this is when the physician was notified of the significant weight loss. Resident 1's appetites for the first 14 days of December were poor and continued to be poor. No new interventions were added due to the 10 pound weight loss on 12/9/10 to attempt to slow or stop the weight loss. Resident 1 was sent to the ER to be evaluated and was admitted due to dehydration, abdominal bloating, [MEDICAL CONDITION], failure to thrive, and [MEDICAL CONDITION]. Findings as follows: On 7/30/10 a new policy for weighing residents was put into place. The Policy includes the following: Long term care resident will be weighed on a weekly basis. The reason for the change is to identify a weight loss or gain quicker and to correct any inaccuracies. The physician and dietitian needs to be notified timelier if there is a significant weight gain or loss. The bath sheet is updated to reflect the weight on shift of weekly bath, previous week weight and last month weight. Directions for the parameters of weights are to: A 3 pound or greater weight discrepancy requires that following follow-up action be taken , 1) Notify Dietary via Dietary Communication Form, 2) Place on 24 hour board, pink dot for reweigh following day shift, 3) Nurse compare reweigh and notify the MD immediately if continues with 3 pound or greater discrepancy. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Report for Nursing Home Discharge form dated 11/29/10 states that she has po (per os or by mouth) intake without nausea, but poor appetite. The hospital weight is 201#. Resident 1's care plan dated 12/8/10 initiates a potential for alteration in nutrition due to mechanically altered diet and high BMI (body mass index). Resident 1's goal is that she will eat at least 73% with weight to 185-195#. Interventions listed are: diet per MD order, dietary to determine food and fluid preferences, observe for signs of dehydration, provide bedside source for water at all times, monitor food intake and document, nutritional supplements per RD, wt per schedule, and Monitor as NAR r/t potential for inadequate nutrition. There are no updates or interventions changed on Resident 1's care plan since initiated on 12/8/10. Resident 1's CAA ( Care Area Assessment) for eating pattern dated 12/8/10, states that Resident 1 leaves significant proportion of meals, snacks, and supplements daily. The analysis and findings section of the CAA states that Resident 1 triggers related to mechanically altered diet and high BMI. Nutritional status complicated by poor appetite, which has also happened in the past after surgeries. Risk of weight loss. Resident receives nutritional supplement with meals. Risk of electrolyte imbalance related to diuretic. Resident 1's initial Dietary assessment dated [DATE] indicates that Resident 1 is at nutritional risk due to poor appetite, bowel surgery, and morbidly obese BMI, and Resident 1 is at great risk of dehydration due to being on 3 diuretics used to manage fluid balance. The plan is to monitor for adequacy of intake to meet nutrition and hydration needs. A dietary note dated 12/1/10 sates that Resident 1's daughter was spoken with and stated that her appetite has improved a little since the summer due to [MEDICAL CONDITION] diarrhea, was drinking ensure at home, and likes yogurt. Will request hydration program and will provide mighty shakes with meals. On 12/1/10 a Physician's telephone order states, "Hydration Program- 80 cc TID." Resident 1's weight on 11/30/10 was 194# on 12/1/10 was 195#, on 12/2/10 was 190 pounds. This is a 5 pound weight discrepancy in 1 day and there is no reweigh of this weight to confirm the weight on 12/3/10, per policy. Resident 1's meal intake averages for the first 8 days of December were as follows: 12/1-33%, 12/2-33%, 12/3-25%, 12/4-67%, 12/5-83%, 12/6-25%, 12/7-25%, and 12/8-25%. This is an average of 39% intake of meals per day. On 12/8/10 a Dietary Progress note states, "Wt 11/30 194#, 12/1 195#, and 12/2/10 190#. Resident to be weighed tomorrow. PO intakes usually 25-50%. Will request 2 -Cal with med pass. Resident states that in the past after surgeries she has had poor po intakes. States she drinks the mighty shakes. A physician's telephone order dated 12/8/10 reveals that an order for [REDACTED]. A physician Tetephone message from the clinic dated 12/8/10, no time noted, states that the Dietitian calls, Re: wt. loss, 2 cal 80 cc with med TID ok per MD initials. The message does not indicate what the weight loss is. Resident 1's weight tracking sheet has Resident 1's next weight as 180.9 on 12/9/10. On 12/10/10 the square is boxed in and 're-weigh' is written in the box but no weight was documented. There is no indication that dietary was made aware or followed up on the Resident 1's weight for a continued weight loss of 10 pounds in a week. On 12/9/10 a Dietary progress's note states that care conference was held, and 2 cal has been ordered. Discussed intakes and weight. There is still no indication that Dietary or a physician was made aware of Resident 1's 10 pound weight loss in 1 week. Resident 1's daily meal consumption is recorded and is averaged on a daily basis as 12/9-16%, 12/10-25%, 12/11-8%, 12/12-0%, 12/13-16%, and 12/14-0%. This is a daily average of 11% of meal consumption. On 12/11/10 a Dining Service Communication form was in Resident 1's medical record which stated in the comments section, Decrease in fluid intake-780cc, 960cc, and 780 cc. There is no documentation in Resident 1's medical record that this Nursing to Dietary communication form was acted upon by dietary. No new interventions are added to Resident 1's care plan even though continued weight loss was occurring. A review of Resident 1's nursing notes dated 12/1/10 at 2:20 PM reveals that her blood pressure had been running low (87/54, 78/49) and the MD was called and updated with orders received to discontinue her [MEDICATION NAME] (diuretic). On 12/10/10 at 4:13 PM nursing note indicates that Resident 1's Blood Pressure was again abnormally low (71/41) and her MD stated to discontinue her [MEDICATION NAME]. A nursing note on 12/11/10, at 11/05 PM indicates that her blood pressure is still low (84/48) and an order is received to decrease her [MEDICATION NAME] from twice daily to once daily. There is no information that at any phone call the physician was updated on Resident 1's significant weight loss. On 12/13/10 at 2:03 PM a nursing notes indicate that Resident 1 was accidentally and erroneously given [MEDICATION NAME] 4 mg for 6 days and she had a critically high INR (International Normalized Ratio) called from the lab. Resident 1 was assessed and an MD was called and told of the medication error and continued loose stools. Resident 1 was given Vitamin K to counteract the blood anti-clotting effects of [MEDICATION NAME] on 12/13 and 12/14. On 12/14/10 at 5:30 PM Resident 1 was having abnormal abdominal concerns and orders were received to get X-rays, and to follow up with Resident 1's surgeon on 12/15/10 with an evaluation. Resident 1 was diagnosed with [REDACTED]. It occurs most commonly after abdominal surgery, particularly when the intestines have been manipulated. Symptoms are nausea, vomiting, and vague abdominal discomfort). Resident 1 had a total of 20 pound weight loss in 14 days with no specific physician notification of the actual loss. On 12/15/10 Resident 1 was sent to the emergency room for evaluation. Resident 1 was admitted with abdominal bloating, [MEDICAL CONDITION], failure to thrive, dehydration and [MEDICAL CONDITION]. Resident 1's hospital Clinical Nutrition Consult/assessment dated [DATE] indicates the following assessment: "Per pt's RN pt has a very poor appetite with chronic diarrhea. Pt has not been tolerating ensure at the nursing home prior to admission. Consult received regarding pt with very poor appetite. Ensure until pt evaluated further. admitted with dehydration/[MEDICAL CONDITION]/diarrhea. Height 5 feet. Weight history-11/19/10-198#, 11/28/10- 201 #, and 12/15/10 173#. Pt is at nutrition risk given her advance age, chronic diarrhea, recent bowel surgery and 25 pound weight loss in approximately a months time. On 2/3/10 at 3:45 PM Surveyor interviewed Dietitian F regarding Resident 1's weight loss. Dietitian F reviewed her notes and Resident 1's medical record and stated that she had requested 2 Cal for Resident 1's weight loss but was unable to state if she told the MD what the weight loss was. Dietitian F stated that she made the request on 12/8 so the weight loss from her admission to 12/6 is what she was calling the MD about. Dietitian F also stated that she did not have the 10 pound weight loss information when she attended the care conference on 12/9/10.

Based on interview and record review the facility did not ensure that residents are free of any significant medication errors for 2 residents out of 9 reviewed (Residents 1 and 9). Resident 1 did not have an order to receive [MEDICATION NAME], a medication to prevent clotting of the blood, when admitted to the facility. On 12/6/10 an order was written for [MEDICATION NAME] 4 mg to be given to Resident 1. Resident 1 received [MEDICATION NAME] for 6 days in error; the order was actually given for a different resident with a similar name. Resident 1 was noted with a critical high INR (International Normalized Ratio) on 12/13/10 and received 2 doses of Vitamin K to counteract any bleeding symptoms. Resident 9 was admitted to the facility with a physician order [REDACTED]. Resident 9 missed 3 doses of [MEDICATION NAME] 40 mg SQ after admission to the facility. He received the medication every other day instead of every day for the first 5 days placing the resident at risk for a blood clot. Findings as follows: Example 1 Resident 1 was admitted to the facility on [DATE] after bowel surgery for [REDACTED]. On 12/6/10, staff received a physician telephone order for [MEDICATION NAME] 4 mg po (by mouth) re-check INR (International Normalized Ratio) on 12/13/10. During the phone call it was stated to "change" the dose of [MEDICATION NAME]. Resident 1 was not on any [MEDICATION NAME] before this order on 12/6/10. A nursing note on 12/13/10 at 2:03 PM states that MD was called to report continued loose stools and also updated on critically high INR of 5.8. (A normal INR for a person who is not on [MEDICATION NAME] therapy 0.86-1.4 and a person who is on [MEDICATION NAME] the INR should be between 2 and 3.) A physician's orders [REDACTED]." A nursing note on 12/13/10 at 10:18 PM states that orders were obtained for a dose of Vitamin K for high INR results, guaiac stools, and to monitor for bleeding. Resident 1's INR lab result for 12/14/10 is 4.9. On 12/14/10 orders were received for another dose of Vitamin K 5 mg PO "now." A nursing note on 12/14/10 at 6:54 PM, states to hold ASA (Aspirin) for the next 7 days. A note at 9:12 PM states that MD was updated due to stool was positive for blood. The physician also stated to be sure to make sure that she is sent out to see surgeon on 12/15/10 as planned. Resident 1 was admitted to the hospital on [DATE]. Resident 1's Hospital Discharge Summary dated 12/23/10 states the following: Resident 1 was admitted to the hospital on [DATE] with abdominal bloating, [MEDICAL CONDITION], failure to thrive, dehydration and [MEDICAL CONDITION]. The patient had been incorrectly and accidently started on [MEDICATION NAME] for 1 week prior to admission by the nursing staff at (facility name) and her pro time/INR was 4.9. It was not felt that this was a direct contributing factor to the ileus. A review of Resident 1's Medication Error Report dated 12/13/10 reveals the following investigation of the details of the error. The nurse received an order for [REDACTED]. The [MEDICATION NAME] was not intended for Resident 1. Interventions that were implemented as a result of the medication error are to Update INR/[MEDICATION NAME] form to include MD to be notified, birthdays, and goal. New protocol with all telephone orders to identify residents name and date of birth to ensure correct resident. A memo will be sent to all licensed staff as well as further discussion at licensed staff meeting on 12/21 and 12/23/10. On 1/18/11 and 1/20/11 an agenda of a nurses meeting states that [MEDICATION NAME] order transcriptions for licensed nurses will be covered and 17 nurses signed off as attending and receiving the information. The facility did not have any information that residents' that are currently in the facility were reviewed to make sure that they were receiving the correct [MEDICATION NAME] dose. On 2/3/11, at 2:00 PM Surveyor interviewed DON B regarding medication errors. DON B stated that since the medication error of [MEDICATION NAME] the procedure for obtaining any orders related to [MEDICATION NAME] have changed to ensure the correct patient and the right orders. Nurses have had inservices related to [MEDICATION NAME] orders. Medication errors are tracked and brought to every Quality Assurance committee. We have reviewed other errors and now pharmacy is supposed to review our medication administration records with the admission orders [REDACTED]. Example 2 Resident 9's [DIAGNOSES REDACTED]. On 12/16/10 Resident 9 was admitted to the facility with a physician order [REDACTED]. Resident 9 missed his dose of [MEDICATION NAME] 40mg SQ on 12/17/10. This placed him at risk for developing blood clots due to his lack of mobility. The next dose of [MEDICATION NAME] Resident 9 missed was 12/19/10. This placed the resident at risk for developing blood clots. Resident 9 did not receive [MEDICATION NAME] 40mg SQ on 12/21/10, again, placing the resident at risk for developing blood clots. On 2/3/11, at 2:45 pm Surveyor asked RN (Registered Nurse) D what the facility's process is to make sure the medications are given as ordered. She said the unit secretary transcribes the physician order [REDACTED]. She said the unit secretary put the order in the computer as every other day then the nurse checked it but the mistake was not noted and changed.

Based on observation, interview and record review the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care related to pain for 3 resident out of 18 reviewed (Residents 3, 4, and 5), contributing to ongoing pain. The facility did not assess Resident 3 with regard to her continuing pain, did not care plan pain management interventions, and did not assess and document the effectiveness of the medications given. The facility did not assess Resident 4 with regard to her continuing pain, and did not assess and document the effectiveness of the medications given. The facility did not assess Resident 5 with regard to her continuing pain, and did not assess and document the effectiveness of the medications given. This is evidenced by: The facility policy "Pain Management" dated Revised 4/08 indicates: "Statement of Pain Management: All residents have a right to pain relief." Health care providers will: 1. Inform residents at the time of admission that relief of pain is an important part of their care. 2. Respond quickly to reports of pain. 3. Ask residents on initial assessment and as a part of regular assessments about the presence, location, quality, and intensity of their pain. the residents self report will be their primary indicator of pain. 4. Review and modify the plan of care for residents who have unrelieved pain. Standard I: Key points indicates the following.... 1. The pain intensity and pain relief as reported by the residents will be assessed and documented: on admission, quarterly, after known pain-producing events, with each new report of pain, weekly to be addressed in the nursing summary, and at the time PRN (as needed) dosing with narcotic pain medication. 2. Residents with PRN [MEDICATION NAME] (pain medications) will be assessed using an appropriate pain scale, Example 0-10 numerical pain scale with an acceptable level of pain (ALP). Those residents with a significant cognitive impairment will be assigned a behavior pain scale. Pain scale will be done at the time of the administration of the pain medication and pain scale to be completed with effectiveness one hour after the pain medication administration. Significant unrelieved pain will be reported to the physician.... On 11/30/10 at 1:25 PM Surveyor 4 spoke with Licensed Practical Nurse (LPN) H regarding the documentation of effectiveness after a resident has received a pain medication (med). LPN H stated she has not been going back and asking the residents if the pain medication was effective after giving a PRN (as needed) pain medication. LPN H also indicated the effectiveness documentation is to be placed into the computer on how effective the pain medication was by using the pain scale rating. LPN H stated she is not sure what the next shift does after a pain medication is given, but if there is no note documented and no scale rating used then there is no follow up for effectiveness completed. On 12/1/10 at 9:40 AM Surveyor spoke with Unit Manager (UM) F regarding documentation after a PRN pain medication was given. UM F stated the expectation is that the nurses are to go back to the resident after 1 to 1 1/2 hours of taking the pain medication and ask the resident if the pain medication was effective. UM F indicated that going back to ask is the facility's standard of practice. UM F stated that if the pain medication is not effective then the nurse is expected to update the physician on the ineffective pain management. UM F indicated that the word effective meant that the pain was under control according to the resident and the plan of care. UM F indicated that the nurse should document in the nurses notes the effectiveness, but there is no clear system in place at the facility for documenting the effectiveness of the pain medication. UM F continue to indicate the expected time for a resident is to wait for a PRN pain medication to be given after the resident requested one is 5-7 minutes maximum. On 12/1/10 at 1:50 PM Surveyor spoke with LPN H regarding pain management and medication administration. LPN H indicated when giving any resident a PRN (as needed) pain medication she will ask the resident how many pills the resident would want; if the resident only wants 1 pain pill, LPN H indicated she will only give the resident 1 pain pill. LPN H continued to indicate if the resident's pain is 10 out 10 on the pain scale and 1 pill was not effective before to manage the residents pain but the resident wanted just 1 pain pill, then LPN H would give the resident only 1 pain pill. On 12/1/10 at 1:50 PM Surveyor continued to speak with LPN H regarding what indication or justification does LPN H use when giving medication that is ordered to "give 1 or 2 tablets" or when the order indicates "give 5 mg, 10 mg or 15 mg [MEDICATION NAME]" without any directions to give. LPN H stated I give what ever the resident wants; if the resident wants 1 pain pill, LPN H indicates she would give 1 pain pill. LPN H further indicated she would give 1 pain pill no matter how high the resident pain was on the 0-10 pain scale. On 12/1/10 at 2:15 PM Surveyor spoke with Director of Nursing (DON) B regarding indication of usage for pain medication and when to give a certain amount of pain medication. DON B stated the expectation would be to call the physician and clarify the order of when to give the number or amount of pain medication according to the amount of pain the resident is having. DON B continued to indicate the expectation is that every resident who receives a PRN pain medication is to have a pain scale done prior to the giving of the medication and at least 1 hour after receiving the pain medication to make sure the medication is effective. Example 1 Resident 3 was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Resident 3's Minimum data set (MDS), dated [DATE], indicates that Resident 3's pain has been frequent over the past five days, and Resident 3 indicates that she rated her pain level at its worse at the time of the assessment as a 10. Resident 3's Care Area Assessment summary (CAAS) indicates that during the pain interview for the MDS Resident 3 stated she has chronic back pain and the pain comes and goes. Resident 3 also stated that the pain gets worse when she stays in one position too long and also when Resident 3 does too much activity. Resident 3 indicated that the pain medications keep her pain tolerable but the pain medication never eliminates the pain. Resident 3's CAAS also indicate Resident 3's pain could be causing forgetfulness and inability to concentrate at times. Resident 3' pain assessment, dated 11/10/10, indicates that Resident 3 had pain that was sharp at all times. The quality of life/activities of daily living affected by Resident 3's pain include sleep, physical activity, concentration and elimination. The assessment continues to indicate that Resident 3's present level of pain is a 4 and the worse her pain has gotten was a level 10 on a 0-10 scale. The assessment further indicates that Resident 3's best pain level after pain relief interventions as a level 4. The assessment indicated that an acceptable level of pain for Resident 3 is a level 2 on a scale of 0-10. The pain assessment plan indicated for Resident 3's pain indicates will treat pain sensation as MD (physician) ordered. The admission care plan (no date indicated) indicates an approach of "monitor pain" chronic lower back and, non-drug interventions." The care plan does not indicate how the monitoring will be done or what types on non drug interventions will be used. An interdisciplinary care plan, dated 11/18/10, states a problem of "Comfort altered pain r/t (related to), hx (history) of Compression fx (fracture), [MEDICAL CONDITION], general discomfort." The goal documented as Resident 3 will verbalize pain relief 1 hour after pain medication delivery. The approaches for this problem indicate, "address pain promptly with meds (medications). Administer medication as ordered for pain relief, Assess effectiveness of pain medication, assist with repositioning as needed to promote comfort, Observe for pain with med (medication) pass, cares, meals and prn (as needed), Observe for physical/nonverbal s/s (signs and symptoms) of pain and report i.e. (examples of): moaning, restlessness, agitation, guarding of pain site, crying. Offer pain meds prior to therapy, Teach importance of early intervention to pain. Resident 3's Medication Administration Record (MAR) dated 11/10 indicates Resident 3's pain medication regimen to include; [MEDICATION NAME] 500 mg (milligram) two times daily to take every 12 hours take 1/2 to 1 tablet, [MEDICATION NAME] 50 mg every 6 hours scheduled, [MEDICATION NAME] 5/325 mg every 6 hours scheduled (alternate with [MEDICATION NAME]) , [MEDICATION NAME] 50 mg as necessary 1 tablet every 6 hours as needed ( alternate every 3 hours with [MEDICATION NAME]), [MEDICATION NAME] 50 mg as necessary 2 tablets every 6 hours as needed (alternate every 3 hours with [MEDICATION NAME]). Resident 3's nursing notes on 11/23/10 at 6:54 PM indicate that Resident 3 is resting in a recliner chair rates pain 3 out of 10, reports [MEDICATION NAME] and [MEDICATION NAME] help take the edge off. Resident 3 continued to indicate she is unable to tolerate sleeping in the bed, states it is pure agony. Review of the MAR for 11/23/10 indicates Resident 3 received her next pain medication, [MEDICATION NAME] 5/325 mg 1 tablet, at 8:06 PM, 2 hours after the complaint of pain by Resident 3 indicating "pure agony." Also important to note, Resident 3's pain assessment indicated an acceptable level of pain is a 2 on a 0 - 10 scale. Resident 3' nursing notes on 11/26/10 at 1:45 AM indicates Resident 3 had an abrupt increase in pain after repositioning in the bed, unable to get comfortable until she got up and sat in the recliner chair. No pain rating scale was indicated for Resident 3 at the time of the pain. Nursing notes also indicated Resident 3 received pain medication at 3:00 AM 1 hour after the onset of Resident 3's pain. Resident 3's nursing notes on 11/26/10 indicates Resident 3 reported she had terrible pain during the night, pounding pain to middle of her back and rated the pain 10 out of 10 on the pain scale. Resident 3's nursing notes continued to indicate Resident 3 received scheduled and PRN (as needed ) pain medications and Resident 3 reported no relief from the pain medications. Resident 3's physician was contacted with new orders received to send Resident 3 to the emergency room (ER) for an evaluation of Resident 3's back pain. On 11/26/10 at 2:09 PM Resident 3's Hospital ER (emergency room ) discharge instructions indicate to start [MEDICATION NAME] 5-325 mg 1-2 tablets every 6 hours scheduled, document in the medication administration record notes how many tablets are given, and discontinue the medication [MEDICATION NAME], "apply heating pad to back, use a chair with good back support, do not bend over at waist, wear comfortable flat shoes, do not sit for a long time, when sitting prop your feet up on a stool." Resident 3's nursing notes dated 11/27/10 at 5:23 PM indicated Resident 3 rates her pain as "really bad" and she is unable to give a numerical pain rating. Resident 3's nursing notes also indicate the nurse practitioner is to be updated on effectiveness of the new pain medication on 11/29/10. No further information was provided regarding physician notification regarding increase onset of pain. Resident 3's nursing notes dated 11/28/10 at 3:39 AM indicate Resident 3's pain is only controlled if she does not move. The nursing notes continue to indicate Resident 3 was not repositioned due to Resident 3's pain. No pain scale level was indicated during the time of the nursing note. Resident 3's nursing notes, dated 11/28/10, indicate Resident 3's pain does increase greatly with any movement. The physician was notified and new orders received to send to ER if the pain has not improved or worsens, and to follow up with the primary Physician on 11/29/10. Resident 3's nursing notes, dated 11/28/10, at 10:26 PM indicates Resident 3 consistently rated her lower back pain at the time of the nursing notes as "really bad," and the nurse practitioner is to be contacted on Monday (11/29/10) with an update regarding Resident 3's pain control. Additionally, it is important to note Resident 3 did not go to the ER when her pain did not improve. Resident 3's nursing note, dated 11/29/10, at 11:12 AM indicates a telephone call was placed to the physician for an update on Resident 3's current pain medication management and pain control. Nursing notes also indicate staff is awaiting a return call. No further documentation was present to indicate the physician was consulted regarding the pain management of Resident 3. On 12/1/10 at 12:40 PM Surveyor spoke with LPN I regarding Resident 3's pain and physician notification on 11/29/10. LPN I stated she contacted the nurse practitioner (NP) on 11/29/10 about Resident 3's pain. LPN I continued to state that the NP did return the telephone call regarding Resident 3 and LPN I stated she did receive orders to call the pain clinic and get Resident 3 into the pain clinic for her pain. LPN I also stated she forgot to chart the call and did not follow the NP order to call the pain clinic on 11/29/10. LPN I indicated she was calling the pain clinic today, 12/1/10, for Resident 3. Resident 3's nursing note, dated 11/30/10, at 10:13 PM indicates Resident 3's pain rating is a 10 out of 10 on the pain scale. The nursing notes also indicate Residents 3's pain was rated 4 out of 10 after taking 2 [MEDICATION NAME]. No further information was provided for follow up regarding non effective pain management and not meeting Resident 3's acceptable pain level. On 12/1/10 at 9:25 AM Surveyor spoke with Resident 3 regarding her pain management and the effectiveness of the pain medications. Resident 3 indicated her pain level, currently sitting in the recliner, is at a 4. Resident 3 also stated the pain remains at a 4 only if Resident 3 sits completely still. Resident 3 indicated the pain increases if she moves at all, then the pain will elevate to a 10 on the pain scale. Resident 3 also stated she is nauseated from the pain and doesn't eat well because the pain interferes with her appetite and moving. Resident 3 stated she has to sit up to eat and sitting up increases her pain. Resident 3 stated she wants her pain better controlled so she can move and walk more. The MAR indicates Resident 3 received 14 -18 doses of as necessary [MEDICATION NAME] 50 mg, there are discrepancies between the nursing notes, MAR and the PRN pain medication documentation sheets, from 11/11 - 11/30. 3 of these doses indicate Resident 3's pain level prior to receiving the medication, and none of these doses indicate Resident 3's pain scale level after receiving the medication to determine if the [MEDICATION NAME] was effective. Additionally, the MAR indicates Resident 3 received 14 -18 doses of as necessary [MEDICATION NAME] from 11/11- 11/30, again, there are discrepancies between the nursing notes, MAR and the PRN pain medication documentation sheets. Only 1 of these doses indicates Resident 3's pain level prior to receiving the medication, and none of these doses indicate Resident 3's pain scale level after receiving the medication to determine if the [MEDICATION NAME] was effective. The facility did not fully assess Resident 3's pain level, when and what level pain medication would be given or assess Resident 3's pain level after Medication per the pain policy which indicated Pain scale to be done at time of administration and 1 hour after administration. Significant unrelieved pain will be reported to the physician. Example 2 The pain assessment for Resident 4, dated 11/22/10, indicates that Resident 4 had pain that was sharp and burning. The quality of life/activities of daily living affected by Resident 4's pain was not documented on this section of the pain assessment form. The assessment continues to indicate that Resident 4's present level of pain is a 2 and the worse her pain has gotten was a level 10 on a 0-10 scale. The assessment further indicates that Resident 4's best pain level after pain relief interventions a level 2. The assessment also indicates that an acceptable level of pain for Resident 4 is a level 4 on a scale of 0-10. The interdisciplinary care plan dated 12/1/10 states a problem of "potential for pain r/t (related to) RTKA (right total knee replacement) [MEDICAL CONDITION], spinal stenosis, OA ([MEDICAL CONDITION]) and general discomfort." The goal documented as Resident 4 will verbalize pain relief 1 hour after pain medication delivery. the approach for this problem indicate, "address C/O (complaint of) pain promptly with meds (medications), Administer medications ordered for pain relief, assess effectiveness of pain medication, Assist with repositioning as needed to promote comfort, Observe for pain with med pass, cares, meals, and prn (as needed), offer pain med prior to therapy, and Teach importance of early intervention to pain." Resident 4's Minimum data set (MDS), dated [DATE], indicates that Resident 4's pain has been frequent over the past five days and Resident 4 indicates that she rated her pain level at its worse, at the time of the assessment, at a 10. Resident 4's Care Area Assessment summary (CAAS) indicates that during the pain interview for the MDS Resident 4 stated her pain as frequent but intermittent. Resident 4 also stated that the pain gets worse with movement but with moving her pain can reach up to a 10 out of 10 on the pain scale. Resident 4 also indicated that she sometimes gets shooting pain to her right knee and lower leg area that is temporary. The CAAS continue to state Resident 4 can usually fall asleep ok but often awakens because of the pain in her right knee. Resident 4 also indicated she would not be at the facility if the pain did not limit her day to day activities. On 11/29/10 at 9:25 AM during the facility initial tour, Surveyor and Unit Manager (UM) F observed Resident 4 sitting in her wheel chair in Resident 4's room with the breakfast tray in front of Resident 4. Resident 4 had not eaten any of the food on the tray. Resident 4 stated she has been "waiting over an hour" for her pain medication that she had requested. Resident 4 stated she has to eat when she takes her pain medication or she will become ill to include nauseated. Surveyor observed UM F leave Resident 4's room to inform the nurse Resident 4 is waiting for the pain medication. UM F returned to Resident 4's room with Licensed Practical Nurse (LPN) H and Resident 4's medication. On 11/29/10 at 9:25 AM Surveyor spoke with Resident 4 regarding her pain management and receiving pain medication when Resident 4 requests the medication. Resident 4 indicated she usually has to wait or keep asking for her pain medication usually it is worse in the morning. Resident 4 also stated it interferes with Resident 4's day not to get the pain medication early. Resident 4 also indicated she has to have the pain medication 45 minutes prior to therapy in order to perform therapy. If the nurses do not give the medication, then therapy has to be postponed. Resident 4 stated if Surveyor was not in the room Resident 4 would still be waiting for pain medication. Resident 4 was admitted to the facility on [DATE] with pain medication orders for [MEDICATION NAME]-[MEDICATION NAME] (APAP) 5-325 mg (milligram) 1 -2 tablets every 4 hours prn for pain, [MEDICATION NAME] 650 mg every 4 hour a PRN for pain. There are no indicators in Resident 4's record on when to give [MEDICATION NAME]-APAP 1 tablet, or [MEDICATION NAME]-APAP 2 tablets or when to try non- pharmalogical interventions. The MAR for Resident 4 indicates she received 9 -14 doses of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. There are discrepancies between the nursing notes, MAR and the PRN pain medication documentation sheets, from 11/22 - 12/1, 3 of these doses indicate Resident 4's pain level prior to receiving the medication, and none of these doses indicates Resident 4's pain scale level after receiving the medication to determine if the [MEDICATION NAME]-[MEDICATION NAME] was effective. Additionally 3 doses of as necessary [MEDICATION NAME] from 11/22- 12/1; again, there are discrepancies between the nursing notes, MAR and the PRN pain medication documentation sheets. 1 of these doses indicates Resident 4's pain level prior to receiving the medication, and none of these doses indicates Resident 4's pain scale level after receiving the medication to determine if the [MEDICATION NAME] (APAP) was effective. On 11/25/10 Resident 4's nurses notes indicate Resident 4 received APAP for right knee pain rated at a 7 out of 10 on the pain scale, and no post pain scale rate was documented. On 12/1/10 at 12:49 AM Resident 4 received [MEDICATION NAME] 650 mg for pain rating 10 out of 10 on the pain scale and no post pain scale rating was identified. The facility did not fully assess Resident 4's pain level, when and what level pain medication would be given or assess Resident 4's pain level after Medication per the pain policy which indicated Pain scale to be done at time of administration and 1 hour after administration. Significant unrelieved pain will be reported to the physician. On 11/30/10 at 1:45 PM Surveyor observed Resident 4 lying in bed refusing to be turn or be assisted out of bed. Resident 4 indicated she had too much pain to move and was waiting for her pain medication that Resident 4 had previously asked for, a half hour ago. Resident 4 indicated therapy was due to come and she hasn't had her pain medication before therapy. On 12/1/10 at 9:40 AM, Surveyor spoke with UM F, regarding pain medication and therapy schedules. UM F stated the therapy schedule is given to each nurse so the nurse will know when the resident is going to therapy. UM F stated the expectation of the nurse is to pre-medicate every resident at least 45 minutes prior to therapy. UM F also indicated when a resident asked for a prn pain medication they should not have to wait more then 5 - 7 minutes prior to receiving medication, UM F stated she is aware there are pain medication problems with several resident receiving medications on time. UM F did not provide any additional information. Example 3 The pain assessment for Resident 5, date was not on assessment form, indicates that Resident 5 had pain that was sharp. The quality of life/activities of daily living affected by Resident 5's pain include decreased appetite, decreased physical activity, and concentration. The assessment indicates that Resident 5's present level of pain is a 0 and the worse her pain has gotten was a level 10 on a 0-10 scale. The assessment further indicates that Resident 5's best pain level after pain relief interventions a level 0. The assessment also indicates that an acceptable level of pain for Resident 5 is a level 2-3 on a scale of 0-10. The pain assessment also indicated non pharmalogical interventions which previously relieved pain are positioning, ice and rest. Resident 5's interdisciplinary care plan dated 12/1/10 states a problem of "potential for pain r/t (related to) right hip dislocation, OA ([MEDICAL CONDITION]) and deconditioning." The goal documented as Resident 5 will verbalize pain relief 1 hour after pain medication delivery. The approach for this problem indicates, "address C/O (complaint of) pain promptly with meds (medications), Administer medications (meds) ordered for pain relief, assess pain coping strategies, Encourage to discuss feelings of frustration anxiety and fear, Observe for pain with med pass, cares, meals, and prn (as needed),On going assessment of pain status." Resident 5's Minimum Data Set (MDS), dated [DATE], indicates that Resident 5's pain has been occasional over the past five days and Resident 5 indicates that she rated her pain level at its worse as a 7. Resident 5's Care Area Assessment summary (CAAS) indicates that during the pain interview for the MDS Indication that pain is present. Resident 5 has increased levels of pain related to right hip dislocation. No further information was provided on the CAAS. On 11/29/10 at 8:55 AM during the initial tour of the facility Surveyor and UM F observed Resident 5 sitting in the wheel chair in Resident 5's room. The call light outside Resident 5's room was on at the time of entering the room. Resident 5 indicated she had pain and would like her pain medication. Resident 5 also indicated Surveyor and UM F were the 4th persons Resident 5 told about wanting pain medication in over an hour. Surveyor observed UM F leave Resident 5's room and return within 5 minutes with the requested pain medication. On 11/29/10 at 8:55 AM Surveyor spoke with Resident 5 regarding pain medication. Resident 5 stated she has to wait a long time to receive the medication she has requested. Resident 5 also indicated she requests the medication at the same time every morning why can't they schedule it. Resident 5 stated the current pain level on the 0-10 scale is a 9. Resident 5 was admitted to the facility on [DATE] with pain medication orders for [MEDICATION NAME] 5 mg (milligram) 1 -3 tablets every 4 hours prn for pain. There are no indicators in Resident 5 record on when to give [MEDICATION NAME] 1 tablet, [MEDICATION NAME] 2, [MEDICATION NAME] 3 tablets or when to try non- pharmalogical interventions. Review of the MAR for Resident 5 indicates she received 4-6 doses of [MEDICATION NAME] 5 mg; there are discrepancies between the nursing notes, MAR and the PRN pain medication documentation sheets. From 11/1 - 12/1, none of these doses indicates Resident 5's pain level prior to or after receiving the medication, to determine if the [MEDICATION NAME] was effective. Resident 5 received 11-14 doses of [MEDICATION NAME] 10 mg; again, there are discrepancies between the nursing notes, MAR and the PRN pain medication documentation sheets, from 11/1 - 12/1, 5 of these doses indicate Resident 5's pain level prior to receiving the medication, and none of these doses indicates Resident 5's pain scale level after receiving the medication to determine if the [MEDICATION NAME] was effective. In regard to [MEDICATION NAME] 15 mg, there are discrepancies between the nursing notes, MAR and the PRN pain medication documentation sheets from 11/1 - 12/1; 2 of these doses indicate Resident 5's pain level prior to receiving the medication, and none of these doses indicates Resident 5's pain scale level after receiving the medication to determine if the [MEDICATION NAME] was effective. Resident 5 received 15 mg of [MEDICATION NAME] 3 times over the past 30 days. On 3 occasions Resident 5 received 10 mg [MEDICATION NAME] when Resident 5 described her pain scale as 7 or greater. There was no pain scale identified when Resident 5 received 5 mg of [MEDICATION NAME]. The facility did not fully assess Resident 5's pain level, when and what level pain medication would be given or assess Resident 5's pain level after Medication per the pain policy which indicated Pain scale to be done at time of administration and 1 hour after administration. Significant unrelieved pain will be reported to the physician. On 12/1/10 at 1:50 PM Surveyor spoke with Licensed Practical Nurse (LPN) H regarding Resident 5's pain management and when she would give 5 mg, 10 mg or 15 mg [MEDICATION NAME] to Resident 5 with out any directions to give. LPN H stated I give what ever the resident wants if they want 1 LPN H indicates she would give 1. LPN H further indicated she would give 1 no matter how high the resident pain was on the 0-10 pain scale.