Every finding on record at Heritage House of Marshall Health & Rehabilitation

Based on record review and interviews, the facility failed to ensure the resident's right to dignity and respect by regarding financial matters by not providing necessary assistance with a Medicaid application for 2 (Resident #11 and Resident #22) of 4 residents resulting in delayed eligibility and a coverage gap.The facility failed to ensure the residents were treated with dignity and respect regarding financial matters by not providing necessary assistance with a Medicaid application, resulting in delayed eligibility and a coverage gap for Resident #11 and Resident #22.These failures compromised the resident's right of personal dignity and self-determination. The findings included: Record review of an undated facesheet revealed Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of major depressive disorder (a serious mental health condition characterized by persistent, severe sadness, low mood, or loss of interest in activities lasting at least two weeks), bipolar disorder (a chronic mental health condition characterized by intense, fluctuating mood shifts, ranging from high-energy manic or hypomanic episodes to deep depressive lows), and kidney failure (occurs when kidneys lose their ability to filter waste from the blood, usually occurring when function drops below 15%).Record review of a quarterly MDS dated [DATE] revealed Resident #11 had a BIMS of 15, which indicated no cognitive impairment. Resident #11 required partial assistance (helper does less than half the work) with ADLs such as dressing, transfer, and toileting. Record review of a MESAV dated 04/22/2026 revealed Resident #11 had a gap in Medicaid coverage from 07/18/2025 through 07/28/2025. During an interview on 04/22/2026 at 9:00 a.m., Resident #11 stated he was unaware of what transpired during the filing of his Medicaid application. He stated his family took care of all his financial dealings. Attempted calls to Resident #11's family attempted on 04/22/2026 at 9:30 a.m. and 04/23/2026 at 11:00 a.m., with messages left and no return call. During an interview on 04/22/2026 at 10:00 a.m., the Corporate Business Office Manager (BOM) stated the previous BOM (BOM A) failed to file the original Medicaid application for long-term care Medicaid for Resident #11 within the 30-day window for approval to cover the resident's entire stay. She stated this meant Resident #11 qualified for long-term care Medicaid to begin on the day he admitted to the facility, but because of the untimely filing of the application there was a period of about 20 days Resident #11 did not have Medicaid coverage. She also stated it was the facility's policy to assist the resident and resident's family by guiding them through the process of filing out the application and gathering supportive documentation required by Medicaid to prove eligibility. She stated BOM A failed to provide guidance to the resident and his family. The Corporate Business Office Manager stated it was the policy of the facility to attempt to collect reimbursement for the gap in coverage by billing the resident and/or the family. She stated this was done for Resident #11 and the uncollected balance was sent to collections and then written off per company protocol. She stated no services were denied to Resident #11 because of the gap in Medicaid coverage. 2. Record review of an undated facesheet revealed Resident #22 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of dementia (a general term for a progressive decline in mental ability-including memory loss, confusion, and behavioral changes-severe enough to interfere with daily life, caused by physical brain changes), insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking too early, often resulting in daytime fatigue, mood changes, and poor concentration), and kidney disease (occurs when kidneys are damaged, preventing them from filtering waste and excess water from the blood, often caused by diabetes or high blood pressure). Record review of a quarterly MDS dated [DATE] revealed Resident #22 had a BIMS of 14, which indicated no cognitive impairment. Resident #22 required partial assistance (helper does less than half the work) with ADLs such as dressing, bed mobility, and toileting. Record review of a MESAV dated 04/22/2026 revealed Resident #22 had a gap in Medicaid coverage from 02/18/2025 through 03/10/2025. During an interview on 04/22/2026 at 10:38 a.m., Resident #22 stated she was aware that she received a bill for the first 3 weeks she was in the facility because BOM A had not filed her application by the deadline. She stated she and her family provided all the information needed within the first couple of weeks. She stated she was not required to pay anything on the bill and the facility wrote the expense off, but it was a little humiliating to get notice I was being kicked out, when it was not my fault. Resident #22 stated she had not missed any care because of the gap in Medicaid coverage. During an interview on 04/22/2026 at 11:00 a.m., the Corporate Business Office Manager (BOM) stated the previous BOM failed to file the original Medicaid application for long-term care Medicaid for Resident #22 within the 30-day window for approval to cover the resident's entire stay. She stated this meant Resident #22 qualified for long-term care Medicaid to begin on the day she admitted to the facility, but because of the untimely filing of the application there was a period of about 20 days Resident #22 did not have Medicaid coverage. She stated the facility followed their protocol for Resident #22 and attempted to collect reimbursement for the gap in coverage. She stated the uncollected balance for Resident #22 was sent to collections and then written off per company protocol. She stated no services were denied to Resident #22 because of the gap in Medicaid coverage. Attempted call to BOM A on 04/23/2026 at 12:10 p.m., message left and no return call. During an interview on 04/23/2026 at 1:00 p.m., the DON stated she was not aware at the time that BOM A was not assisting and filing the Medicaid applications for all residents. She stated the Administrator was the person in the facility over financial issues. She stated she had not witnessed or been reported any change in the emotional state of Resident #11 and Resident #22 related to their Medicaid status. The DON stated staff assistance in all aspects of the resident's life was a basic right of the resident and should be promoted. During an interview on 04/22/2026 at 2:00 p.m., the Administrator stated she was not at the facility during the time period that BOM A was employed, but she was made aware of the issues that she had faced and how it had affected the residents. She stated it was her expectation for the BOM to assist the residents in any way that was ethical to gain any benefits they are entitled to. She stated it was a basic right of the residents to have assistance by the facility that promoted or enhanced their lives. Review of a facility policy titled Resident Rights dated 2021 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights.

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 6 residents (Resident #32) reviewed for pharmacy services. The facility failed to administer the injectable Repatha (a prescription-strength, injectable used to significantly lower bad [LDL-low density lipoprotein] cholesterol and reduce the risk of heart attack and stroke) for Resident #32 on 01/26/2026. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications.Findings include: Record review of Resident #32's, undated, face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #32 had diagnoses which included CVA (stroke, occurs when blood flow to the brain is blocked or a vessel ruptures, causing brain tissue damage), hemiplegia (form of paralysis affecting one side of the body, caused by brain or spinal cord damage such as stroke, trauma, or congenital conditions), and hyperlipidemia (condition characterized by abnormally high levels of lipids [fats] in the blood). Record review of Resident #32's admission MDS assessment, dated 12/18/2025, revealed Resident #32 had a BIMS of 13, which indicated no cognitive impairment. She required substantial (helper does more than half the work) assistance with ADLs. Record review of care plan, dated 12/12/2025, revealed Resident #32 had interventions to administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #32's MAR, dated January 2026, revealed Resident #32's Repatha 140mg/ml (1) syringe subcutaneous every 2 weeks was not administered on 01/26/2026 by LVN A. Record review of consolidated physician orders, dated February 2026, revealed Resident #32 had an order for an injection of Repatha 140mg/ml (1) syringe subcutaneous every 2 weeks for hyperlipidemia. During an interview on 02/19/2026 at 10:12 a.m., Resident #32 stated she missed her cholesterol medication injection at the end of January and no one called the MD to let her know. Resident #32 stated it was very important to get the injection because she had strokes in the past from having blockages in her arteries from cholesterol build up. She stated her family brought the medication to the facility the day after it was due. She stated she worried about it for two weeks until she got another injection. Resident #32 stated it had not caused her to miss sleep, miss meals, or be tearful to have missed the injection. During an interview on 02/19/2026 at 11:00 a.m., LVN A stated she missed giving Resident #32 the injection of Repatha which was due at 10:00 a.m. on 01/26/2026. She stated the family provided the medication and the weather would not permit the family member to bring it until 01/28/2026. LVN A stated she signed the medication out as not given but failed to make a note about the missed dose and did not contact the MD. LVN A stated she was unaware she needed to call the MD. LVN A stated she was counseled by the DON on the proper way to handle an available medication and in the future would call the MD if a medication was unavailable. She stated the next dose given to Resident #32 was on 02/09/2026, which was the next date it was due. LVN A stated there were no adverse effects to the resident because a lipid panel was done when the MD was notified and her cholesterol was in normal limits. During an interview on 02/19/2026 at 2:30 p.m., the DON stated Resident #32 missed her injection of Repatha on 01/26/2026 because the family member could not make it to the facility to bring it because of the ice storm. She stated it was worked out prior to admission that the family would supply the medication because of the cost. She stated LVN A should have notified the MD that day that the medication was not administered and got an order to hold the medication or send the resident to the hospital if the MD felt the missed medication, was an urgent situation. The DON stated LVN A had not notified anyone that she held the medication, and it was brought to the facility's attention when the resident made a complaint about missing the medication on 02/09/2026. The DON stated she notified the MD on 02/09/2026 and the MD stated to have a lipid panel drawn to see if any adverse effects were present because of the missed medication. The DON stated she got a stat lipid panel and the results were normal. The MD ordered to resume the Repatha every 2 weeks as ordered, and the injection was given on 02/09/2026. She stated it was the responsibility of the floor nurses to ensure medications were reordered and available for administration. The DON stated the nurses were instructed to contact her immediately if they were having issues getting medications. During an interview on 02/19/2026 at 3:30 p.m., the ADM stated she expected the nurses to follow MD orders and contact the physician, the DON and the family if medications were missed. She stated not administering medications as ordered could lead to serious health problems for the residents. Record review of the facility's, undated, policy Medication Administration stated: .To provide practice standards for safe administration of medication for residents in the facility. XVII. Holding medications.A. Whenever a medication is held for any reason, the Licensed Nurse will initial the appropriate area on the MAR and circle his/her initials. The Licensed Nurse will document the reason the medication was held on the back of the MAR and notify the physician.

Based on interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 1 resident reviewed for care plans in that: The facility failed to ensure CNA D followed the comprehensive person-centered care plan for a proper transfer on 11/10/25 with Resident #1. This failure could place residents in the facility at risk of injury, not receiving the necessary care and services and having personalized plans developed to address their needs.Based on interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 1 resident reviewed for care plans in that: The facility failed to ensure CNA D followed the comprehensive person-centered care plan for a proper transfer on 11/10/25 with Resident #1. This failure could place residents in the facility at risk of injury, not receiving the necessary care and services and having personalized plans developed to address their needs.Findings include: Record review of Resident #1's face sheet dated 12/01/25, revealed an admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #1's facility history and physical dated 12/02/25, revealed, an [AGE] year-old female diagnosed with cerebral palsy (a group of neurological disorders that affect movement, balance, and posture), repeated falls, difficulty in walking, muscle wasting and atrophy, unsteadiness on feet, lack of coordination, symptomatic epilepsy (a type of epilepsy where seizures are caused by an identifiable, underlying issue in the brain) and osteoarthritis (the most common type of arthritis, characterized by the breakdown of joint cartilage, which causes bone-on-bone friction). Record review of Resident #1's quarterly MDS assessment dated [DATE], revealed moderate impaired cognition to be able to recall or make daily decision BIMS score of 9. Resident #1 was dependent and needed 2 or more helpers with toilet transfer, tub/shower transfer and chair/bed-to-chair transfer. Resident #1 was marked as a wheelchair for mobility device. Resident #1 was diagnosed with difficult in walking, lack of coordination, and Cerebral Palsy. Record review of Resident #1's Care Plan dated 11/7/25, revealed the resident has an ADL self-care performance deficit related to limited mobility, pain and fluctuations in cognition related to cerebral palsy. Bathing/ showering: The resident is totally dependent on staff x2 to provide shower. Bed mobility: The resident requires extensive staff assist x2 bed mobility. Toilet use: The resident requires extensive staff assist x2 for toileting. Transfer: The resident requires extensive staff assist x2 to move between surfaces. During an interview on 12/01/25 at 3:11 P.M., with CNA A she said she was coming from hall 300 and went through the shower door when she saw CNA D and she said Resident #1 was sliding down on 11/10/25. CNA A said Resident #1 had a shower and was fully dressed trying to transfer from the shower chair to her wheelchair. CNA A said Resident #1 was a 2-person assist, but CNA D was transferring her from the shower chair to her wheelchair by herself. CNA A said Resident #1 started sliding down to the floor and she told CNA D they were not going to put Resident #1 in the wheelchair; they lowered Resident #1 to the floor. CNA A said she went to get the charge nurse and explained to him what happened. CNA A said Resident #1 should be a 2-person assist. During an interview on 12/01/25 at 4:05 P.M., Resident #1 said she does not remember the incident in the bathroom when she was lowered to the floor by CNA D and CNA A. Resident #1 said when staff transferred her from her bed to her wheelchair it was usually 2 people. During an interview on 12/01/25 at 4:46 P.M., with the Regional Compliance Nurse she said the aide could go to the resident's plan of care in point click care (an electronic health record) and pull it up in the kardex (a genericized trademark for a nursing record-keeping system) to see what assistance a resident need for a transfer. She said if the aides were unsure how to transfer a resident, they could ask the charge nurse or the DON how the resident was supposed to be transferred. During an interview on 12/01/25 at 4:55 P.M., with LVN B said the aides could look up the resident's kardex in point click care to see how a resident was supposed to be transferred. During an interview on 12/01/25 at 4:57 P.M., with LVN C she said the aides know how to transfer a resident by the kardex and by word of mouth. During an interview on 12/01/25 at 5:01 P.M., with Regional Compliance Nurse she said the MDS Nurse said the care plan was generated on 2/17/25 and he documented Resident #1 was a 1-person assist. She said the MDS Nurse said he opened another care plan on 2/18/2025 and documented Resident #1 was a 2-person assist, but it should have been resolved. During an interview on 12/02/25 at 9:16 A.M., with CNA D she said on 11/10/25 Resident #1 was a 1-person assist. She said she used a gait belt while transferring her. CNA D admitted she was transferring Resident #1 by herself. CNA D said Resident #1 was standing and assisting with the transfer from the shower chair to the wheelchair. CNA D said Resident #1 got weak and said she needed to sit down. CNA D said CNA A came into the bathroom and helped her lower Resident #1 to the floor; then CNA A went and got the charge nurse. CNA D said the charge nurse assessed Resident #1 and they put the resident in her wheelchair. CNA D said she knew where to find what assistance a resident required; she said the information was in the resident's kardex in point click care. During an interview on 12/02/25 at 10:05 A.M., with the Staffing Coordinator she said the Kardex asked the staff if a resident was a 1 or 2-person assist. She said if an aide was unsure how a resident should be transferred, they should go to their charge nurse and ask them how the resident was to be transferred. She said she was not sure if Resident #1 was a 1 or 2-person assist before the incident. She said when she worked with Resident #1, she would pivot. She said when Resident #1 had a bad day she would tell staff and they would have to get another person to help transfer her. During an interview on 12/02/25 at 10:12 A.M., with CNA A she said staff could find the information in the kiosk if a resident was a 1 or 2-person assist. She said the day she assisted CNA D with Resident #1 she was a 2- person assist. During an interview on 12/02/25 at 10:47 A.M., with the Regional Compliance Nurse she said she was not here on 11/10/25 and she did not know why the kardex, and the care plan did not match. She said she would not deny there were 2 different care plans. She said she resolved the 2-person assistance in the care plan for 2/18/25. She said she educated the staff on the care plans yesterday and updated them. She said she had staff audit the care plans so that all knew how the residents should be transferred. During an interview on 12/02/25 at 11:18 A.M., with the MDS Nurse he said he was educated on updating the care plans. He said he agreed that there was a discrepancy with Resident #1's care plan. He said Resident #1 was a 2-person assist now, but before the incident she was supposed to be a 1-person assist. He said on 2/18/2025 he saw Resident #1 was a 2-person assist, but she was supposed to be a 1-person assist. He said he was updating the care plans and made the mistake of documenting her as a 2-person assistant on 2/18/25. He said he took full responsibility for the mistake. He said the negative effect of an incorrect care plan was a big error and it throws everyone caring for the residents off. He said an improper transfer could be performed due to an incorrect care plan and a fall could occur. During an interview on 12/02/25 at 11:41 A.M., with the Director of Nursing she said the staff had been educated to update the care plans. She said the MDS Nurse was responsible for updating changes in the care plans and reporting changes to the care plan. She said Resident #1 was a 1-person assistant. She said the Regional Compliance Nurse told her not to create a new care plan; she was supposed to update the original care plan. She said she agreed on 2/18/25 that Resident #1's care plan was documented as a 2-person assist and it should have been resolved. She said all nursing staff needed to be knowledgeable of how the care plan works. She said she expected the staff to follow the care plan when transferring the residents. She said if the care plan was not accurate staff could not give adequate care. During an interview on 12/02/25 at 11:57 A.M., with the Administrator she said she expected the staff to follow the resident's care plan. She said she expected the care plan and the kardex to match, because the aides could not see the care plans. She said a negative effect of an incorrect care plan was if a resident was a 2-person assist and was transferred by 1-person, they were more than likely to be injured. Record review of the CNA Proficiency Aduit- Competency Evaluation, dated 11/18/25, reflected CNA A met the performance criteria for transfers, with no comments noted. Record review of the CNA Proficiency Aduit- Competency Evaluation, dated 11/18/25, reflected CNA D met the performance criteria for transfers, with no comments noted. Record review of Comprehensive Care Planning policy undated revealed The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to make a resident medical, nursing, and mental psychosocial needs are that are identified in the comprehensive assessment. Comprehensive care plans may include, but are not limited to resident Kardex records, baseline care plans, and task listings. The comprehensive care plan will describe the following.The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Record review of Moving A Resident, Bed to Chair/Chair To Bed policy undated revealed The purpose of this procedure are to allow the resident to be his or her bed as much as possible and provide for a safe transferring of the resident.9. b. If transferring the resident to a wheelchair: i. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.

Based on interview and record review the facility failed to ensure the notice to residents when changes in coverage were made to items and services covered by Medicare as soon as is reasonably possible was provided to 2 of 3 residents (Resident #15 and Resident #39) reviewed for Medicare services. 1. The facility failed to notify Resident #15 at least 2 days before the end of Medicare Part A coverage.2. The facility failed to notify Resident #15 with a complete Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) form before the end of Medicare Part A coverage.3. The facility failed to notify Resident #39 and/or his representative in writing of potential non-coverage due to the end of Medicare Part A coverage. These failures could affect residents who use skilled services and could place them at risk of not being aware of changes to provided services.Findings included: 1. Record Review of a face sheet, dated 07/29/22, revealed Resident #15 was admitted on [DATE] with diagnoses including history of falling, rhabdomyolysis (a serious condition where damaged muscle tissue releases its contents into the bloodstream, potentially harming the kidneys), and heart failure (occurs when the heart can't pump enough blood to meet the body's needs). The face sheet revealed the resident had not been discharged . Record Review of an admission MDS dated [DATE], revealed Resident #15 had a BIMS of 15 which indicated intact cognition. The MDS indicated Resident #15 was dependent on staff with most ADLs. Record review of a Notice of Medicare Non-Coverage form revealed Part A (Skilled) coverage for Resident #15 ended on 07/22/25. The form was signed by Resident #15 on 07/23/25. Record review of a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form indicated, “…Beginning on 07/23/25, you may have to pay out of pocket for this care…Physical Therapy…Occupational Therapy…Choose the option below about whether to get the care listed above…”. The “Options” section was not completed. The form was signed by Resident #15 on 07/22/25. 2. Record Review of a face sheet, dated 07/29/22, revealed Resident #39 was initially admitted on [DATE] with diagnoses including peripheral vascular disease (a circulatory problem where narrowed or blocked blood vessels restrict blood flow to limbs and organs, excluding the heart and brain), anxiety, and stroke. Record Review of quarterly MDS for Resident #39 dated 07/07/25, revealed a BIMS was not conducted due to Resident #39 being rarely to never understood. The MDS indicated Resident #39 was dependent on staff with most ADLs. Record review of a Notice of Medicare Non-Coverage form revealed Part A (Skilled) coverage for Resident #39 ended on 06/04/25. The form was signed by Resident #39’s representative on 06/02/25. Record review of documentation provided by the facility between 07/27/25 – 07/29/25 for the Beneficiary Notice task did not reveal a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form for Resident #39. During an interview on 07/29/25 at 1:14 p.m., MDS Nurse C said the Social Worker was responsible for completing the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms. She said the MDS nurses did help when the Social Worker was not in the facility. She said she would have expected Resident #15 to have been notified at least 2 days before her coverage ended, and she would have expected for the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form to have been complete. She said Resident #39 was notified but she could not find the signed Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms. She said she felt Resident #37’s representative was notified by phone. During an interview on 07/29/25 at 1:29 p.m., the Social Worker said she was responsible for issuing the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms to the residents. She said she did not know why Resident #15 was not notified at least two days prior to the end of her Medicare Part A coverage. She said she let the resident fill out the form. She said she did not know why the form was not completed. She said she notified Resident 39's representative over the telephone. She said Resident #39 was nonverbal and unable to sign his own forms. She said a resident not being notified in time could affect their therapy services. During an interview on 07/29/25 at 1:41 p.m., the DON said the MDS Nurses, and the Social Worker were responsible for completing and issuing the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms. She said she would have expected Resident #15 to have notified in the correct time frame, and she would have expected for the form to have been completed. She said she would have expected a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form to have been completed for Resident #39. She said a resident not being notified correctly could affect their plan of care and possibly cause them to have to pay out of pocket for services. During an interview on 07/29/25 at 1:52 p.m., the Administrator said the Social Worker was responsible for completing the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms. She said she would have expected the Social Worker to have notified Resident #15 at least 2 days before her Part A coverage ended and the form to have been complete. She said she would have expected a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form to have been completed for Resident #39. She said the residents needed to have been notified that they were about to be without coverage. Record review of a Resident Rights facility policy last revised on 11/28/2016 indicated, “…The resident has the right to be informed of, and participate in, his or her treatment, including…The right to be fully informed in language that he or she can understand…The right to be informed, in advance, of changes to the plan of care…The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident…The resident has a right to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident’s personal funds…The facility must inform, orally and in writing, the resident requesting an item or service for which a charge will be made that there will be a charge for the item or service and what the charge will be…The facility must inform each resident before…and periodically during the resident’s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid…Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan…”.

Based on observation, interview and record review the facility failed to ensure parenteral fluids was maintained consistent with professional standards of practice for 1 of 1 residents (Resident #76) reviewed for parenteral fluids central venous lines (a thin, flexible tube that's inserted into a large vein to provide access to the circulatory system. The facility failed to change a midline catheter (a type of central venous line) dressing according to facility protocol for Resident #76. Resident #76 midline catheter dressing change was due on 7/25/25 and was not changed until 7/27/25. This failure could place residents with central venous lines at risk of an infection and hospitalization. Findings included: Record review of Resident #76’s face sheet dated 7/27/25 indicated a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #76 had diagnoses including cellulitis (is a bacterial infection of the skin and underlying tissues) of right and left lower limb, extended spectrum beta lactamase resistance (is an enzyme produced by certain bacteria that makes them resistant to many commonly used antibiotics) and displaced fracture media malleolus of left tibia (the bony bump on the inside of the left ankle (the medial malleolus) has broken and moved out of its normal position). Record review of Resident #76’s quarterly MDS assessment dated [DATE] indicated Resident #76 was usually understood and usually had the ability to understand others. Resident #76 had a BIMS score of 05 which indicated severe cognitive impairment. Resident #76 required substantial assistance for oral and toilet hygiene, shower/bathe self, and dressing. Resident #76 required partial assistance for eating and personal hygiene. Record review of Resident #76’s care plan dated 7/21/25 indicated Resident #76 had osteomyelitis (is a bone infection, most often caused by bacteria). Interventions included contact isolation, assist to turn and reposition, treatment as ordered, and follow up appointment with surgeon. Record review of Resident #76’s order summary report dated 7/27/25 indicated PICC line dressing change every 7 days one time a day every Friday, right upper arm. Start date 7/25/25. Record review of Resident #76’s Treatment Administration Record dated 7/1/25-7/31/25 indicated: * PICC line dressing change every 7 days one time a day every Friday, right upper arm. Start date 7/25/25. Resident #76’s TAR did not indicate the dressing change was completed on 7/25/25. * PICC line dressing change every 7 days one time a day every Sunday dressing change. Discontinued 7/27/25 at 6:39 p.m. Resident #76’s TAR indicated RN D completed the dressing change on 7/27/25. During an observation on 7/28/25 at 9:15 a.m., RN A administered an intravenous (is a medical process that administers fluids, medications and nutrients directly into a person's vein) antibiotic medication in Resident #76’s PICC line. Resident #76’s PICC line dressing was intact and dated 7/27/25. Resident #76’s PICC line site did not have redness or drainage noted. During an interview on 7/29/25 at 12:55 p.m., RN A said she was assigned Resident #76 last Friday (7/25/25). She said Resident #76’s PICC line dressing change was due last Friday (7/25/25). She said the nurses documented on the resident’s MAR/TAR when the dressing change was completed. She said Resident #76’s PICC line dressing was the last thing on her to do list, and she did not get to it. She said she did not let the DON, or the oncoming shift know, Resident #76’s dressing did not get changed on her shift. She said she totally forgot that Resident #76’s PICC line dressing did not get done on 7/25/25. She said she normally told the oncoming shift if she did not get to something so it could be completed. She said the DON called her on Sunday (7/27/25) and asked about Resident #76’s PICC line dressing change. She said it was important to do the scheduled PICC line dressing change to not mess up the scheduled timeframe of the dressing changes. She said when the PICC line dressing changes were not done as scheduled, it placed the resident at risk for an infection. She said the resident could then need more antibiotics. During an interview on 7/29/25 at 1:00 p.m., the DON said the nurses were responsible for the PICC line dressing changes. She said the nurse documented on the resident’s MAR/TAR when the PICC line dressing change was completed. She said she contacted RN A on 7/27/25 about Resident #76’s PICC line dressing change. She said the PICC line dressing change was not signed off on Resident #76’s TAR for 7/25/25. She said she contacted RN A to see if she forgot to document the dressing change on 7/25/25 or if it was not done. She said when they found out Resident #76’s PICC line dressing change was not done, they called and notified the MD. She said Resident #76’s PICC line site looked good and there were no signs of infection. She said it was important to do a resident’s scheduled PICC line dressing changes to make sure there was no infection. She said not doing a resident’s dressing change could place them at risk for an infection. She said the ADONs was responsible for ensuring the nurses completed the scheduled PICC line dressing changes. During an interview on 7/29/25 at 1:10 p.m., ADON B said she was responsible for Hall 300 and 400. She said Resident #76 resided on Hall 300. She said the LVNs, and RNs were responsible for the PICC line dressing changes. She said the LVNs had to be checked off to do the PICC line dressing changes. She said the PICC line dressing changes should be completed as ordered which was normally every 7 days. She said Resident #76 was admitted on [DATE] so the PICC line dressing change was due on 7/25/25. She said she wrote it on her calendar and reminded RN A it was due on 7/25/25. She said after reviewing Resident #76’s chart on 7/27/25, she noticed the PICC line dressing was not done. She said she notified the DON, and the DON contacted RN A to see why the dressing change was not done. She said after the DON spoke with RN A and confirmed it was not done on 7/25/25, she rescheduled it for 7/27/25. She said another nurse completed the PICC line dressing change on 7/27/25. She said the PICC line dressing change flags on the resident’s MAR/TAR for the nurse to complete it. She said it was important to complete the scheduled dressing change because the PICC line was a central line and went into the body. She said when the PICC line dressing changes were not done as scheduled, it placed the resident at risk for infection. She said the ADONs were responsible for ensuring the nurses completed the scheduled PICC line dressing changes. She said she also felt the RNs should not need to be reminded to complete a PICC line dressing change. During an interview on 7/29/25 at 2:04 p.m., the ADM said the nurses were responsible for completing the resident’s scheduled PICC line dressing changes. She said she expected the nurses to complete the PICC line dressing changes on the scheduled day. She said it was important to complete the scheduled PICC line dressing change to make certain there was no infection, everything was attached, and to follow the facility’s policy and procedure. She said when the PICC line dressing change was not done it placed the resident at risk for an infection. She said if the resident developed an infection, they could need hospitalization or more antibiotics. She said the Infection Control Preventionist, ADON, and/or DON should ensure the nurses were completing the PICC line dressing changes. She said they should be monitoring this process by chart audits and looking at the resident’s PICC line sites. Record review of a facility’s “Central Venous Catheters” policy dated 2003 indicated, “…a central line…is a temporary or long-term intravenous catheter inserted into one of the major veins of the neck, chest, or…peripherally through the brachial or cephalic vein…central lines are used for administration of intravenous (IV) fluids, antibiotics…PICC lines…dressing…24hr after insertion, then transparent dressing every 7 days and prn…central line dressing should be changed according to facility protocol and when the dressing is damp, loose, or soiled…dressings minimize the buildup of skin microorganisms, provide protection against external contamination, and keep the exit site dry…”

Based on interview and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 8 residents reviewed for resident rights. (Resident #1 and Resident #2) The facility failed to provide care to Resident #1 in a respectful manner on 4/4/25. The facility failed to provide care to Resident #2 in a respectful manner within the last three months. These failures could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety. Findings included: Record review of Resident #1's face sheet dated 4/8/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses including vascular dementia (is a type of dementia caused by impaired blood flow to the brain, leading to damage and eventual loss of brain cells), mild, with agitation (a state of being agitated, feeling restless, anxious, or worried, and can manifest in various behaviors like pacing, irritability, or even aggression) and major depressive disorder (is a mood disorder characterized by persistent sadness, loss of interest or pleasure in activities, and other symptoms like changes in sleep, appetite, and energy levels). Record review of Resident #1's annual MDS assessment dated [DATE] indicated Resident #1 was usually understood and had the ability to understand others. Resident #1 had adequate hearing, clear speech, and impaired vision. Resident #1 had a BIMS score of 10 which indicated moderately impaired cognition. Resident #1 required moderate assistance for oral hygiene, substantial assistance for upper body dressing and personal hygiene, and dependent for toileting hygiene, shower/bathe self, lower dressing, and putting on/taking off footwear. Resident #1 was always had incontinence for urine and frequently incontinence for bowel. Record review of Resident #1's care plan dated 4/3/25 indicated Resident #1 had an ADL self-care performance deficit related to dementia and impaired balance. Intervention included assist with personal hygiene. Record review of a facility provided statement dated 4/4/25 at 11:15 a.m., indicated [Resident #1] reported to DON and [ADON E] that she [Resident #1] was afraid of [CNA B] .[Resident #1] stated that the [CNA B] is mean to her and doesn't like her .When we asked her why she feels that way, she stated that when [CNA B] was dressing her this morning, she put her head in through her shirt first and expected her to assist .Writer [DON and ADON E] asked her if she thought the [CNA B] was wanting her to get some exercise by assisting with putting on her shirt .The resident [Resident #1] stated 'no' .She said the other CNA always put her arms through her shirt first .When asked if [CNA B]has ever hit her, she stated 'No, darling.' .The resident [Resident #1] stated that she didn't want the [CNA B] back in her room . During an interview on 4/8/25 at 11:21 a.m., Resident #1 said CNA B had been verbally rough to her. She said CNA B told her to stand up, I'm [CNA B] not going to bend over and You [Resident #1] can do it! She said when CNA B spoke to her like that, it hurt her feelings and made her cry. She said she did not want to get up sometimes when CNA B worked the hall. She said CNA B did not talk rough to her all the time but often. She said CNA B had never grabbed her, just said words. Record review of Resident #2's face sheet dated 4/9/25 indicated Resident #2 was a [AGE] year-old male admitted on [DATE]. Resident #2 had diagnoses including muscle wasting and atrophy (shortening), vascular dementia (is a type of dementia caused by impaired blood flow to the brain, leading to damage and eventual loss of brain cells), cerebral infarction (is a condition where a part of the brain is damaged or dies due to a lack of blood supply) and hemiplegia (is a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (is one-sided muscle weakness) affecting right dominant side. Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2 understood and had the ability to understand others. Resident #2 had adequate hearing, clear speech, and adequate vision with corrective lenses. Resident #2 had a BIMS score of 11 which indicated moderately impaired cognition. Resident #2 was dependent for toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. Resident #2 required moderate assistance for upper body dressing and personal hygiene. Resident #2 was always incontinent for urine and bowel. Record review of Resident #2's care plan revised on 10/4/23 indicated Resident #2 had an ADL self-care performance deficit, dementia, and history of nontraumatic intracerebral hemorrhage (is a type of stroke where bleeding occurs inside the brain tissue itself, usually due to the rupture of a blood vessel). Intervention included bed mobility, the resident required assistance with turning and repositioning every 2 hours, as needed, and as necessary. During an interview on 4/8/25 at 11:30 a.m., a family member of Resident #2, who also resided in the same room as Resident #2, said she had heard CNA B talking rough or mean to the residents. She said CNA B also spoke rough to Resident #2. She said it seemed CNA B was irritated she had to assist her bed bound family member, Resident #2. She said it seemed like CNA B was tired all the time and did not want to work. She said CNA B had acted that way within the past 3 months. She said CNA B acted that way every time she worked the 200 hall. She said she dreaded when CNA B worked and took care of Resident #2. She said she had never reported how CNA B treated Resident #2. She said she did know to report abuse to the nurse. Resident #2 nodded his head in agreement when asked if he agreed with the family member's statement. During an interview on 4/8/25 at 1:45 p.m., LVN A said she had not personally heard CNA B speak to a resident in an unkind way. She said no residents had complained to her about CNA B. She said if a resident felt rushed, it could be upsetting to the resident. She said the residents should not feel like when they asked for assistance, the staff would get irritated. She said when staff rushed care of the residents, they could cause falls or skin tears. She said when worked with CNA B, CNA B had reported she was tired a lot. She said when staff were tired, it could affect their mood, performance level, patience, and job quality. Attempted interview on 4/8/25 at 2:44 p.m.; called CNA B and left a voicemail. During an interview, Confidential Staff C said CNA B spoke to residents in a rude and condescending ways. Confidential Staff C said CNA B talked about the residents in their presence. Confidential Staff C said it seemed like CNA B hated her job and the residents. Confidential Staff C said CNA B seemed overworked and took it out on the residents. Attempted interview on 4/9/25 at 8:59 a.m.; called CNA B and left a voicemail. During an interview on 4/9/25 at 9:15 a.m., the DON said Resident #1 had reported to her and ADON E that CNA B was rough with her during dressing. She said Resident #1 had explained it was not physically but verbally. She said Resident #1 had reported CNA B assisted her in dressing differently than another CNA. She said CNA B was suspended pending the investigation. She said the social worker had completed safe surveys on a different hall with no negative results after the incident. She said the social worker was going to complete a safe survey on the correct hall, where CNA B worked today (4/9/25). She said there had not been any complaints or grievances related to CNA B until 4/4/25. She said she expected staff to treat the residents with respect and to get to know the residents. She said the staff should make the resident feel comfortable, improve their quality of life, and look forward to seeing them. She said when the residents felt rushed or being a bother, they could feel bad. She said everyone deserved to be treated with dignity and respect. She said the facility tried to ensure the residents were being treated with dignity and respect by doing in-services and encouraging interaction with the residents to get to know them. During an interview on 4/9/25 at 9:45 p.m., the Administrator said CNA B had not been named in any other reported abuse allegations. He said CNA B had not been reported in any grievances or had any disciplinary action related to abuse and neglect. The administrator said he expected staff to be friendly, kind and caring to the residents. He said he wanted the residents to have the highest quality life and care. He said it depended on how it could affect the resident if they were not treated with dignity and respect. He said the facility tried to ensure residents were treated with dignity and respect by doing in-services, interviewing the residents, monitoring, and training the staff. During an interview on 4/9/25 at 1:43 p.m., CNA B returned the surveyor's phone call after exit. CNA B said she worked with Resident #1 on 4/4/25. She said Resident #1 was hard to turn over and resisted. She said Resident #1 was resistive with cares. She said she had to brace herself against Resident #1. She said Resident #1 tried to help during care but she would push against her. She said Resident #1 always apologized afterwards because she was pushing against her (CNA B) during care. She said she always told Resident #1 it was okay, she knew Resident #1 was trying help. She said she took her time with each resident. She said the 200 hall was a heavier hall and had a lot of total care residents. She said she did get tired between taking care of the residents. She said she felt like she treated the resident with dignity and respect. She said the staff was there to take care of the residents and should be treated like family. Record review of an undated facility Resident Rights policy indicated, .the resident has a right to a dignified existence .the resident has a right to be treated with respect and dignity .

Based on interview and record review, the facility failed to ensure each resident had the right to be free from misappropriation of property, and exploitation for 1 of 5 residents (Resident #3) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #3's Promethazine-Dextromethorphan (is commonly used to reduce coughing and other symptoms from allergies or common cold) on 2/25/25. The noncompliance was identified as PNC. The noncompliance began on 2/25/25 and ended on 2/27/25. The facility had corrected the noncompliance before the investigation began on 4/8/25. This failure could place residents at risk for misappropriation of physician ordered medications which could result in residents not having medications/treatments available and a decline in health. Findings included: Record review of Resident #3's face sheet dated 4/8/25 indicated Resident #3 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses including cerebral infarction (is a condition where a part of the brain is damaged or dies due to a lack of blood supply), hemiplegia (is a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (is one-sided muscle weakness) affecting left non-dominant side, type 2 diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), epilepsy (s a brain disease where nerve cells don't signal properly, which causes seizures), and gastrostomy (is the placement of a feeding tube through the skin and the stomach wall) status. Record review of Resident #3's consolidated physician's order dated 2/1/25 indicated Promethazine-Dextromethorphan Syrup 6.25-15mg/5ml, give 5ml via gastrostomy every 6 hours as needed for nausea. Start date 5/18/23. Record review of Resident #3's significant change MDS assessment dated [DATE] indicated Resident #3 was sometimes understood and usually had the ability to understand others. Resident #3 had a BIMS score of 00 which indicated severely impaired cognition. Record review of Resident #3's care plan revised on 2/24/25 indicated Resident #3 had impaired cognitive function/dementia or impaired though processes. Intervention included administer medications as ordered. Resident #3's care plan did not address use of Promethazine-Dextromethorphan Syrup. Record review of the facility's Provider Investigation Report dated 2/25/25 indicated, .an officer with the .County sheriffs office contacted this administrator to inform me that during a traffic stop the officers found a bottle of liquid medication that had one of our residents name on it that LVN D had in her possession .investigation findings: confirmed . Record review of an incident/offense report by a local county sheriff's office, dated 2/25/25 indicated, .evidence .drugs .exhibit 1: (1) 16 ounce bottle of suspected Promethazine, Hydrochloride, and Dextromethorphan Hydrobromide Oral Solution .suspected arrestee .LVN D .a vehicle search was conducted and in the front passenger seat .a black backpack .inside the backpack was an almost full Promethazine, Hydrochloride, and Dextromethorphan Hydrobromide Oral Solution Bottle, which the label showed to be prescribed to Resident #3 .LVN D stated the Promethazine bottle ended up in her work bag but could not provide any other information than that . Attempted interview on 4/8/25 at 2:48 p.m.; called LVN D and left a voicemail. During an interview on 4/8/25 at 4:23 p.m., the DON said LVN D worked at the facility as a LVN and MA. She said LVN D's background check was good upon hire. She said there had not been any reports of LVN D acting suspicious. She said the Administrator notified her about the incident involving LVN D on 2/25/25. She said the facility did not know where Resident #3's Promethazine bottle was stored prior to the incident on 2/25/25. She said Resident #3's liquid medication was stored either in the medication cart or room. She said she did not think Resident #3's Promethazine had been used in the last three months. She said LVN D called the facility, after the incident on 2/25/25 to explain why she had not come to work that week. LVN D did not mention having Resident #3's medication. She said the labeled bottle was in LVN D's possession when she was arrested. She said when another person had a resident's property it was called theft or a drug diversion. She said the facility had to reorder the missing medication and bill the facility. She said after the incident on 2/25/25, the facility in-serviced nursing staff on medication storage and narcotic counting. She said the facility implemented counting the narcotic blister package cards and bottles each shift. She said ADON F did weekly narcotic sheet monitoring. During an interview on 4/8/25 at 5:03 p.m., the Administrator said LVN D was found with Resident #3's bottle of Promethazine. He said the facility did not know how she got Resident #3's medication. He said LVN D possibly got Resident #3's medication from the medication room. He said he had not spoken to LVN D about the incident. He said LVN D had called saying she had gotten arrested for traffic tickets. He said LVN D got silent when he mentioned the county sheriff's department had notified the facility about Resident #3's medication being in her possession. He said when another person had a resident's property, unauthorized, it was considered theft. He said the facility had to reorder the medication and depending on the situation, pay for it. Attempted interview on 4/9/25 at 9:05 a.m.; called LVN D and left a voicemail. LVN D did not return the call prior to or after exit. The facility took the following actions to correct the non-compliance: Conducted an observation and record review on 4/8/25 at 10:44 a.m., of the 300 hall medication cart with RN G. All narcotic medications in the locked medication box were reviewed and accounted for. Conducted an observation and record review on 4/8/25 at 10:55 a.m., of the 400 hall medication cart with LVN A. All narcotic medications in the locked medication box were reviewed and accounted for. Conducted an observation on 4/8/25 at 11:05 a.m., of the facility's only medication room with LVN A. All liquid narcotics were stored in the refrigerator, in a locked, affixed box. The non-narcotic disposal box was locked with a padlock. Interviews of sampled residents during the course of investigation 4/8/25 to 4/9/25 revealed no residents complained of resident abuse/neglect or misappropriation. The sampled residents verified they had received pain medications on schedule and as needed and the medication relieved the pain. During interviews on 4/8/25, starting at 10:44 a.m., RN E, LVN A, ADON F, and LVN H had been in-serviced on narcotics sheets, medication destruction, storage, and notifying the DON and ADM if a staff was suspected of being under the influence. They said they were not aware of any abuse, neglect, or misappropriation of property and if so, would report it to the abuse coordinator, (Administrator). Record review of LVN D's undated employee disciplinary report indicated, .LVN D .date of infraction: 2/25 .type of disciplinary action: discharge .LVN D failed to adhere to the Corporate Code of Conduct .On 2/25, LVN D was in possession of resident medication outside of the facility .LVN D is aware of all policies and procedures via their signature on the employee handbook acknowledgement .LVN D meets criteria for immediate termination .LVN D will be terminated effective immediately .DON .Administrator . Record review of LVN D's employee disciplinary report action request dated 2/25/25 indicated, .LVN D .charge nurse LVN .hire date: 1/16/25 .date of infraction: 2/25/25 .request action: discharge .on 2/25/25 at around 10:00 pm .county sheriff's office contacted me to inform me that LVN D had been pulled over and was in possession of drugs that belonged to the facility .Administrator .2/26/25 . Record review of LVN D payroll input/personnel action form dated 2/26/25 indicated, .reason for submission: termination .LVN D .termination dated 2/26/25 .last day worked 2/25/25 .reason for separation: failed to adhere to the corporate code of conduct .eligible for rehire: no .possession of resident medications outside of the facility .Human Resource Clerk . Record review of LVN D license verification report dated 2/26/25 indicated, .LVN D .unencumbered .active . Record review of LVN D's verification of criminal history checks provided on 4/8/25 indicated, .date check was conducted: 1/16/15 .determined to be employable: Yes .Human Resource . Record review of the facility's Abuse/Neglect policy revised 9/9/24 indicated, the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings . Record review of a facility conducted in-service, Narcotic Count Sheets dated 2/26/25 reflected 14 of 22 nursing staff were provided education on the topic. Record review of a facility conducted in-service, Medication Destruction, Storage of Controlled Substance, and Medication Administration dated 2/26/25 reflected 12 of 22 nursing staff were provided education on the topic. Record review of a facility conducted in-service, If You Suspect that an Employee the Influence dated 2/27/25 reflected 19 staff members were provided education on the topic. Record review of the facility's safe surveys dated 2/26/25 indicate 28 of 28 residents surveyed had received their medications and received as needed medication when asked. Record review of narcotic count sheets audit provided on 4/8/25 by the Administrator indicated no discrepancies for 12 residents who had been administered narcotics by LVN D. Record review of facility incident/accident reports for the past three (3) months revealed no concerns in the area(s) of Resident Abuse; Resident Neglect; Misappropriation of property. Appropriate facility responses and investigations were done as necessary. Incident report for Misappropriation of property was addressed with appropriate facility response and investigation. LVN D was terminated and referred to the Board of Nursing. Misappropriation cited. Record review of facility complaints for the past three (3) months revealed no concerns in the area(s) of Resident Abuse; Misappropriation of property; or Resident Neglect. The noncompliance was identified as PNC. The noncompliance began on 2/25/25 and ended on 2/27/25. The facility had corrected the noncompliance before the investigation began on 4/8/25.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 8 (Resident #4) residents reviewed for abuse and neglect. Confidential Staff C failed to report to the Administrator CNA B allegedly called Resident #4 pissy and smelly. Confidential Staff C said the incident had happened within the last 3-6 months. This failure to report could place the residents at risk for further abuse which could result in psychosocial harm and a diminished quality of life. Findings included: Record review of Resident #4's face sheet dated 4/9/25 indicated Resident #4 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #4 had diagnoses including dementia (is a general term for a decline in mental ability, including memory, thinking, and reasoning, severe enough to interfere with daily life, and is not a specific disease, but rather a group of symptoms), hypertension (is when the force of blood pushing against your artery walls is consistently too high), and chronic obstruction pulmonary disease (is a group of lung diseases that cause airflow obstruction, making it difficult to breathe and worsen over time). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated Resident #4 was usually understood and usually had the ability to understand others. Resident #4 had a BIMS score of 15 which indicated intact cognition. Resident #4 required moderate assistance for toileting hygiene. Resident #4 was frequently incontinent of urine and bowel. Record review of Resident #4's care plan dated 2/23/25 indicated: *Resident #4 has potential impairment to skin integrity of related to incontinence of bowel and bladder. Resident #4 was resistive to incontinence care. Resident #4 refused to allow staff to change her briefs on a routine basis. Intervention included report resident incidents of refusal of care to charge nurse for intervention. *Resident #4 had a behavior problem resistive to care. Resident #4 verbalizes she did not want to be disturbed during the night to receive toileting or incontinence care. Intervention included caregivers to provide opportunity for positive interaction and attention. *Resident #4 had an ADL self-care performance deficit related to activity intolerance, dementia, and impaired balance. Intervention included Resident #4 request to only be checked once per night after being assisted to bed. Check Resident #4 for incontinence in early morning per resident request. During an interview Confidential Staff C said CNA B spoke to residents in a rude and condescending ways. Confidential Staff C said CNA B talked about the residents in their presence. Confidential Staff C said it seemed like CNA B hated her job and the residents. Confidential Staff C said CNA B seemed overworked and took it out on the residents. Confidential Staff C said CNA B told Resident #4 she was pissy and smelly. Confidential Staff C said CNA B and Resident #4 were having a heated argument. Confidential Staff C said she/he did not report CNA B. Confidential Staff C said because previous administration had not done anything when she/he had reported CNA B for another incident. Confidential Staff C said it was important to report verbal abuse because it could become physical. Confidential Staff C said if abuse or neglect was not report then it could continue. Confidential Staff C said abuse or neglect should be reported to the Abuse Coordinator immediately. During an interview on 4/9/25 at 9:21 a.m., the DON said abuse and neglect should be reported immediately. She said abuse and neglect should be reported to the nursing administration and the Abuse Coordinator, which was the Administrator. She said using words like pissy or smelly could be considered verbal abuse or belittling. She said the allegations had never been reported to her by any staff or residents. She said it was important to report abuse or neglect to protect the residents. She said the facility provided in-services to staff to prevent abuse and neglect. She said the facility also provided in-services on reporting abuse. During an interview on 4/9/25 at 9:45 a.m., the Administrator said he expected staff to report abuse and neglect to the Abuse Coordinator/Administrator. He said when abuse and neglect were not reported, the resident could not be protected. He said he was never made aware of CNA B saying pissy or smelly to a resident. He said the facility provided many in-services on abuse, neglect, and reporting. He said it was frustrating that the facility hounded into the staff about reporting and the staff still did not report. During an interview and observation on 4/9/25 at 10:19 a.m., Resident #4 was lying in bed. Resident #4's room had a strong urine smell. Resident #4 said no one had said any means words towards her. She said she could not recall any CNAs telling her she was smelly. During an interview on 4/9/25 at 1:43 p.m., CNA B returned the surveyor's phone call after exit. CNA B said she took care of Resident #4. She said Resident #4 got made about being asked to shower and would cuss at the staff. She said Resident #4 threw her wet briefs on the floor or in the trash and her room would smell like pee. She said she had told Resident #4 her room or sheets smelled like pee but never told Resident #4 she did. She said telling a resident they were smelly or pissy would make them feel bad. She said she would never do that. Record review of a facility's Abuse/Neglect policy revised 9/9/24 indicated, .the resident has the right to be free from abuse, neglect .when suspected abused, neglected, exploited, mistreated .comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee .facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents .to the facility administrator .

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 4 of 4 resident's reviewed for pharmacy services. (Resident's #1, #2, #3, and #4) 1. The facility failed to ensure LVN A reconciled Resident #1's hydrocodone-acetaminophen (controlled medication used for pain) on the individual control drug record after it was given on 01/28/25. 2. The facility failed to ensure LVN A reconciled Resident #2's hydrocodone-acetaminophen (controlled medication used for pain) on the individual control drug record after it was given on 01/28/25. 3. The facility failed to ensure LVN A reconciled Resident #3's Tylenol #3 (controlled medication used for pain) and lorazepam (controlled medication used for anxiety) on the MAR and the individual control drug record after it was given on 01/28/25. 4. The facility failed to ensure LVN A reconciled Resident #4's hydrocodone-acetaminophen (controlled medication used for pain) on the MAR and the individual control drug record after it was given on 01/28/25. These failures could place residents at risk for medication errors and loss of medications through drug diversion. The findings included: 1. Record review of the face sheet, dated 01/29/25, reflected Resident #1 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of other specified injuries of lower back. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #1 had clear speech and was understood by others. The MDS reflected Resident #1 was able to understand others. The MDS reflected Resident #1 had a BIMS score of 11, which indicated moderately impaired cognition. The MDS reflected Resident #1 had occasional, moderate pain which occasionally made it hard to sleep at night, participate in rehabilitation therapy, and limited his day-to-day activity during the 5-day look-back period. The MDS reflected Resident #1 received opioid (pain) medication during the look-back period. Record review of the comprehensive care plan, last reviewed on 11/06/24, reflected Resident #1 had chronic pain related to multiple old injuries and refused to be evaluated for pain management. The interventions included: monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Record review of the order summary report, dated 01/29/25, reflected Resident #1 had an order, which started on 01/28/25, for hydrocodone-acetaminophen (controlled medication used for pain) 10-325 mg - give 1 tablet by mouth every 6 hours as needed for pain, may have medication between 10 PM - 11 PM on night dose. Record review of the MAR, dated January 2025, reflected Resident #1 received hydrocodone-acetaminophen (controlled medication used for pain) 10-325 mg on 01/28/25 at 6:45 AM with effective results. 2. Record review of the face sheet, dated 01/29/25, reflected Resident #2 was an [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of dementia (memory loss), a broken left femur (leg), and broken lumber vertebra (lower back). Record review of the quarterly MDS assessment, dated 01/03/25, reflected Resident #2 had unclear speech and was sometimes understood by others. The MDS reflected Resident #2 was sometimes able to understand others. The MDS reflected Resident #2 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS reflected Resident #2 had frequent pain that rarely made it hard to sleep at night, occasionally limited participate in rehabilitation therapy, and occasionally limited day-to-day activities during the 5-day look-back period. The MDS reflected Resident #2 rated her worse pain during the look-back period at a 5, which indicated moderate to severe pain. The MDS reflected Resident #2 received opioid (pain) medication during the look-back period. Record review of the comprehensive care plan, last reviewed on 01/08/25, reflected Resident #2 had chronic pain related to diabetic neuropathy (numbness or tingling in hands or feet). The interventions included: monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Record review of the order summary report, dated 01/29/25, reflected Resident #2 had an order, which started on 04/27/24, for hydrocodone-acetaminophen (controlled medication used for pain) 7.5-325mg - give one tablet by mouth two times a day for pain. Record review of the MAR, dated January 2025, reflected Resident #2 received hydrocodone-acetaminophen (controlled medication used for pain) 7.5-325 mg on 01/28/25 at 9 AM. 3. Record review of the face sheet, dated 01/29/25, reflected Resident #3 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of chronic pain and anxiety disorder. Record review of the quarterly MDS assessment, dated 11/29/24, reflected Resident #3 had no speech but was sometimes understood by others. The MDS reflected Resident #3 was sometimes able to understand others. The MDS reflected Resident #3 had a BIMS score of 0, which indicated severe cognitive impairment. The MDS reflected Resident #3 had an active diagnosis of chronic pain and anxiety. The MDS reflected Resident #3 had pain during the look-back period and rated it at 5, which indicated moderate-severe pain. The MDS reflected Resident #3 was unable to answer all the pain interview questions so a staff assessment was conducted. The MDS reflected Resident #3 had vocal complaints of pain 3-4 days of the 5-day look-back period. The MDS reflected Resident #3 received opioid (pain) medication during the look-back period. The MDS reflected Resident #3 did not receive an antianxiety medication during the look-back period. Record review of the comprehensive care plan, last reviewed 01/14/25, reflected Resident #3 had pain. The interventions included: monitor/record/report to nurse resident complaints of pain or requests for pain treatment. The care plan further reflected Resident #3 had a history of anxiety. The interventions included: administer medication per orders. Record review of the order summary report, dated 01/29/25, reflected Resident #3 had the following orders: 1. Tylenol #3 (controlled medication used for pain) 300-30 mg - give 1 tablet via gastrostomy tube two times a day for pain, which started on 09/07/24. 2. lorazepam (controlled medication given for anxiety) 0.5mg - give 1 tablet via gastrostomy tube every 6 hours as needed for pain, which started on 01/18/25. Record review of the MAR, dated January 2025, reflected Resident #3 received Tylenol #3 (controlled medication used for pain) 300-30 mg on 01/28/25 in the AM. The MAR further reflected Resident #3's lorazepam (controlled medication used for anxiety) 0.5 mg was blank for 01/28/25, which indicated the medication was not signed out as given. 4. Record review of the face sheet, dated 01/29/25, reflected Resident #4 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of broken lumber vertebra (lower back). Record review of the admission MDS assessment, dated 10/14/24, reflected Resident #4 had clear speech and was understood by others. The MDS reflected Resident #4 was able to understand others. The MDS reflected Resident #4 had a BIMS score of 11, which indicated moderately impaired cognition. The MDS reflected Resident #4 had occasional, moderate pain which occasionally made it hard to sleep at night, limited participation with rehabilitation therapy, and limited day-to-day activities during the 5-day look-back period. The MDS reflected Resident #4 received opioid (pain) medication during the look-back period. Record review of the comprehensive care plan, last reviewed 01/14/25, reflected Resident #4 had the potential for uncontrolled pain. The interventions included: monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Record review of the order summary report, dated 01/29/25, reflected Resident #4 had an order, which started on 12/10/24, for hydrocodone-acetaminophen (controlled medication used for pain) 7.5-325 mg - give one tablet by mouth every 6 hours as needed for pain. Record review of the MAR, dated January 2025, reflected Resident #4's hydrocodone-acetaminophen (controlled medication used for pain) 7.5 mg was blank, which indicated the medication was not signed out as given on the 6 am to 6 pm shift on 01/28/25. During an observation and record review on 01/28/25 beginning at 4:52 PM, the ADON obtained the 400 hall medication cart and keys to reconcile narcotic (controlled) medications with the surveyor. During the narcotic (controlled) medication reconciliation: 1. Resident #1's hydrocodone-acetaminophen 10-325 mg medication cards were attached with a rubber band. Resident #1's hydrocodone-acetaminophen mediation cards had 27 pills on one card, and 60 pills on the other card for a total of 87 pills. The individual control drug record for the hydrocodone-acetaminophen 10-325 mg medication reflected Resident #1 had 88 pills left. The count was off by 1 pill. 2. Resident #2's hydrocodone-acetaminophen 7.5-325 mg medication card was empty. The individual control drug record for the hydrocodone-acetaminophen 7.5-325 mg medication reflected Resident #2 had 1 pill left. The count was off by 1 pill. 3. Resident #3's Tylenol #3 300-30 mg medication card had 23 pills. The individual control drug record for the Tylenol #3 reflected Resident #3 had 24 pills left. The count was off by 1 pill. 4. Resident #3 had two medication cards for the lorazepam 0.5 mg in the lock box. One card had 29 pills and the next card had 30 pills for a total amount of 59 pills. The individual control drug record for the lorazepam 0.5 mg medication reflected Resident #3 had 60 pills left. The count was off by 1 pill. 5. Resident #4's hydrocodone-acetaminophen 7.5-325 mg medication card had 8 pills. The individual control drug record for the hydrocodone-acetaminophen 7.5-325 mg reflected Resident #4 had 9 pills left. The count was off by 1 pill. During an interview on 01/28/25 beginning at 5:14 PM, ADON B stated controlled medication should have been signed out as it was given. ADON B stated she was going to perform in-service training with the nurses. During an interview on 01/28/25 beginning at 5:23 PM, LVN A stated he administered all the missing medications to the residents. LVN A stated he believed when he signed out the medication in the computer that was sufficient while passing his medication. LVN A stated he was going to sign the paper record at a later time. LVN A stated he realized he made a mistake. LVN A stated it placed the residents at risk for a medication error and drug diversion, especially if he had to leave unexpectedly and the count was off. During an interview on 01/29/25 beginning at 7:36 AM, ADON B stated in-service training was performed on 01/28/25 with LVN A. ADON B stated Resident's #1, #2, #3, and #4 were assessed for pain with no indicators of pain noted. ADON B stated she expected the nursing staff to ensure controlled medications were signed out as it was given. ADON B stated it should have been signed out in the MAR and the individual drug control record. ADON B stated it was important to ensure controlled medication was signed out as it was given because anything could have happened. ADON B stated it placed the residents at risk for medication errors and drug diversion. During an interview on 01/29/25 beginning at 7:46 AM, the Administrator stated he expected controlled medications to be signed out when they were given. The Administrator stated the controlled medications should have been signed out in the MAR and on the paper form. The Administrator stated nursing management and pharmacy staff were responsible for monitoring to ensure medications were signed out as they were given. The Administrator stated it was important to ensure medications were signed out as given to prevent a medication error or a drug diversion. Record review of the Medication Administration Procedures policy, revised 10/25/17, reflected .administer the medication and immediately cart doses administered on the medication administration record .it is recommended that medication be charted immediately after administration, but if facility policy permits, medications may be charted immediately before . Record review of the Storage and Documentation of Controlled Medications policy, year dated 2003, reflected Disposition of controlled substances is maintained on the sheet supplied by the Pharmacy with each controlled substance .entries are to be made in pen each time a controlled substance is used .the nurse administering the medication will record the following information: date and time drug is administered, amount of drug administered, remaining balance of drug, and signature of nurse administering drug .

Based on observation, interview, and record review, the facility did not ensure treatment and services was provided, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 1 of 4 residents reviewed for quality of care. (Resident #38) 1. The facility failed to appropriately assess Resident #38's skin and wounds after readmission from 06/20/24 through 06/23/24. A new wound to the right lateral glute was identified by the facility on 06/24/24 when it was a Stage III pressure injury (a full thickness loss of skin extending to the subcutaneous tissue). 2. The facility failed to follow previous wound care recommendations from the wound care physician for wounds to the sacrum and left foot for Resident #38 from 06/20/24 through 06/23/24. 3. The facility failed to provide appropriate skin and wound care after readmission on 06/20/24 through 06/23/24. 4. The facility failed to notify the Dietician of Resident #38's wounds. 5. The facility failed to order supplements to promote wound healing. 6. The facility failed to provide appropriate wound care when LVN A placed a urine-soaked brief over a newly placed dressing during wound care to the unstageable wound to the sacrum. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 06/25/24 at 5:30 p.m. While the IJ was removed on 06/26/24 at 11:05 a.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries. Findings included: Record review of Resident #38's face sheet dated 06/25/24 indicated Resident #38 was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dementia, Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and heart disease. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #38 was usually understood and usually understood others. The MDS indicated a BIMS score of 99 which indicated Resident #38 was unable to complete the interview. The MDS indicated Resident #38 was dependent on staff for all ADLs. The MDS indicated Resident #38 was at risk of developing pressure ulcers/injuries. The MDS did not indicate any unhealed pressure ulcers/injuries. Record review of the care plan last revised on 06/03/24 indicated Resident #38 had potential for impairment to skin integrity and pressure ulcers related to incontinence of bowel and bladder, decreased mobility, use of anticoagulant medications, scratches buttocks causing abrasion or broken skin. There was an intervention to follow facility protocols for treatment of injury. The care plan indicated Resident #38 had an unstageable deep tissue injury to the left medial foot. There were interventions to administer and encourage compliance with supplements to promote wound healing and to administer medication and treatment (skin prep every day) as ordered. The care plan indicated Resident #38 had actual impairment related to an open wound area of the sacrum (area located at the base of the lumbar spine where it connects to the pelvis). There was an intervention to encourage good nutrition and hydration in order to promote healthier skin. Record review of Resident #38's consolidated physician orders dated 06/25/24 indicated an order to cleanse sacrum with wound cleanse and pat dry, apply collagen sheet and cover with island border, daily and as needed for wound treatment. There was an order to cleanse a Stage 3 pressure wound to the right lateral glute (right upper buttock) with wound cleanse, pat dry, apply collagen, cover with dry dressing every day, and as needed, with a start date of 06/24/24. The consolidated physician orders did not indicate orders for wound care for a deep tissue injury to the left foot, Vitamin C, Zinc, a protein supplement, or a dietary consultation. Record review of a facility Weekly Skin Assessments and Treatments In-Service Training Report for nursing staff dated 05/28/24 indicated, .when wound care nurse is not here you are responsible for weekly skin assessments and corresponding wound progress assessments. For every wound the resident has you must complete a weekly skin observation .Treatments are to be completed as ordered . Record review of Resident #38's electronic medical record accessed on 06/24/24 and 06/25/24 did not indicate dietary notes or a skin assessment for 06/20/24. Record review of a Weekly Skin assessment dated [DATE] at 2:45 p.m. indicated Resident #38 had a pressure (an injury to the skin from prolonged pressure), venous (a wound on the leg or ankle caused by abnormal or damaged veins), arterial (an ulcer caused from arterial insufficiency), or diabetic (an ulcer caused by complications with diabetes) ulcer. The assessment did not indicate the type, location, or size of the ulcer. Record review of a Weekly Skin assessment dated [DATE] at 6:27 a.m. indicated Resident #38 had a deep tissue injury to right buttocks and left medial foot with current treatments in place for both. The assessment did not indicate the size of the injuries. Record review of a Weekly Skin Assessment for Resident #38 dated 06/24/24 at 1:07 a.m. indicated, .Noted bleeding to sacrum (area that is located at the base of the lumbar spine, where it connects to the pelvis) area, and to bil (bilateral buttocks) . The size was documented as 5 centimeters x 5.5 centimeters. The assessment did not indicate a pressure, venous, arterial, or diabetic ulcer. Record review of a Weekly Skin assessment dated [DATE] at 19:27 a.m. indicated Resident #38 had a pressure, venous, arterial, or diabetic ulcer. The assessment did not indicate the type, location, or size of the ulcer. Record review of a Wound Evaluation and Management Summary report by the Wound Care Physician dated 06/05/24 indicated an Unstageable DTI (deep tissue injury) of the left, distal (sites located away from a specific area), medial (middle) foot undetermined thickness. The deep tissue injury to the left foot measured 2 centimeters in length x 1.8 centimeters in width. The depth of the wound was no measurable. The Dressing Treatment Plan indicated, Primary Dressing: Betadine apply once daily for 23 days. The report indicated an Unstageable DTI of the right, medial buttock (sacrum). The wound size was 2.8 centimeters in length x 0.8 centimeters in width x 0.1 centimeters in depth. The Dressing Treatment Plan indicated, Primary Dressing: Collagen sheet apply once daily for 30 days. Secondary Dressing: Gauze Island with border apply once daily for 30 days. The report was signed by the Wound Care Physician. The report did not indicate a pressure injury to the right later glute. Record review of a Wound Care Evaluation and Management Summary report by the Wound Care Physician dated 06/12/24 indicated Resident #38 was not seen due to a non-wound-related hospitalization since last visit. Record review of Consult to Wound Care for High Risk Braden Score hospital record dated 06/13/24 at 11:21 a.m. indicated, Resident #38 was admitted to the hospital on 06/12/24. The record indicated a Braden Score of 13 which indicated Resident #38 was at moderate risk for pressure injury. The record indicated a pressure injury to the left foot that measured 3 centimeter in length x 3.2 centimeter in width x 0.0 centimeter in depth. The pressure injury to the left foot was staged as a deep tissue pressure injury. The wound was black in color and was intact. The record indicated a wound to buttocks (sacrum wound) that measure 3 centimeters in length x 1 centimeter in width x 0.1 centimeter in depth. The wound was described as red in color with defined edges. The pressure injury was staged as a deep tissue pressure injury. The record indicated a pressure injury to right trochanter (right glute). The record indicated the wound measured 1 centimeter in length x 1 centimeter in width x 0.0 centimeter in depth. The wound was described as pink, red, and non-blanchable. The pressure injury was staged as a Stage 2 pressure injury. The note was signed by a registered nurse and a physician. Record review of Progress Note, Hospital Day 6, dated 06/18/24 at 11:36 a.m. indicated Resident #38 had an unstageable pressure injury to ball of left foot and a sacral pressure injury. There was no documentation of measurements or wound description. The progress note was signed by a Nurse Practitioner. Record review of a Readmission Nurses' Note dated 06/20/24 at 6:30 p.m., indicated Resident #38 was readmitted from the hospital. The notes did not include an assessment of the skin or wound care. The note was signed by LVN R. Record review of Hospice Skilled Nursing Visit Note dated 06/20/24 between 6:37 p.m. and 8:40 p.m. indicated an unstageable pressure ulcer to the left medial proximal foot great toe. The wound measurements were 2 centimeters in length x 1.5 centimeters in width. The notes indicated the wound to the sacrum had a dry and intact dress. The note indicated the wound was not visualized due to the fact Resident #38 was hollering with position change for visualization. The note indicated an area to the right posterior lateral outer lower torso hip (right glute). The note indicated this was a Stage 1 pressure ulcer. An additional note describing the wound indicated, Scatter areas of 'white' tissue that are intact. There were no measurements of the area. The Hospice Skilled Nursing Visit Note indicated a Pressure Ulcer Risk Assessment total score of 9 which indicated Resident #38 was a very high risk for pressure ulcers. The Hospice Skilled Nursing Visit Note was signed by Hospice Nurse T. Record review of a Hospice Skilled Nursing Visit Note dated 06/21/24 at 10:00 a.m. indicated, .Wounds not observed at this time as the nurse stated they just turned him and got him settled. Facility staff does wound care . The note was signed by Hospice Nurse S. Record review of a Nursing Progress Note for Resident #38 dated 06/24/24 at 7:08 p.m. indicated, New stage 3 pressure wound of right lateral glute noted 2 cm x 0.9 cm x 0.1 cm light serous drainage noted no foul odor or s/s (signs or symptoms) infection. 25% slough (dead tissue separating from living tissue) noted to wound bed surrounding skin intact normal color. Edges are intact and flush to skin. Hospice notified. NEW ORDER per (Wound Care Physician): Cleanse with wound cleanser, pat dry, apply collagen cover with border gauze QD (daily). Continues with Unstageable DTI (deep tissue injury) of he left distal medial foot 2.7 cm x 2.5 cm x UTD (unable to determine) area is not open dark purple in color. Continues with unstageable to right medial buttock that has extended to left buttock/sacral area. 7.5 cm x 1.2 cm x 0.1 cm. [NAME] eschar to wound bed <25% . Record review of a Weekly Ulcer assessment dated [DATE] at 7:29 p.m. indicated Resident #38 had an ulcer to the left distal medial foot. The type of ulcer was pressure. The Pressure Ulcer Stage was deep tissue injury. The documented wound measurement was 2.5 centimeters in length x 3 centimeters in width. The depth could not be measured. The assessment indicated the current wound treatment was to cleanse with wound cleanser, pat dry, apply betadine every day. There was a note to continue orders from the Wound Care Physician. Record review of a Weekly Ulcer assessment dated [DATE] at 7:36 p.m. indicated Resident #38 had an ulcer to the sacrum. The type of ulcer was pressure. The Pressure Ulcer Stage was deep tissue injury. The documented wound measurement was 5 centimeters in length x 8.7 centimeters in width. The depth could not be measured. The assessment indicated the current wound treatment was to cleanse with wound cleanser, pat dry, apply collagen, and cover with a border gauze daily. There was a note that indicated, wound labeled per (Wound Care Physician) as unstageable of the right medial buttock has extended over to the sacral area. Record review of a Weekly Ulcer assessment dated [DATE] at 7:48 p.m. indicated Resident #38 had an ulcer to the right lateral glute. The type of ulcer was pressure. The Pressure Ulcer Stage was Stage III. The documented wound measurement was 2.7 centimeters in length x 1 centimeters in width. The depth could not be measured. The assessment indicated the current wound treatment was to cleanse with wound cleanser, pat dry, apply betadine every day. Record review of a Wound Administration Record for June 2024 for Resident #38 indicated an order to cleanse right medial buttocks with wound cleanse and pat dry, apply collagen sheet and cover with island border gauze daily with a discontinued date of 06/24/24. The documentation of wound care to the right medial buttock indicated Resident #38 did not receive wound care of this wound on 06/20/24, 06/21/24, 06/22/24, 06/23/24, and 06/24/24. There was an order to cleanse sacrum with wound cleanse and pat dry. Apply collagen sheet and cover with island border gauze daily and as needed one time a day for wound treatment. The documentation of wound care to the right medial buttock indicated Resident #38 did not receive wound care of this wound on 06/20/24, 06/21/24, 06/22/24, 06/23/24, and 06/24/24.There was an order to cleanse an unstageable deep tissue injury of the left distal medial foot with wound cleanser, pat dry, they apply betadine everyday times 30 days. The order was discontinued on 06/13/24. The documentation of wound care to the unstageable deep tissue injury of the left distal medial foot indicated Resident #38 did not receive wound care of this wound on 06/02/24, 06/06/24, 06/20/24, 06/21/24, 06/22/24, 06/23/24, and 06/24/24. There was an order for a stage 3 pressure wound of the right lateral glute to cleanse with wound cleanser, pat dry, apply collagen, and cover with a dry dressing every day and as needed. The documentation of wound care to the right lateral glute indicated Resident #38 did not receive wound care of this wound on 06/20/24, 06/21/24, 06/22/24, and 06/23/24. During an observation and interview on 06/24/24 at 11:08 a.m., LVN F provided wound care to Resident #38. She said Resident #38 had been out to the hospital and was not on the Wound Care Physician's list on 06/19/24. There was wound to the sacrum that was measured by LVN F. The wound measured 7.5 centimeters in length x 7.2 centimeters in with. She said this wound was unstageable because of the slough to the wound bed. There was a wound to right glute 2 centimeters in length x 0.9 centimeters in width. She said this wound was a stage III. Each wound was cleansed with wound cleaner and a collagen dressing was applied. The deep tissue injury to the left foot was not observed and wound care to the wound was not provided by LVN F. During an interview on 06/25/24 on 2:49 p.m., the Wound Care Physician said typically if she was present in the facility, staff would let her know when a resident had returned to the facility. She said if she was not present in the facility staff wound not have to notify her unless there was a new skin issue. She said anytime wound care was not done there was a problem with that. She said Resident #38 had a pressure injury on the left foot and unstageable pressure injury to the right buttock when he left to the hospital. She said she was notified 6/24/24 of the new pressure injury to the right glute. She said staff were allowed to call her for new orders. She said she would expect to be notified anytime a new wound was found. During an observation and interview on 06/25/24 at 3:40 p.m., LVN A provided wound care to Resident #38. LVN A said it was the first time he was seeing Resident #38's wounds. LVN A measured the deep tissue injury to the left foot. The measurements were 2.5 centimeters x 3.0 centimeters. The wound appeared black and was not open. LVN A measured the wound to the right glute. The wound measured 2.7 centimeters x 1 centimeter. The wound was Stage III. The wound open with a small amount of slough. LVN A measured the wound to the sacrum. The wound measured 5 centimeters x 8.7 centimeters. The wound bed was red with slough. During the wound care LVN A did not remove a urine-soaked brief that was under Resident #38. After cleansing the wound to the sacrum, LVN A pulled the urine-soaked brief over the clean dressing in order to turn the resident in bed. During an interview on 06/26/24 at 11:12 a.m., LVN R said when she came on duty on 6/20/24, Resident #38 was already at the facility. She said she did complete his readmission assessment. She said she did not complete a skin assessment because the hospice nurse was in the room admitting him to hospice. She said she was in the room during part of the skin assessment by the nurse. She said she was 100% sure it was done. She said she did not obtain any wound care orders. She said she did not provide any wound care. She said she contacted the ADON off and on during the night of 06/20/24 concerning Resident #38's orders, what needed to be done, and what the resident needed. She said she called the ADON and gave her a verbal report on the morning of 6/21/24 and the ADON told her she would handle it. During an interview on 06/26/24 at 1:34 p.m., a family member of Resident #38 said they were notified of Resident #38's wounds on 6/25/24. They said they were made aware of the new wound at that time. They said Resident #38 only had two wounds present that they were aware of while he was in the hospital. During an interview on 06/26/24 at 1:48 p.m., Hospice Nurse S said Hospice Nurse T was the on-call Hospice nurse when Resident #38 was readmitted to the facility. She said Hospice Nurse T was the nurse that assessed Resident #38. She said Hospice Nurse T did not complete a skin assessment because Resident #38 was agitated and tried to bite her. She said no wound care orders were placed at that time. She said she would have expected for the facility to have followed up on obtaining a skin assessment and obtaining wound care orders. Especially, since he had been to the hospital and had previous wound care orders from the Wound Care Physician. During an interview on 06/26/24 at 1:56 p.m., Hospice Nurse T said she did a skin assessment on Resident #38. She said she was able to observe all wounds except for the sacrum. She said he became agitated and was hitting and biting staff. She said a facility CNA was in the room helping her. She said she documented the wounds in her notes. She said the wound to the right glute was not open when she did the assessment on 06/20/24. She said it was a white area. She said it was only at risk. She said she called the Hospice MD and notified him that she was unable to assess the sacral wound. She said she also told Hospice Nurse S. She said hospice worked in coordination with the facility. She said hospice had 5 days to complete a skin assessment. During an interview on 06/26/24 at 2:40 p.m., LVN A said he had provided care to Resident #38 beginning the morning of 06/21/24. He said Resident #38 had returned on the night of 06/20/24. He said he did not complete a skin assessment. He said he did not know Resident #38 had any wounds and did not lay eyes on his wounds until 6/25/24. He said on the 06/21/24 he was not aware of any skin issues Resident #38 had. He said there were no orders on 06/21/24 for wound care for Resident #38. He said if there had been it would have been his responsibility to have provided wound care. He said at times they do have treatment nurses that volunteer to do wound care for the day. He said there was not a treatment nurse on 6/21/24. He said the admitting nurse should done a skin assessment within 4 hours. Any skin issues should have been assessed and the doctor should have been called to receive orders for the wound. He said during wound care on 06/25/24, he did cover up the new dressing to the sacrum with the urine-soaked brief. He said he was just so focused wound care and did not think about the urine-soaked brief. He said he had been in-serviced on proper incontinent care during wound care. During an interview on 06/26/24 at 3:03 p.m., the ADON said LVN R did not do a skin assessment when Resident #38 was readmitted to the facility. She said even though the hospice nurse did a skin assessment, she would have expected for LVN R to have done a skin assessment immediately. She said the previous orders from the Wound Care Physician should have been immediately restarted to the two wounds that were present on 6/12/24. She said LVN R should have communicated with the hospice nurse concerning wound care. She said she would have expected LVN R to have seen the new skin issue and obtained doctor's orders. She said she had talked to LVN R on the night of 06/20/24 about what all needed to be done. She they discussed assessments, oxygen needs, dietary needs, and care in general. She said she thought between LVN R and the hospice nurse, everything was taken care. She said she did not go in to assess the resident's wounds on 06/21/24. She said that would have been LVN A's responsibility. She said the admitting nurse was responsible for obtaining orders including supplements and a dietary consult. She said all wound care was documented in resident's electronic medical record on the Wound Care Administration Form. She said it was her job and the DON's job to monitor to make sure those things were being done. She said they had a meeting each morning and they went over the new admissions to make sure the assessments had been done. She said if a resident had an incontinent episode, the resident should be cleaned, and a dry brief should have been placed under the resident prior to wound care. She said a resident not receiving timely wound care could cause worsening skin issues, could cause gangrene, or the resident could expire. She said by a wet brief being placed over a freshly cleaned and dressed wound could cause germs to get in the wound and make it worse. During an interview on 06/26/24 at 3:29 p.m., LVN F said she was a charge at the facility. She said she was acting as the treatment nurse on 6/24/24. She 6/24/24 was the first time she provided wound care for Resident #38. She said the nurses were responsible for wound care to their residents. She said 6/24/24 was the first time she had ever assessed his wounds. She said the admitting nurse had 4 hours to do a skin assessment. She said the admitting nurse should then restart any previous orders and obtain new orders for any new skin issues. During an interview on 06/26/24 at 3:59 p.m., the DON said the facility had not had a full-time treatment nurse since first of June 2024. She said the charge nurse was responsible for providing wound care since they did not have a treatment nurse. She said she would have expected for LVN R to have completed a skin assessment on Resident #38 on 6/20/24 regardless of whatever assessments the hospice nurse had completed. She said the nurse should have then called the doctor and/or hospice to get a treatment order. She said the skin assessment should have been completed with 4 hours by the admitting nurse. She said the resident did go from the 06/20/24 to the 06/24/24 without wound care. She said by a resident not having skin assessments could cause the resident to miss treatments and cause a wound to worsen. She said the treatment nurse typically makes the dietician notification. She said now the charge nurse should report to her any skin issues and was responsible for notifying the dietician. She said when Resident #39 readmitted to the facility, supplements should have been ordered. She said she was not notified of any new wounds on 6/20/24 or 6/21/24. She did not find out about the new wound until 6/24/24. She said she had notified the dietician. She said she would have expected for supplements to have been started on 6/21/24. She said not having supplements could delay wound healing. She said LVN A should have completed the incontinent care before starting wound care. She said urine-soaked brief could cause infection to a wound. She said a resident not receiving wound care could cause a delay in healing and cause a wound to worsen. She said all wound care treatments were charted on the Wound Care Administration Form in the electronic medical record. She said herself and the ADON monitor by doing audits Monday - Friday to make sure resident receive the appropriate wound care. She said she was not working on 6/21/24 but she would have expected for the ADON to have followed up. During an interview on 06/26/24 at 4:41 p.m., the Administrator said she expected skin assessments to be completed within 4 hours of admission by the treatment nurse, designee, or the charge nurse. She said she would have expected for Resident #38 to have been assessed within 4 hours of being readmitted to the facility. She said she would have expected for the physician to have been notified and the dietician to have been notified of any skin issues so new wound care orders could be obtained. She said Resident #38 needed wound orders so his wounds would not heal. She said she would have expected wound orders for wounds present prior to the hospital stay to have been restarted as long as the wounds were of the same caliber. She said if they had changed, she would have expected the wound care doctor to be notified for order clarification. She said she would have expected for the wound care doctor to have been notified of the new wound. Record review of a Skin Assessment facility policy dated 08/15/16 indicated, .It is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to ensure appropriate intervention are initiated in a timely manner .All new admits and resident returning from a hospital stall will have a head-to-toe skin assessment completed by the Treatment Nurse/designee within four (4) hours of the resident's arrival at the facility .If the Treatment Nurse/designee is not available, then the charge nurse should complete the skin assessment with four (4) hours of the resident's arrival at the facility .The DON (Director of Nursing) or designee, along with the Treatment Nurse/designee and other team members will review for the follow-up assessment and recommendations .Any alterations in skin integrity will be treated according to physician orders. Notify DON and responsible family member. Documentation will then be entered into the resident's chart . Record review of a Pressure Injury: Prevention, Assessment and Treatment facility policy dated 08/12/16 indicated, .Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury, and infection .Early prevention and/or treatment is essential upon initial assessment of the condition of the skin on admission and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sore(s) is indicated and notify the Treatment Nurse/designee of any potential problems .Notify the physician of pressure sore and obtain and follow any orders as directed by the physician .Notify family and dietary department. Document notification .Maintain adequate nutrition .Assess for early signs of skin breakdown and report any abnormal findings .Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage .Notify physician; obtain an order and monitor site daily .Assessment of the pressure injury should also include the site, size, and WxLxD of the injury. Surrounding tissue, color, exudate, wound edges, sinus tracts, odor, tunneling and undermining should also be documented at least weekly and upon decline . Record review of a Skin Integrity Management facility policy dated 10/05/16 indicated, .If wound is noted, perform an assessment and initiate a treatment plan as soon as possible .Correction of the resident's underlying medical, surgical, and/or nutritional problems must be accomplished if proper healing of pressure sores etc. is to occur .Wound care should be performed as ordered by the physician . The Administrator was notified of an IJ on 06/25/24 at 5:32 p.m., was given a copy of the IJ template, and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 06/26/24 at 8:08 a.m. and included the following: On 6/25/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services had determined that the condition at the facility constituted an Immediate jeopardy to resident health and safety. Problem: F 686 Treatment/Services to Prevent/Heal Pressure Ulcer Interventions: o A head-to-toe assessment was completed on resident # 38 on 6/25/24 by the DON. Weekly ulcer assessments for resident #38 were completed on 6/25/24 to include measurements by DON and Regional Compliance Nurse. o The MD was notified on 6/25/24 of resident #38 new pressure wounds by the DON. Orders were received for treatment and implemented on 6/25/24. o The Dietician was notified on 6/25/24 of resident #38 new pressure wounds by the DON. Recommendations were received and implemented on 6/25/24. o Wound care treatments for residents #38 were completed by the DON as ordered on 6/25/24. o 100% skin rounds were initiated on 6/25/24 by DON, ADON and Compliance Nurse. No additional pressure wounds were identified. o All wound care orders were reviewed on 6/25/24 by DON, ADON, and Compliance Nurse to ensure wound care recommendations are being followed appropriately for all residents. o All residents with wounds have appropriate supplements in place to promote wound healing. Reviewed and completed by the DON and Compliance Nurse on 6/25/24. o Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on 6/25/24 on the following topics. Completed 6/25/24. o Pressure Injury Prevention, Assessment, and Treatment Policy o Skin Integrity management Policy and Skin assessment policy to include appropriate skin care on admission and readmission which includes skin assessments on admission and readmission. o Notification of a Change in Condition Policy- will notify MD with any new or worsening pressure wounds. o Abuse and Neglect - failure to provide a physician ordered treatment to a pressure wound. o Incontinent care to include- placing a clean brief when wound care is being provided. In-services: o The following in-services were initiated by Regional Compliance Nurse, DON on 6/25/24 for all charge nurses. Any charge nurses not present or in-serviced on 6/25/24 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All agency staff or staff on leave will in serviced prior to assuming their next assignment. o Pressure Injury Prevention, Assessment, and Treatment Policy to include providing appropriate wound care. o Skin Integrity management Policy and Skin assessment policy to include appropriate skin assessments on admission and readmission. o Notification of a Change in Condition Policy- will notify MD with any new or worsening pressure wounds. o Abuse and Neglect - failure to provide a physician ordered treatment to a pressure wound. o Incontinent care to include- placing a clean brief when wound care is being provided o All charge nurses will complete wound care for their assigned residents during their shift. o Policies for Pressure Injury Prevention, Assessment, Treatment policy, and Skin Integrity were reviewed on 6/25/24 by the Divisional Director of Clinical, Compliance Nurse, Area Director, Administrator, and DON. No revisions to the policies were made. o The Medical Director was notified of the immediate jeopardy situation on 6/25/24 by the administrator. o An ADHOC QAPI meeting was held with the Administrator, DON, ADON,

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 4 of 16 resident reviewed (Residents #30, #36, #45 and #212) for assessments. 1. The facility failed to ensure Resident #30's diagnosis of anxiety was coded on her MDS. 2. The facility failed to ensure Resident #36's dialysis (is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) status was coded on his MDS. 3. The facility failed to ensure Resident #45's vision impairment was reflected on his MDS. 4. The facility failed to ensure Resident #212's fall on 04/03/24 was coded on her MDS. These failures could place residents at risk of not having individual needs met. Findings include: 1. Record review of Resident #30's face sheet, dated 06/24/24, reflected a [AGE] year-old, female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #30 had diagnoses which included Parkinson's disease (is a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and generalized anxiety disorder (means that you are worrying constantly and can't control it). Record review of Resident #30's quarterly MDS assessment, dated 04/18/24, reflected Resident #30 was understood and understood others. Resident #30 had a BIMS score of 15, which indicated her cognition was intact. Resident #30 had depression, but it did not include a diagnosis of anxiety. Record review of Resident #30's care plan, dated 03/27/23, reflected Resident #30 had depression and anxiety related to the disease progress. Intervention included administer medications as ordered. 2. Record review of Resident #36's face sheet, dated 06/25/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #36 had a diagnosis which included end stage renal disease (is the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). Record review of Resident#36's quarterly MDS assessment, dated 05/13/24, reflected Resident #36 was understood and understood others. Resident #36 had a BIMS score of 15, which indicated his cognition was intact. The MDS did not indicated Resident #36 received dialysis treatment while a resident of the facility and within the last 14 days. Record review of Resident #36's care plan, dated 02/17/23, reflected Resident #36 needed hemodialysis (is a treatment to filter wastes and water from your blood) related to renal failure. Intervention included resident received dialysis 3 times a week. Record review of Resident #36's Dialysis Communication Records, dated April-May 2024, reflected treatment on: *04/18/24 *04/23/24 *04/25/24 *05/04/24 *05/07/24 *05/11/24 3. Record review of Resident #45's face sheet, dated 06/24/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #45 had diagnoses which included nontraumatic intracerebral hemorrhage (bleeding into the brain tissue) and glaucoma (is a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve). Record review of Resident #45's quarterly MDS assessment, dated 04/05/24, reflected Resident #45 was usually understood and sometimes understood others. Resident #45 had adequate hearing and vision, and clear speech. Resident #45 had a BIMS score of 00, which indicated severe cognitive impairment. The MDS assessment did not indicated Resident #45's vision impairment. Record review of Resident #45's care plan, dated 04/05/23, reflected Resident #45 had impaired visual function related to glaucoma. Intervention included tell the resident where you are placing their items. Be consistent. 4. Record review of Resident #212's face sheet, dated 06/24/24, reflected a [AGE] year-old, female who was admitted to the facility on [DATE] and readmitted on [DATE], and 05/25/24. Resident #212 had diagnoses which included pulmonary embolism (is a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs), Type 2 diabetes (is a chronic medical condition in which the levels of sugar, or glucose, build up in your bloodstream), and chronic kidney disease, stage 4 (severe loss of kidney function), and lack of coordination. Record review of Resident #212's quarterly MDS, dated [DATE], reflected Resident #212 was understood and understood others. Resident #212's BIMS score was not indicated on her MDS, dated [DATE]. Resident #212's MDS did not reflect a fall had occurred. Record review of Resident #212's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated her cognition was intact. Resident #212 required partial assistance for oral and personal hygiene, and dressing, and dependent for toilet hygiene. Resident #212 did not have any falls since admission/entry or reentry or the prior assessment. Resident #212 did not have any falls in the last month, last 2-6 months prior to admission/entry or reentry. Record review of a care plan dated 03/22/24, revised 05/30/24, reflected Resident #212 had a fall on 04/3/24 which was not witnessed. Intervention included encourage resident to pull call light for assistance. Record review of the facility's Incident Report, dated 04/01/24-04/30/24, reflected: *Un-witnessed fall, Resident #212, 04/03/24, 9:35 a.m. During an interview on 06/26/24 at 2:30 p.m., the MDS coordinator said she had been employed at the facility since 05/01/24. She said she was responsible for certain sections of the MDS. She said Resident #212's fall should be coded, if it occurred during the 7 day look back or assessment period of the dated MDS. She said Resident #30's anxiety diagnosis should be coded on her MDS. She said if Resident #45's care plan stated he had impaired vision related to glaucoma, then his vision should be coded inadequate on the MDS. She said the resident's vision status was given by the SW or the MDS coordinator asked the nursing staff. She said Resident #36 being on dialysis should be coded if he attended during the assessment period. She said Resident #36 attended dialysis, three times a week. She said it was important for the resident's MDS's to be accurate, so it showed on the facility's 802 (summary of resident's triggered care areas on their MDS), it affected the facility's billing, and showed the care the residents needed or received. She said inaccurate MDS's risked lack of care to the residents and information not being placed on the resident's care plan. During an interview on 06/26/24 at 3:05 p.m., the DON said accuracy of the MDS was the responsibility of the MDS coordinator. The DON said she was not responsible for the oversight of MDS transmission, completion or accuracy. She said the regional MDS coordinator was the one who provided oversight and monitored the MDS coordinator. She said the MDS's should reflect the resident's status. She said Resident #212's fall, Resident #30 anxiety diagnosis, and Resident #36 dialysis status should be on their MDS. She said Resident #45 had impaired vision related to glaucoma so his vision would not be adequate. She said inaccurate MDS's affected the resident's plan of care and the facility's billing. During an interview on 06/26/24 at 4:45 p.m., the ADM said the MDS coordinator was responsible for accurate MDS assessments. She said she expected the MDS coordinator to complete and submit, timely and accurate MDS's. She said the care plan was based on the MDS assessment. She said an inaccurate MDS assessment placed residents at risk for not being accurately taken care of. Record review of the facility's Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy 2.2021, dated 10/2023, reflected .the purpose of the MDS policy is the ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident .the MDS is a core set of screening, clinical, and functional status elements .which forms the foundations of a comprehensive assessment for all residents .the items in the MDS standardize communicate about resident problems and conditions within nursing homes .require that .the assessment accurately reflects the resident's status

Based on interview and record review the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident and life in the facility and be able to demonstrate their response and rationale for the response for 7 of 7 anonymous residents (AR) reviewed for grievances. (AR#1-AR#7) The facility failed to follow-up and monitor previous grievances to resolve resident concerns for AR#1-AR#7. This failure could place residents at risk of not having the right to voice their concerns and grievances to be followed-up on in a timely manner. Findings include: Record review of the Resident Council Minutes, dated 3/1/2024, reflected .ice passes are not consistent .aids standing in hallway talking about personal matters .staff have been in-serviced Record review of the Resident Council Minutes, dated 5/1/2024, reflected .only get shower on Tuesdays .states aids will enter room, turn off the call light say they will be back and never return . Findings reflected .No concerns voiced. During a confidential resident group interview the residents in attendance voiced multiple grievances that were previously addressed and continue to occur within the facility related to voiced concerns of staff not filling their water and ice but one time a week and residents were required to get their own water, ice, and bedtime snacks. The confidential attendees said they would push their call light and staff would not answer for hours later or ask want you want and never return with the request. The confidential group said residents depended on each other for assistance. During a confidential interview with 7 of 7 resident attendees, the attendees voiced staff not filling up water and ice, staff not responding timely to call lights, staff not returning to room, and staff on phone during resident care. During an interview on 6/26/2024 at 2:12 PM, CNA V said she had not heard anyone complain of loud noises at night and snacks were offered and the staff would bring snacks to resident rooms. CNA V said the snacks were located at the front of nurse's station when dietary would set it out at night. During an interview on 6/26/2024 at 3:04 PM, the SW said the ADM was the grievance coordinator. The SW said if a resident had a complaint, they would come to her and discuss the issue and file a formal grievance. The SW said the facility followed up in the investigation. The SW said she had complaints of call lights not being answered timely and the facility in-serviced and talked with staff about the concerns. During an interview on 6/26/2024 at 2:30 PM, LVN M said if a resident complained about abuse, staff immediately notified the ADM. LVN M said if it was something else, the staff tried to take care of it. LVN M said he had not had any recent complaints about loud noises at night and he expected the staff to answer call lights immediately in case a resident had an emergency or had fallen. During an interview on 6/26/2024 at 2:40 PM, the ADON said she could initiate a grievance and would report immediately to the ADM of any abuse. The ADON said the charge nurse would contact the ADON, DON and ADM to report a grievance. The ADON said she heard of a resident staying up at night listening to loud music. The ADON said residents were able to have bedtime snacks due to some residents having weight loss requiring snacks. The ADON said she had not heard of other staff telling residents to get their ice, water, or snacks. The ADON said ice and water should be passed on every shift. During an interview on 6/26/2024 at 3:40 PM, the DON said the SW was responsible for grievances. The DON said the SW talked to the residents about loud music at night. The DON said the residents were not responsible for getting their own bedtime snacks and staff should pass them out. The DON said residents complained in the past about staff being on their phone and the facility in-serviced staff on customer service . During an interview on 6/26/2024 at 4:37 PM, the ADM said she expected the grievances to be documented, recorded, and investigated by the grievance officer. The ADM said the facility was addressing staff on phones and not answering call lights on the night shift and in-services were completed. The ADM said she expected care to be provided to one-on-one without phone calls and said the residents should not have to wait to receive care. The ADM said staff should offer snacks to the residents in the evening and the snacks should be delivered to them. During record review on 7/2/2024 of grievances and in-services, the facility had multiple complaints regarding the call lights not being answered and were voiced in the confidential resident group interview. The confidential grievances were documented and in-serviced by nursing administration. Record review of the facility policy, dated 11/2/2024, titled Grievances reflected .the resident has a right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear off discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which had not been furnished, the behavior of staff and of other residents; and other concerns regarding their long-term care facility stay. The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievances the resident may have. 1. The facility will notify the residents on how to file a grievance orally, in writing or anonymously with posting in prominent locations. 2. The grievance official of this facility is the administrator or their designee. 3. The grievance official will . oversee the grievance process .receive and track grievances to their conclusion, lead and necessary investigations by the facility, maintain the confidentiality of all information associated with grievances, issue written grievance decisions to the residents

Based on interview and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 3 of 3 resident reviewed for dialysis services. (Resident #36, Resident #212, and Resident #112) 1. The facility failed to ensure post-dialysis assessments were completed and documented on Resident #36 and Resident #212's dialysis communication forms. 2. The facility failed to document Resident #112's dialysis communications. These failures could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: 1. Record review of Resident #36's face sheet, dated 06/25/24, indicated Resident #36 was a [AGE] year-old, male and was admitted to the facility on [DATE] and 05/02/24 with diagnosis including end stage renal disease (is the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). Record review of Resident #36's quarterly MDS assessment, dated 05/13/24, indicated Resident #36 was understood and understood others. Resident #36 had a BIMS score of 15, which indicated his cognition was intact. The MDS did not indicated Resident #36 received dialysis treatment while a resident of the facility and within the last 14 days. Record review of a care plan dated 02/17/23, indicated Resident #36 needed hemodialysis (is a treatment to filter wastes and water from your blood) related to renal failure. Intervention included resident received dialysis 3 times a week. Record review of Resident #36's order summary, dated 06/25/24, indicated transport resident to local dialysis center on Tuesday-Thursday-Saturday for hemodialysis chair time 10:30 a.m., one time a day, start date 03/13/24. Record review of Resident #36's Dialysis Communication Record forms, from March 2024, April 2024, and May 2024, indicated missing or incomplete facility nurse assessment upon return from dialysis for the following dates: *03/12/24 *03/14/24 *03/19/24 *03/23/24 *03/26/24 *03/28/24 *04/02/24 *04/04/24 *04/06/24 *04/11/24 *04/18/24 *04/25/24 *05/04/24 *05/07/24 *05/11/24 *05/16/24 2. Record review of a face sheet, dated 06/24/24, indicated Resident #212 was a [AGE] year-old, female, admitted to the facility on [DATE], 11/22/23, and 05/25/24 with diagnoses including pulmonary embolism (is a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs), Type 2 diabetes (is a chronic medical condition in which the levels of sugar, or glucose, build up in your bloodstream), and chronic kidney disease, stage 4 (severe loss of kidney function), and lack of coordination. Record review of Resident #212's quarterly MDS, dated [DATE], indicated Resident #212 was understood and understood others. Resident #212's BIMS score was not indicated on her MDS dated [DATE]. Resident #212's quarterly MDS dated [DATE], indicated a BIMS score of 15, which indicated her cognition was intact. Resident #212 received dialysis while a resident of the facility and within the last 14 days. Record review of a care plan, dated 12/06/23, revised 03/22/24, indicated Resident #212 needed hemodialysis related to renal failure. Intervention included monitor vital signs. Record review of Resident #212's order summary, dated 06/24/24, indicated Dialysis days Monday-Wednesday-Friday have ready by 10 am, one time a day, start date 05/10/24. Record review of Resident #212's Dialysis Communication Record forms, from March 2024, April 2024, and May 2024, indicated missing or incomplete facility nurse assessment upon return from dialysis for the following dates: *03/11/24 *03/13/24 *03/25/24 *03/27/24 *03/29/24 *04/05/24 *04/08/24 *04/11/24 *04/12/24 *04/19/24 *04/22/24 *04/26/24 *04/29/24 *05/06/24 *05/15/24 44128 3. Record review of Resident #112's face sheet dated 06/26/24 indicated Resident #112 was a [AGE] year-old female and admitted on [DATE] with diagnoses including acute kidney failure, chronic kidney disease, and unsteadiness on feet. Record review of Resident #112's admission MDS assessment dated [DATE] indicated Resident #112 was understood and understood others. The MDS indicated Resident #112 had a BIMS score of 13 which indicated intact cognition. The MDS indicated Resident #112 had an active diagnosis of acute kidney failure. The MDS indicated Resident #112 received dialysis within the last 14 days of the assessment period. Record review of Resident #112's care plan dated 06/24/24 indicated Resident #112 needed dialysis (HEMO). Intervention included monitor labs and report to the physician as need, monitor/document/report to physician any signs or symptoms of infection to access site, and to monitor/document/report to the physician as needed any signs or symptoms of renal insufficiency. Record review of Resident #112's consolidated physician's orders dated 06/26/24 indicated and order with a start date of 06/14/24 for dialysis every Monday, Wednesday, and Friday afternoon. Record review of Resident #112's electronic medical record did not indicate any communication from between the facility and the dialysis center. During an interview on 06/24/24 at 10:01 a.m., Resident #112 said she received dialysis every Monday, Wednesday, and Friday. She said she had not had any problems with dialysis. During an interview on 06/26/24 at 8:26 a.m., the DON said Resident #112 did receive dialysis. The dialysis communication forms were requested at this time. During an interview on 06/26/24 at 8:26 a.m., the DON said Resident #112 did receive dialysis. The dialysis communication forms were requested at this time. During an interview on 06/26/24 at 12:40 p.m., the DON said they did not have completed dialysis communication forms for Resident #112. She said she was waiting for them to be faxed from the dialysis center. They were not received prior to exit. During an interview on 06/26/24 at 1:30 p.m., RN E said a dialysis communication form had to be completed before the dialysis resident left for treatment and when they returned. She said the dialysis communication form should be entirely filled out. She said when Resident #36, Resident #112 and Resident #212 returned from dialysis, vital signs should be done and documented on the dialysis communication form. She said the charge nurse should review the dialysis center portion for any pertinent informant then fill out the bottom portion of the form. She said dialysis communication forms were important to notice if the resident had a change of condition and it relayed information between staff, facility, and treatment center. She said when the dialysis communication forms were not done, the resident could have issues and staff would be unaware. During an interview on 06/26/24 at 3:05 p.m., the DON said the charge nurses were responsible for filling out the dialysis communication forms. She said the form should be filled out with the resident's information before they leave and when they return from dialysis treatment. She said she expected the nurses to fill in the vitals and complete an assessment of the access site. She said the dialysis communication form provided continuity of care. She said the form was important to monitor the resident's vital and see a possible issue. She said not completing the dialysis communication form placed the resident at risk for staff not being aware of signs of hypotension and fluid overload if the treatment was not completed. During an interview on 06/26/24 at 4:45 p.m., the ADM said the charge nurses sent the dialysis communication form with the resident to dialysis treatment. She said the dialysis resident should return to the facility with the form filled out by the treatment center section. She said the charge nurse should then fill out the bottom portion on the form. She said the form should be filled out in its entirety. She said when the dialysis communication was not done or missed documentation then it risked a breakdown in communication between the facility and dialysis center. She said the DON, ADON, and Medical Records should be overseeing the completion of the dialysis communication form. Record review of a Dialysis facility policy dated November 2013 indicated, .The facility will document the resident's vital sign, general appearance, orientation, and additional baseline data as need. The resident's clinical record will be documented with this information. The date and time of the resident's return to the facility will be recorded by the nurse .

Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 16 residents reviewed for pharmacy services. (Residents #45) The facility failed to keep, in stock, medications for Resident #45. Resident #45 did not receive Levetiracetam (is a medicine used to treat epilepsy (seizures)), Hydrochlorothiazide (is commonly used to treat high blood pressure), or Scopolamine patch (helps prevent nausea and vomiting) on 06/04/24, 06/05/24 and 06/06/24. This failure could place residents at risk for inaccurate drug administration. Findings included: 1. Record review of Resident #45's face sheet, dated 06/24/24, indicated resident #45 was a [AGE] year-old, male and was admitted to the facility on [DATE] and 11/28/23 with diagnoses including nontraumatic intracerebral hemorrhage (bleeding into the brain tissue), hypertensive crisis (a sudden, severe increase in blood pressure), and convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body). Record review of Resident #45's quarterly MDS assessment, dated 04/05/24, indicated Resident #45 was usually understood and sometimes understood others. Resident #45 had adequate hearing and vision, and clear speech. Resident #45 had a BIMS score of 00, which indicated severe cognitive impairment. Record review of a care plan, dated 04/05/23, indicated: *Resident #45 had hypertension. Intervention included give anti-hypertensive (a class of drugs that are used to treat hypertension) medications as ordered. *Resident #45 had a seizure disorder. Intervention included give seizure medications as ordered by doctor. *Resident #45 had nausea and vomiting related to disease process, cerebral hemorrhage, and seizure disorder. Intervention included administer anti-emetics (are medications that can manage nausea and vomiting) as ordered routinely. Record review of Resident #45's order summary dated 06/24/24, indicated: *Hydrochlorothiazide tablet 25mg, give 1 tablet enterally one time a day for hypertension. Start date 07/01/22, no end date. *Levetiracetam oral solution 100mg/ml, give 5 ml via g-tube two times a day for seizures. Start date 11/29/23, no end date. *Scopolamine Transdermal Patch 72-hour 1mg/3 days, apply 1 mg transdermal (the application of a medicine or drug through the skin) one time a day every 3 days for nausea and vomiting, behind the ear. Start date 03/29/23, no end date. Record review of Resident #45's MAR, dated 06/01/24- 06/30/24 indicated: *Hydrochlorothiazide tablet 25mg, give 1 tablet enterally one time a day for hypertension. 06/06/24 0900: Hold/See Nurse Notes by LVN F *Levetiracetam oral solution 100mg/ml, give 5 ml via g-tube two times a day for seizures. 06/04/24 2000: Other/See Nurse Notes by RN N 06/05/24 2000: Other/See Nurse Notes by RN N 06/06/24 0800: Other/ See Nurse Notes by LVN F 06/06/24 2000: Hold/ See Nurse Notes by LVN O *Scopolamine Transdermal Patch 72-hour 1mg/3 days, apply 1 mg transdermal (the application of a medicine or drug through the skin) one time a day every 3 days for nausea and vomiting, behind the ear. 06/06/24 0900: Hold/See Nurse Notes by LVN F Record review of Resident #45's progress notes dated 05/25/24-06/25/24 indicated: *06/05/24 3:19 a.m. by RN N: Levetiracetam oral solution 100mg/ml, give 5 ml via g-tube two times a day for seizures, on order. *06/06/24 5:54 a.m. by RN N: Levetiracetam oral solution 100mg/ml, give 5 ml via g-tube two times a day for seizures, on order. *06/06/24 7:51 a.m. by LVN F: Levetiracetam oral solution 100mg/ml, give 5 ml via g-tube two times a day for seizures, med unavailable. *06/06/24 9:26 a.m. by LVN F: Hydrochlorothiazide tablet 25mg, give 1 tablet enterally one time a day for hypertension, med unavailable. *06/06/24 9:26 a.m. by LVN F: Scopolamine Transdermal Patch 72-hour 1mg/3 days, apply 1 mg transdermal (the application of a medicine or drug through the skin) one time a day every 3 days for nausea and vomiting, behind the ear, med unavailable. *06/06/24 11:33 p.m. by LVN O: Levetiracetam oral solution 100mg/ml, give 5 ml via g-tube two times a day for seizures, medication not available from pharmacy. During an interview on 06/26/24 at 1:35 p.m., LVN F said she took care of Resident #45 on 06/06/24. She said Resident #45 had 3 medications not available that day for administration. She said the facility had been having issues with the pharmacy due to change of ownership and pharmacy company. She said nursing staff were not able to order resident's medication through the facility's computer system during the change. She said the resident's prescription number to match their medications had also changed. She said nursing staff could not see what had or had not been ordered which caused duplicate refill orders. She said the new pharmacy company complained about the duplicate orders then would not fill the orders. She said there was a lack of communication between the nurses related to reordering of resident's medications. She said it depended on what the medication was being taken for, depended on the risk to the resident if a dose was missed. She said Resident #45 missing his Levetiracetam, risk him having seizures. She said Resident #45 missing his Hydrochlorothiazide, risk him having high blood pressure. She said Resident #45 missing the application on his Scopolamine Patch, risked him having nausea and vomiting. During an interview on 06/26/24 at 3:05 p.m., the DON said the facility had a process in place when ownership change regarding ordering resident's medications. She said the facility was still able to order and receive medication from the old pharmacy until everything switch over to the new pharmacy. She said the nursing staff had to fax new prescription numbers for the new pharmacy. She said she was not made aware Resident #45 had missed doses for 3 medications. She said she expected to be notified when resident missed medication doses. She said Resident #45 missing his medication place him at risk for hypertension, stroke, hypertensive crisis, headache, seizure, and nausea/vomiting. During an interview on 06/26/24 at 4:45 p.m., the ADM said charge nurses were responsible for ensuring resident had their prescribed medication for administration. She said she expected the nursing staff to notify the DON, resident's physician, and ADM when medication doses were missed. She said Resident #45 missed doses of his medication placed him at risk for seizure, high blood pressure which could result in a heart attack and stroke, and other health issues. She said the ADON/DON should oversee the charge nurse to ensure medication was reordered timely and doses not missed. Record review of an undated facility's Ordering Medications policy and procedure, indicated .medications and related products are received from the pharmacy supplier on a timely basis .the facility maintains accurate records of medication order and receipt .reorder medication three to four days in advance of need to assure an adequate supply is on hand .

Based on interview and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 resident reviewed for infection control. (Resident #46 and Resident #50) The facility failed to isolate Resident #46 and Resident #50 after urine cultures (test checks urine for germs (microorganisms) that cause infections) revealed ESBL (enzymes break down and destroy some commonly used antibiotics) in their urine. This failure could place residents at risk for being exposed to health complications and infectious diseases. Find included: 1. Record review of Resident #46's face sheet, dated 06/26/24, indicated Resident #46 was a [AGE] year-old, female and was admitted to the facility on [DATE] and 12/06/22 with diagnoses including chronic kidney disease (means you have mild to moderate loss of kidney function) and Type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #46's quarterly MDS assessment, dated 01/20/24, indicated Resident #46 was understood and understood others. The MDS indicated a BIMS score of 14, which indicated her cognition was intact. Resident #46 was always incontinent for urine and bowel and required moderate assistance for toilet hygiene. Resident #46 received an antibiotic during the last 7 days of the assessment period. Record review of a care plan dated 03/23/23 indicated Resident #46 had bladder incontinence related to activity intolerance, disease process, overactive bladder, and impaired mobility. Resident #46 used briefs but placed incontinent pads, towels, and sheets into her briefs. Record review of a care plan dated 04/04/24 indicated Resident #46 had an history of reoccurring UTIs. Intervention included administer antibiotics if ordered and monitor for adverse reactions or side effects. Record review of Resident #46's order summary, dated active as of 01/01/24, did not reveal isolation orders for ESBL in her urine. Record review of Resident #46's progress notes, dated 01/01/24-03/26/24, did not reveal Resident #46 being on contact isolation (used to help keep individuals safe from spores that spread through contact with a patient or objects in a patient's room.) for ESBL in her urine. Record review of Resident #46's culture and sensitivity results dated 12/19/23 indicated .moderate pathogens detected .Escherichia coli .antibiotic notes .ESBL (Extended Spectrum Beta-lactamase detected .are usually multi-drug resistant .antibiotic resistance genes .ESBL 1 . Record review of Resident #46's Infection Control Surveillance Form, dated 01/10/24, indicated .positive .e coli . No type of isolation was noted .DON . 2. Record review of Resident #50's face sheet, dated 06/26/24, indicated Resident #50 was a [AGE] year-old, female and admitted to the facility on [DATE] with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and type 2 diabetes (a chronic medical condition in which the levels of sugar, or glucose, build up in your bloodstream), and need for assistance with personal care. Record review of Resident #50's admission MDS assessment, dated 02/06/24, indicated Resident #50 was rarely/never understood and rarely/never had the ability to understand others. Resident #50's BIMS score was not assessed due to her being rarely/never understood. Resident #50 had short-and-long term memory recall problem and severely impaired cognitive skills for daily decision making. Resident #50 was dependent for toilet hygiene and was always incontinent of urine and bowel. Resident #50 received an antibiotic during the last 7 days of the assessment period. Record review of Resident #50's care plan, dated 02/09/24, indicated urinary tract infection, effective. Intervention included give antibiotic therapy as ordered. Record review of a care plan, dated 03/05/24, indicated Resident #50 had a urinary tract infection. Intervention included give antibiotic therapy as ordered. Record review of Resident #50's order summary, dated active as of 03/01/24, did not reveal isolation orders for ESBL in her urine. Record review of Resident #50's progress notes, dated 02/01/24-06/26/24, did not reveal Resident #50 being on contact isolation for ESBL in her urine. Record review of Resident #50's culture and sensitivity results dated 02/02/24 indicated .high pathogens detected .Escherichia coli .low pathogens detected .enterococcus faecalis .antibiotic notes .ESBL (Extended Spectrum Beta-lactamase detected .are usually multi-drug resistant .antibiotic resistance genes .detected ESBL 1 . Record review of Resident #50's culture and sensitivity results dated 02/16/24 indicated .high pathogens detected .Escherichia coli . antibiotic notes .ESBL (Extended Spectrum Beta-lactamase detected .are usually multi-drug resistant .antibiotic resistance genes .detected ESBL 1 . Record review of Resident #50's Infection Control Surveillance Form, dated 02/04/24, indicated what type of precautions/or isolation implemented .universal precautions (safety precautions used with every client) .ADON . Record review of Resident #50's Infection Control Surveillance Form, dated 02/18/24, indicated what type of precautions/or isolation implemented .none .DON . During an interview on 06/26/24 at 1:30 p.m., RN E said resident with ESBL in their urine required contact isolation. She said if a resident needed isolation precautions started, and ordered would be placed in the electronic charting system and progress note written. She said the LVN was responsible for sending the lab work to the doctor. She said the nurse and the doctor should fully review the result to make sure information such as ESBL was seen. She said isolating a resident with ESBL was important to prevent the spread of the infection. During an interview on 06/26/24 at 1:55 p.m., the ADON said she was the Infection Control Preventionist. She said she was responsible for antibiotic usage and monitoring, reviewing lab results, tracking and trending infections, in-services, and care plan related to infection control. She said the charge nurses were responsible for sending lab work to the doctor. She said when a resident had an infection requiring isolation, the doctor was notified, and orders were received which was all documented in a progress note. She said if the resident had ESBL, they would be placed in contact isolation until antibiotics were completed. She said she was not aware Resident #50 and Resident #46 had ESBL in their urine. She said Resident #50 and Resident #46 had not been placed on contact isolation from ESBL lab results on 12/19/23, 02/02/24, or 02/16/24. She said the area where the lab company stated the resident had ESBL was easily missed, and she would do an in-service with the nursing staff to look closer at the lab results. She said it was important to isolation residents with MDRO to prevent the spread of the infection. During an interview on 06/26/24 at 3:05 p.m., the DON said the nurse and ICP were responsible for reading the lab results and ensuring residents with MDROs were isolated. She said Resident #46 and Resident #50 should have been placed on contact isolation for ESBL in their urine. She said when isolation was needed for a resident, the doctor was notified then orders were received. She said nursing staff should document when the doctor was notified and the resident being on isolation status in progress notes. She said contact isolation of resistant organisms was important to prevent the spread of the infection. She said it was also important for infection control and prevent cross contamination. During an interview on 06/26/24 at 4:45 p.m., the ADM said the ICP was responsible for ensuring lab results were closely reviewed and residents placed in isolation for resistant infections. She said isolating a resident with ESBL was important to prevent the spread of the infection to residents and staff. Record review of a facility's Infection Control Plan: Overview policy, updated 03/2024, indicated .the facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent he development and transmission of disease and infection .determines that a resident needs isolation to prevent the spread of infection, the facility will isolate the resident . Record review of a facility's Fundamentals of Infection Control Precautions policy and procedure dated 03/2024, indicated .resident placement .appropriate placement is significant component of isolation precautions .when available, a private room is important to prevent direct or indirect contact transmission when the source resident has poor hygiene habits, contaminates the environment, or cannot be expected to assist in maintaining infection control precautions to limit transmission of microorganisms .when possible, a resident with highly transmissible or epidemiologically important microorganisms is placed in a private room with handwashing and toilet facilities to reduce opportunities for transmission of microorganisms . Record review of a facility's Enhanced Barrier Precautions policy, dated 04/01/24, indicated .Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities .many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs .implementing contact versus enhanced barrier precautions .

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 16 residents (Resident #45) reviewed for care plans. The facility failed to ensure Resident #45 care plan was implemented when the resident did not have his abdominal binder (is a wide compression belt that encircles your abdomen) over his PEG feeding tube (Percutaneous endoscopic gastrostomy; is a tube inserted surgically into the stomach through the abdominal wall) on 06/24/24 which was a care plan intervention. This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings include: Record review of Resident #45's face sheet, dated 06/24/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #45 had diagnoses which included nontraumatic intracerebral hemorrhage (bleeding into the brain tissue) and dysphagia (difficulty swallowing). Record review of Resident #45's quarterly MDS assessment, dated 04/05/24, reflected Resident #45 was usually understood and sometimes understood others. Resident #45 had adequate hearing and vision, and clear speech. Resident #45 had a BIMS score of 00, which indicated severe cognitive impairment. Resident #45 had a feeding tube (tubes mainly inserted into the gastrointestinal [GI] tract to provide a patient with a route for enteral nutrition [is a way of sending nutrition right to the stomach or small intestine]) while a resident of the facility and within the last 7 days. Record review of Resident #45's care plan, dated 03/20/23, revised on 06/02/23, reflected Resident #45 required tube feeding related to a diagnosis of dysphagia. Resident #45 was known to pull out the feeding tube and move the abdominal binder to get to his tube. Intervention included abdominal binder for PEG tube protection at all times. During an observation and interview on 06/24/24 at 11:47 a.m. revealed Resident #45 was in the dining room, in a specialty wheelchair. Resident #45 was playing with his shirt and raised his shirt up to expose his abdomen. Resident #45's abdomen had a PEG tube with a dressing over. Resident #45 did not have an abdominal binder around his PEG tube. Attempted to interview Resident #45. Resident #45 kept repeating, why when questions asked. During an interview on 06/26/24 at 1:30 p.m., RN E said resident care plan interventions should be followed. She said Resident #45's abdominal binder should be always over his PEG site if it was a care plan intervention. She said if Resident #45's abdominal binder was not over his PEG site then it risked being dislodged. She said if Resident #45's PEG tube was dislodged then he would have to be sent out for surgery to replace it. During an interview on 06/26/24 at 3:05 p.m., the DON said she expected Resident #45's abdominal binder to be always on like the care plan intervention said. She said it was the LVNs responsibility to ensure Resident #45's abdominal binder was over his PEG site. She said LVN P should have ensured Resident #45 had his abdominal binder on Monday (06/24/24). She said not following Resident #45's care plan intervention, risked his PEG tubing being pulled out. She said if Resident #45's PEG tubing was pulled out, it risked him missing feedings, trauma to the site and infection. Attempted interview on 06/26/24 at 4:00 p.m., with LVN P by phone was unsuccessful and a recording stated, no longer in service. During an interview on 06/26/24 at 4:45 p.m., the ADM said she expected Resident #45 to have on his abdominal binder over his PEG site if it was ordered and on his care plan. She said the charge nurses were responsible for making sure Resident #45 had the abdominal binder on. She said if the abdominal binder was not over Resident #45's PEG site, the tubing could come out. Record review of the facility's, undated, Comprehensive Care Planning policy reflected .the facility will develop and implement a comprehensive person-centered care plan for each resident .interventions are the specific care and services that will be implemented .the facility will ensure that services provided or arranged are delivered

Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #31 and Resident #212) reviewed for Medicare/Medicaid coverage. 1. The facility failed to ensure Resident #31 and Resident #212 were given a NOMNC (is a notice that indicates when your care is set to end from a home health agency, skilled nursing facility, comprehensive outpatient rehabilitation facility, or hospice) when discharged from skilled services prior to his covered days being exhausted. 2. The facility failed to ensure Resident #31 and Resident #212 were given a SNF ABN (is document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. These failures could place residents at risk for not being aware of changes to provided services. Findings include: 1. Record review of Resident #31's face sheet, dated 06/25/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included congestive heart failure (occurs when the heart muscle doesn't pump blood as well as it should) and Type 2 diabetes (is a chronic medical condition in which the levels of sugar, or glucose, build up in your bloodstream). Record review of Resident #31's quarterly MDS, dated [DATE], reflected Resident #31 was understood and understood others. Resident #31 had a BIMS score of 15, which indicated her cognition was intact. Record review of the SNF Beneficiary Notification Review reflected Resident #31 received Medicare Part A skilled services on 01/24/24 and last covered day of Part A was 03/22/24 prior to using up her 100 days of skilled services. The SNF Beneficiary Notification Review reflected the facility/provider initiated the discharge from Medicare Part A Services when benefits days were not exhausted. Resident #31 was not provided a SNF ABN or a NOMNC form due to the SW failed to deliver the forms to the resident. 2. Record review of Resident #212's face sheet, dated 06/24/24, reflected Resident #212 was a [AGE] year-old, female who was admitted to the facility on [DATE] and readmitted on [DATE], and 05/25/24. Resident #212 had diagnoses which included pulmonary embolism (is a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs), Type 2 diabetes (is a chronic medical condition in which the levels of sugar, or glucose, build up in your bloodstream), and chronic kidney disease, stage 4 (severe loss of kidney function). Record review of Resident #212's quarterly MDS, dated [DATE], reflected Resident #212 was understood and understood others. Resident #212's BIMS score was not indicated on her MDS, dated [DATE]. Record review Resident #212's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated her cognition was intact. Record review of the SNF Beneficiary Notification Review reflected Resident #212 received Medicare Part A skilled services on 11/22/23 and last covered day of Part A service was 03/01/24. The SNF Beneficiary Notification Review reflected Resident #212 Part A services was terminated/discharged due to insurance issued a NOMNC. A SNF ABN and a NOMNC were not provided to Resident #212 due to the SW failed to complete the forms. During an interview on 06/26/24 at 2:53 p.m., the SW said with the old company she was responsible for the ABN and NOMNC forms. She said the current company, she was only going to be responsible for the NOMNCs and the MDS coordinator would do the ABNs. She said the ABN letters should be given when the NOMNC was delivered to the resident. She said NOMNC had to be delivered 48 hours prior to the resident being discharged from insurance or facility-initiated discharges. She said when doing ABNs and NOMNC, she notified the resident or RP in person or by phone. She said a copy of the ABN and/or NOMNC letter was given to the resident and placed in the resident's medical records. She said she delivered Resident #212's March 2024 ABN and NOMNC letters to her but could not find a copy in her medical records. She said Resident #212 would not remember if she received the letters since it happened it March 2024. She said Resident #31 had transferred from Medicare to LTC Medicaid and giving the resident her ABN and NOMNC letters was overlooked. She said delivering the resident's ABN and NOMNC letters were important so the resident could make an informed decision about their healthcare, it was part of the discharge process, and it made them aware of their plan of care. She said it was always important to provide the resident with ABNs and NOMNC letters timely because there was an appeal process that was time sensitive. She said when the ABN and NOMNC were not delivered before services were discontinued, it took the residents by surprise, caused a feeling of helplessness and out of the loop, or their voices not being heard. During an interview on 06/26/24 at 4:45 p.m., the ADM said with the old company the SW was responsible for the ABN and NOMNC forms. She said the new company, the MDS coordinator would be responsible. She said the ABN and NOMNC letters had to be delivered to the resident three days prior of when their 100 days ended. She said it was important to give the resident ABN and NOMNC letters, to ensure a plan of care for home was known and if the resident changed to LTC services. Record review of the facility's Advanced Beneficiary Notice NOMNC policy and procedure, revised 05/2024, reflected .a Medicare provider or health plan .must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing .the NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of services if care is not being provided daily Record review of the Advanced Beneficiary Notice ABN policy and procedure, revised 05/2024, reflected, .the ABN is a notice given to beneficiaries in original Medicare to convey that Medicare is not likely to provide coverage in s specific case .the ABN must be reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed .the ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice .in all cases, the notifier must retain a copy of the ABN delivered to the beneficiary on file

Based on interview and record review the facility failed coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program under Medicaid for 1 of 5 residents (Resident #23) reviewed for PASRR screenings. The facility failed to conduct an accurate PASRR Level 1 and 2 screening for Resident #23. This failure could place residents at risk for not receiving appropriate services, depression, and decreased quality of life. Findings include: Record review of Resident #23's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Hemiplegia affecting right dominant side (paralysis on the right side of the body due to damage to the brain or spinal cord) , Type II Diabetes (group of diseases that result in too much sugar in the blood) , Acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and PTSD (a disorder that develops when a person has experienced or witnessed a scary, shocking or terrifying or dangerous even) and Bipolar Disorder (episodes of mood swings ranging from depressive lows to manic highs). During record review of the (admission) MDS, dated [DATE], reflected Resident #23 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The Level II Preadmission screening and resident review of conditions did not indicate Resident #23 had a serious mental illness. Resident #23 was able to make herself understood and was understood by others. Resident #23 had a BIMS of 11, which moderate cognitive impairment and had active diagnoses which included depression, bipolar disorder, and post-traumatic stress disorder. Record review of the (current) MDS, dated [DATE], reflected Resident #23 was not able to complete the BIMS assessment. Resident #23 had active diagnoses which included depression, bipolar disorder, and post-traumatic stress disorder. Record review of Resident #23's, undated, care plan reflected Resident #23 had impaired cognitive function/dementia or impaired thought processes related to impaired decision making and long-term memory loss. The care plan revealed Resident #23 had an order for psychotropic medications related to behavioral management and potential for behavioral problems related to PTSD and bipolar disorder. The care plan revealed Resident #23 had a diagnosis of depression and took antidepressants and no PASRR 1. During an interview on 6/26/2024 at 1:26 PM, the MDS nurse said she had been at the facility for approximately 1 month and she did not have access for PASRR screenings after the new owner took over the facility. She said she did not have access after the end of May. The MDS nurse said the previous company took the passwords and she did not have access. The MDS nurse said the ADM was aware. The MDS nurse said social services knew what the resident needed like out-patient Psychiatric services for one on one therapy. The MDS nurse said there were some resources who came out and talk to the residents. The MDS nurse said if a resident came in the facility with a mental illness, they would obtain the information from their records. The MDS nurse said the mental illness diagnosis did not have to be the primary to receive services. She said if a resident had mental illness, it would be captured on the MDS, and care planned. The MDS nurse said she had not received a list of residents who were PASRR positive that had not received services. The MDS nurse said she was not clear if Resident #23 was receiving services out-patient. During an interview on 6/26/2024 at 3:04 PM, the SW said she has done MDS before and she was not responsible for PASRR. The SW said the MDS nurse was responsible for PASRR. The SW said PASSR was a service the facility offered where the resident received additional services for DME, therapy, service coordination and mental health services for PASSR positive residents. The SW said the facility used a visiting Psychiatry group in the facility and the local mental health authority provide the PASRR and checked to see if a resident needed their services. The SW said not all PASRR positive residents received or wanted services. The SW said a positive PASRR would be care planned. The SW said Resident #23 received Psychiatric services and the referral was made. During an interview on 6/26/2024 at 2:40 PM, the ADON said she did not know much about the PASRR. She said the SW handle the PASRR. The ADON said if a resident had a level 2 or level 3. The ADON said the PASRR positive resident should be care planned. The ADON said if a resident who was PASRR positive, may not get the care they needed if it was not completed, and the resident was positive. The ADON said she would not be aware if PASRR was completed on Resident #23 or not. The ADON said the MDS nurse and SW talk about the PASRR. During an interview on 6/26/2024 at 3:40 PM, the DON said she expected the PASRR to be completed. The DON said she was aware the MDS was having problems with getting things transmitted. The DON said 06/01/24, the facility was purchased. The DON said the facility did not have a username or password to submit. The DON said the MDS nurse reached out to corporate. The DON said the facility was currently not doing anything right now for the PASRR positive residents. The DON said the SW did all the referrals for PASRR and counseling services and said the PASRR positive residents should be care planned if they were positive or when the resident refuses . During an interview on 6/26/2024 at 4:37 PM, the ADM said she expected the MDS to capture psychiatric diagnosis and completing timely and accurately. The ADM said it could affect the resident and was how we base our care plan to care for them correctly. The ADM said a diagnosis of bipolar would indicate positive PASRR and would be a yes on the PASRR screening as positive. The ADM said she expected services to be care planned even if refused . During record review of the facility's policy, dated 10/30/2017, titled PASRR Evaluation PE Policy and Procedure revealed reflected .1. It is the policy of Creative Solutions in Healthcare facilities to ensure the LIDDA and/or LMHA complete a PE within the appropriate time periods (14 days). 2. The nursing facility will monitor for the LA to enter the PE into the TMHP portal within 3 business days of the IDT meeting.

Based on interview and record review the facility failed to ensure a baseline care plan was developed and implemented for each resident that included the instructions for resident care needed to provide effective and person-centered care of the resident that met professional standards of quality of care for 2 of 4 residents (Residents #163 and #213) reviewed for baseline care plans. 1. The facility failed to complete a baseline care plan with Resident #163 and Resident #213 within 48 hours of admission. 2. The facility failed to provide Resident #213 or Resident #213's RP, a copy of the summary of the baseline care plan. These failures could place residents at risk of not receiving care and services to meet their needs. Findings include: 1. Record review of Resident #163's face sheet, dated 06/26/2024, reflected an 86- year-old- female who was admitted to the facility on [DATE]. Resident #163 had diagnoses which included chronic atrial fibrillation (an irregular and often very rapid heart rhythm. An irregular heart rhythm is called an arrhythmia), hypertension (high blood pressure), and mild cognitive impairment (the stage between the expected decline in memory and thinking that happens with age and the more serious decline of dementia). Resident #163 was her own responsible party/representative. Record review of the EHR reflected no admission MDS assessment was completed for Resident # 163. Record review of the baseline care plan acknowledgment form dated 06/19/2024, reflected a copy of the baseline care plan was given to Resident #163 and Resident #163's representative. Record review of Resident #163's baseline care plan reflected it was completed on 06/24/2024. During an interview on 06/25/2024 at 12:22 p.m., Resident #163 stated she had not had any meeting discussing her care since she was admitted and had not received a copy of her baseline care plan. Resident #163 stated she would have liked to have a meeting so she could know what was actually going on in the facility and with her care. 44933 2. Record review of Resident #213's face sheet, dated 06/25/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #213 had diagnoses which included Alzheimer's disease (is a type of dementia that affects memory, thinking, and behavior), retention of urine (is caused by a blockage that partially or fully prevents urine from leaving the bladder or urethra, or a failure of the bladder to squeeze hard enough to expel all of the urine)., overflow incontinence (the inability to control urination), hypertension (high blood pressure), and spinal stenosis (the spaces inside the bones of the spine get too small). Resident #213's RP/RR was a family member. Record review of the EHR reflected Resident #213 was admitted to the facility less than 21 days ago. No MDS for Resident #213 was completed prior to exit. Record review of Resident #213's baseline care plan, reflected it was initiated on 06/24/24. Resident #213's care plan was initiated more than 48 hours after admission which was on 06/20/24. Record review of Resident #213's Baseline Care Plan Acknowledgement, dated 06/20/24, reflected .a copy of the baseline care plan was provided to the resident .06/20/24 00:00 .Struck out by: LVN D . Stuck out reason: Technical Error .Struck Out Date: 06/20/24 . There was no evidence of another Baseline Care Plan Acknowledgement for Resident #213 or Resident #213's RP/RR in the facility's electronic charting system. During an interview on 06/25/24 at 8:37 a.m., Resident #213 said she was admitted to the facility because she could no longer care for herself at home. She said she did not recall receiving a copy of her plan of care from the facility. She said maybe her family member did when she was admitted . Attempted interview on 06/26/24 at 1:20 p.m., with LVN D by phone was unsuccessful. Attempted interview on 06/26/24 at 1:25 p.m. with Resident #213's RP/RR by phone was unsuccessful. Attempted interview on 07/01/24 at 11:57 a.m. with Resident #213's RP/RR by phone was unsuccessful. During an interview on 06/25/2024 at 3:13 p.m., LVN B stated the charge nurse who admitted the new resident was responsible for starting the baseline care plan the day of admission and the Social Worker and MDS nurse were responsible for completing the baseline care plan. She did not know the baseline care plan needed to be completed within 48 hours. She stated there was a form in the EHR that the nurses were trained to always use called acknowledgement of the baseline care plan. LVN B stated she was not sure why that form was filled out or what the purpose of it was. During an interview on 06/26/2024 at 2:00 p.m., the MDS nurse said the baseline care plan was completed by the floor nurse who received the resident for admission. It was one of many assessments completed on admission, but the baseline care plan, the admission assessment, and the skin assessment were priority to complete the day the resident was admitted because they were time sensitive. The MDS nurse said she had not given any resident a copy of their base line care plan, asked them to sign it, or given them a copy of their medication and treatments. During an interview on 06/26/2024 at 11:00 a.m., the DON said baseline care plans were used in place of a comprehensive care plan until one could be developed to direct resident care according to their goals and choices. The DON said the baseline care plan needed to be completed with each department and discussed with the resident and resident representative. The DON said the baseline care plan was given to the resident and family along with a list of any medications and treatments the resident received. The DON said it was her responsibility to inform the nurses of the facility policy on baseline care plans. The DON said she was not aware the nurses were not providing the resident with the baseline care plans or that baseline care plans were not being completed timely. The DON said the resident could have felt left out or rejected when not given the opportunity to take part in their care plan. During an interview on 06/26/2024 at 4:45 p.m., the Administrator said the baseline care plans were an interdisciplinary form that was discussed with the residents on admit. The Administrator said it was the DON's responsibility to ensure the floor nurses completed the baseline care plan and provided a copy to the resident and the family. Record review of the facility's policy titled Base Line Care Plan reflected .Completion and implementation of the baseline care plan within 48 hours of a resident's admission {was} intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and ensure the resident and representative, if applicable, are informed of the initial plan of delivery of care and services by receiving a written summary of the baseline care plan.

Based on interviews and record review, the facility failed to ensure all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness and intellectual disabilities were provided with a PASRR Evaluation assessment for 2 of 5 residents (Residents #32 and #58) reviewed for PASRR screening, in that: 1. The facility failed to coordinate with the Local Intellectual/Developmental Disability and/or Local Mental Health Authority (Local Authority) to ensure an accurate PASRR Level I Evaluation and a PASRR Level II Evaluations were conducted for Resident #32 who had a serious mental illness. 2. The facility failed to coordinate with the Local Intellectual/Developmental Disability and/or Local Mental Health Authority (Local Authority) to ensure an accurate PASRR Level I Evaluation and a PASRR Level II Evaluations were conducted for Resident #58 who had developmental disability and a mental illness. These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings include: 1. Record review of Resident #32's face sheet, dated 06/26/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #32 had diagnoses which included hepatitis C (a viral infection that causes liver swelling, called inflammation), dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities) and major depressive disorder (Major depressive disorder [MDD], also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #32's quarterly MDS assessment, dated 04/30/2024, reflected Resident #32 had a BIMS of 15, which indicated no cognitive impairment. Resident #32 had little interest or pleasure in doing things 7-11 days of the past 14 days, felt down, or depressed 2-6 days of the last 14 days, and had a poor appetite and trouble concentrating 2-6 days of the last 14 days. Resident #32 required supervision for ADLs. Record review of Resident #32's care plan, dated 06/19/2023, reflected Resident #32 had potential to feel depressed related to admission and recent loss of wife. An intervention was listed and arrange for psychiatric consult as needed. Record review of Resident #32's PASRR level 1 screening, dated 02/16/2024, completed by the RN case manager at a local hospital, reflected .mental illness .is there evidence or an indicator this is an individual that has a mental illness .No During an interview on 06/26/2024 at 10:00 a.m., the MDS nurse said she was responsible for entering the information for PASRR on all residents. She said Resident #32 should have been PASRR positive related to his diagnosis of major depressive disorder. She said she was not the MDS nurse who submitted the original PL1. She stated his PL one was not submitted and accepted until 02/16/2024 even though he admitted [DATE]. She stated it appeared the previous MDS nurse put the information into the portal but never followed up to see if the PASRR was not accepted and remained in invalid status until 02/16/2024 when it was resubmitted. Attempt made on 06/26/2024 at 10:15 a.m. to interview previous MDS nurse with no return call. During an interview on 06/26/2024 at 11:00 a.m., the DON said if Resident #32 had a diagnosis of major depressive disorder, then mental illness should have been marked on the PASRR Level 1. She said, then the LA decided if the resident qualified. She said the MDS coordinator was responsible for PASRR Level 1s. She said if a PASRR Level 1 was not done correctly the resident, specialized services were not received. During an interview on 06/26/2024 at 4:45 p.m., the ADM said mental illnesses should be on the PASRR Level 1. She said the MDS Coordinator was responsible for PASRR being completed correctly and ensuring they were approved in the portal. She said when the PASRR Level 1 assessments were not correct, residents lost out on services available to them. 2. Record review of Resident #58's face sheet, dated 06/25/24, reflected Resident #58 was [AGE] years old and was admitted to the facility on [DATE]. Resident #58 had diagnoses which included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Cerebral Palsy (a group of conditions that affect movement and posture caused by damage that occurs to the developing brain, most often before birth), and difficulty walking. Record review of Resident #58's admission MDS assessment, dated 02/23/24, reflected Resident #58 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability. Resident #58 was understood and understand others. Resident #58 had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS indicated active diagnoses of bipolar disorder and cerebral policy. Record review of a care plan, dated 05/10/24, reflected Resident #58 had the potential for psychosocial well-being related to anxiety, bipolar disorder, cerebral palsy, and depression. There was an intervention to initiate referrals as needed. Record review of a List of PASRR Positive Residents, provided by the facility on 06/24/24, reflected Resident #58 was PASSR positive. Record review of Resident #58's PASSR Level 1 Evaluation, dated 01/23/24, reflected Resident #58 did not have a mental illness, intellectual disability, or developmental disability. During an interview on 06/25/24 at 10:24 a.m., the MDS Coordinator said Resident #58 was PASRR positive and her PASRR Level 1 Evaluation was incorrect. She said the PASRR Level 1 Evaluation completed in 01/24 indicated Resident #58 was PASRR negative. She said Resident #58 should have been marked as positive due to her diagnoses. The MDS Coordinator said she began working at the facility in May 2024. She said she conducted an audit at the first of June 2024 and had caught the mistake. The MDS Coordinator said she was unable to request a new PASRR Level 1 Evaluation because she did not have an access number because of changes in the company since 06/01/24. She said a PASRR Level II was not conducted. During an interview on 06/26/24 at 8:33 a.m., Resident #58 said she heard of PASRR Services. She said she did not know if she would have used the PASRR services or not because she never had them before. During an interview on 06/26/24 at 3:59 p.m., the DON said she did not know why a new PASRR Level 1 Evaluation was not requested for Resident #58 since she had a diagnosis of bipolar disorder and Cerebral palsy. She said with those diagnoses she would have expected for a new PASRR Level 1 Evaluation to have been requested. She said the resident not being appropriately evaluated could have caused the resident to have not received PASSR services. She said the MDS Coordinator was responsible for requesting a correct PASRR Level 1 Evaluation. She said there was a lapse of MDS Coordinators until May and that may have been why it was missed. During an interview on 06/26/24 at 4:41 p.m., the Administrator said she would have expected for a new PASRR Level 1 Evaluation to have been requested for Resident #58. She said the resident should be PASRR positive due to her diagnosis of bipolar and cerebral palsy. She said her PASRR Level 1 Evaluation not being correct and not having a PASRR Level II Evaluations could cause Resident #58 not to have received the services she needed. Record review of the facility's, undated, Preadmission Screening and Resident Review (PASRR) policy reflected .all persons needing admission to a nursing facility must have a preadmission screening for possible mental illness and or mental retardation (DD/ID) (Level 1) .all persons who reside in a nursing facility are subject to resident review . The policy did not address accuracy of the PASRR Level 1. 44128

Based on interview and record review based on the comprehensive assessment the facility failed to ensure residents received care consistent with professional standards of practice to promote healing and prevent infection and new pressure sores from developing for 2 of 5 residents reviewed for pressure sores. (Resident #1 and Resident #3) 1. The facility failed to notify the physician of the pressure sores for Resident #1 and Resident #3 2. The facility failed to obtain treatment orders for treatment wounds for Resident #1 and Resident #3 3. The facility failed to ensure the dietician was notified, and the resident receive nutritional interventions Resident #1 and Resident #3 4. They failed to ensure the Wound Care Doctor recommendations were followed for Resident #3 5. They failed to ensure Resident #3 had an order and the correct pressure relieving boot were applied for Resident #3 6. They failed to ensure timely skin assessments for Resident #1 and Resident #3 7. They failed to ensure they had a comprehensive assessment that addressed resident care needs for Resident #1 and Resident #3. An Immediate Jeopardy (IJ) situation was identified on 02/13/23 at 6:05 p.m. While the IJ was removed on 02/15/23 at 6:32 p.m., the facility remained out of compliance at actual harm with a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems These failures placed residents at risk for pain, worsening of wounds, wound infection, emotional distress, harm, and death. Findings Included: Record review of Resident #3's Admission record with a print date of 02/07/23 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis was congestive heart failure, respiratory failure, diabetes, hypertension, kidney disease, and reduced mobility and coordination. The record indicated Resident #3 was discharged on [DATE] with 17 days stay to an acute hospitalization . Record review of Resident #3's admission MDS dated ,d+[DATE]//22 indicated his cognitive status was moderately impaired. His bed mobility was extensive assist with two people. His ability to transfer was limited assistance with one person. He was able to walk in the room with the supervisor of one person. Resident #3's functional abilities indicated he required supervision or touching assistance to put on or take off socks and shoes. He required the set-up help of one staff. Record review of Resident #3's Admission assessment dated [DATE] indicated the resident was admitted to the facility from and ALF due to edema to the bilateral LE with high blood pressure. He was alert times 4. Resident #3 had poor balance and unsteady gait. He was continent of bowel and bladder. His skin assessment revealed right inner arm bruising, lower left leg rear vascular, lower right leg vascular, left gluteal fold redness, and right gluteal fold. His bed mobility, transfers were assisted by staff, and he used a wheelchair. Record review of Resident #3's Baseline Care Plan dated 08/30/22 indicated he required setup help only with eating. Resident #3 required one person assistance with personal hygiene, toilet use, dressing, bathing, bed mobility, and transfers. He required the use of a wheelchair. Resident #3's skin integrity issues were bruises and vascular( areas caused by decreased blood vessel flow) to bilateral LE. Record review indicated Resident #3 did not have a Comprehensive Care Plan. Record review of Resident #3's skin assessment dated [DATE] indicated no skin issues noted. There was no other skin assessment noted. Record review of Resident #3's Braden Scale dated 08/30/22 indicated he had a score of 18 (15-18 high risk) high risk for pressure sores. His skin was occasionally moist, he was chair fast, his mobility was slightly limited, he received adequate nutrition. Resident #3 was not at risk for shear or friction. Record Review of a Physician's Order Form dated 08/29/22 indicated Resident #3 was released from the hospital yesterday. He was weak and unable to care for himself. Please send order for him to go to rehab. Record review of Resident # 3 History and Physical dated 08/31/22 indicated the [AGE] year-old was admitted to the facility due to recent heart failure. He denied any pain and his skin was warm and dry. His restorative potential was fair. Record review of Resident #3's computerized Physician order for September 2022 indicated an order for pressure reducing cushion to the wheelchair and pressure reducing mattress to the bed with a start date of 08/31/22. There were no treatments noted for pressure sores. There was no order for pressure relieving boots. Record review of Resident #3's handwritten orders indicated on 09/07/22 an order for vitamin C 500 mg a day for 14 days, Zinc 50 mg a day for 14 days, B Complex a day for 14 days and Prostat 30ml two times daily for 14 days all for wound healing of the right heel. Record review of Resident #3's MAR and TAR dated September 2022 showed no documentation pressure sores or any indication of treatments completed. The MAR indicated Resident #3 received Zinc 50 mg, Vitamin C 500 mg, and B complex starting on 09/27/22 the was no indication the Prostat( protein supplement) was given or on the MAR Record review of a Wound Evaluation and Management Summary( Wound Doctor Note) dated 09/07/22 The chief complaint was multiple wounds. At the referring providers request and evaluation was performed on Resident #3. He had and unstageable DTI of the right heel for at least 7 days duration. There is light serous exudate. There is no indication of pain associated with this condition. Diabetic Foot Exam indicated left and right foot response to monofilament testing with limited sensation. The exam for Peripheral Vascular, examination of left lower extremities with moderate edema and foot warm, examination of the right lower extremities indicated moderate edema foot warm, wound present. Pedal pulses to left and right dorsalis pedis detected by portable doppler. Focused Wound Exam (site 1) Unstageable DTI of right heal partial thickness, Etiology pressure Unstageable DTI within and around the wound with a duration of 7 days, the size of the wound 5cm by 5 cm the surface area is 25cm, exudate was light serous. The dressing plan was hydrogel wafer apply three times per week for 30 days. Plan of care reviewed and addressed. The recommendations were to off load wound, reposition per facility protocol, sponge boot, Prevalon boot(cushioned bottom that floats the heel off the surface of the matters. A Sage boot.), Zinc sulphate 220 mg by mouth for 14 days, Vitamin C 500 mg twice daily and multivitamin once daily. Site two was a venous wound of the right superior shin partial thickness and site 3 venous wound of the right, inferior shin partial thickness. The plan was to discuss Resident #3's BMI with the dietician. Resident #3's care was discussed with another health care provider assigned nurse (LVN E) during this visit. Discussed the etiology of wound, offloading, repositioning, prevalon boot, nutrition, vitamin supplementation with treatment nurse (LVN E- who said she did not remember anything about Resident #3.) Record review of Resident #3's Mini Nutrition assessment dated [DATE] indicated an admission assessment. The resident weighed 208 pounds. He had no automatic referrals checked. (Pressure sore was listed as an automatic referral. ) The assessment indicated no issues noted, Resident #3 had no weight loss and fed himself. No signature Record review of Medical Nutritional Therapy assessment dated [DATE] indicated Resident #3 weighed 206 pounds. He had no pressure injuries. Indicated intakes and meals adequate to meet his needs. Signed by Dietician. Record review of Occupational Therapy notes indicated the on 09/05/22 Resident #3 performed UB exercise in all planes. Used a can for 2 sets of 25. Resident #3 required moderate assistance with shoes and sink side ADLs with set up assist. Record review of Physical Therapy notes dated indicated on 09/07/22 Resident #3 said he felt great this morning and is ready to work with PT. He was able to ambulate approximate 100 to 150 feet with rolling walker. Record review of a nursing note dated 9/11/22 at 1:03 p.m. indicated Resident #3 continued with skilled services for strengthening and condition. He continued with wound treatment to the right heel. The resident required assistance with transfers to the bathroom, all needs meet at this time. signed by LVN G. (the only nursing note that mentioned wound care.) Record review of Physical Therapy notes dated indicated on 09/13/22 Resident #3 reported pain and discomfort on the right heel with weight bearing. Nursing is aware and a dressing was placed on the heel for protection. The resident was able to ambulate approximately 100 to 80 feet with rolling walker. Record review of a NP note dated 9/13/22 indicated Resident denied any pain or distress. He had 2 plus edema to his bilateral to the LE. Resident #3 was also noted with superficial venous wounds time two the right leg and a DTI to the right heel. The assessment/plan was to continue LE elevation three times a day, Venous insufficiency with right LE wounds, continue follow-up with Wound Care Doctor and wound care, right heel DTI, see above, continue no shoe to right foot, and heel float off the bed while lying or reclined. Record review of Physical Therapy notes dated indicated on 09/14/22 Resident #3 report pain and discomfort in the right heel with all weight bearing tasks, nursing is aware of patient's status. Record review of Resident #3's Wound Evaluation and Management Summary dated 09/14/22 indicated Wound care assessment and evaluation was performed today. Resident #3 had an unstageable DTI of the left posterior, lateral heel and for at least 1 day's duration. There is no exudated. Site 1- Unstageable DTI of the right heel, partial thickness, etiology pressure, size 6 cm by 7 cm the surface area measured 42 cm the duration is greater than 13 days. Wound progression deteriorated. Dressing hydrogel wafer apply three times per week. The plan was off load, reposition per facility protocol. Sponge boot, prevelon boot. Site 4 Unstageable DTI to left posterior, lateral heel, etiology pressure unstageable DTI . size 1.0 x 1.9 dept not measurable treatment plan the same as site 1. Record review of Physical Therapy notes dated indicated on 09/15/22 nursing advised PT that Resident #3 should not ambulate any more due to opening of wound on right hell. Bed mobility performed. Resident #3 is regressing overall due to the wound on the right heel, continue with PT as advised by nursing and Wound Care Doctor. Record review of Physical Therapy notes dated indicated 09/16/22 Resident #3 stated that he felt weak and tired but would try to do his best. Bed mobility preformed. Resident #3 was regressing with all mobility tasks since the worsening of wound on right heal. Record review of Occupational Therapy notes indicated the on 09/16/22 Resident #3 verbalized pain that limed his functional activities. The resident required increased assistance with ADL performance. Resident #3 said the pain exacerbates with standing. The resident described that pain with movement as 5/10, constant in the heel. With increased aching. Nursing notified and discussed sending the patient to the hospital due to change in condition. Review of nursing note dated 9/16/22 indicated at 9:50 a.m. staff voiced the resident with decline in condition, increased weakness and required maximum assistance with all care and ADLs. Review of nursing note dated 9/16/22 at 10:27 a.m. indicated the family was notified of changes in Resident #3's condition and he was going to the hospital. The resident voiced he is feeling tired and not himself. Noted wound to the right heel, therapy indicated he tolerated poorly today. Record Review of Resident #3's hospital records dated 09/16/22 indicated hospital problems were the Primary Right Foot Infection with acute kidney disease. His diagnosis acute renal failure, unspecified, pressure injury of skin of right foot, unspecified injury stage. This [AGE] year-old presented to the emergency department due to generalized weakness and right foot wound. The patient stated generalized weakness for about 3 months and progressively worsening. The patient stated chronic right heel wound. The patient was without redness, and no drainage to the right foot wound the wound was covered and had a compressive boot. Resident #3 arrived form nursing home with inflatable heel boot to relieve pressure. Labs revealed acute kidney injury with creatinine elevated from base line. All labs were review on 09/16/22 at 2:13 p.m. acute coronary syndrome, pneumonia, urinary tract infection, deconditioning, anemia, electrolyte disturbance, pulmonary embolism, COPD , asthma, foot wound, foot ulcer, osteomyelitis, sepsis and congestive heart failure. Patient with bilateral foot wound right with dusky black appearance noted at the right heel. The patient with DP Pt pulse in bilateral legs. Patient able to move legs will. No sensory deficit. Motor strength 5 out of 5 for bilateral lower extremities. Record review of Resident #3's hospital Discharge Course dated 09/26/22 indicated a past history of coronary artery disease, chronic systolic heart failure, stage 3 chronic kidney disease, essential hypertension, prostate cancer, hyperlipidemia who currently resided at the nursing facility came to the hospital with right diabetic food wound. Resident #3 received IV antibiotics during the hospital stay along with two debridement's. His medical status gradually worsened during the hospital stay. Resident #3 had a poor prognosis given his advanced age, and diagnoses. Resident #3 was discharged with hospice services. During record review and interview on 02/13/23 at 3:00 p.m. the DON could not find a physician order or treatments for pressure sores on the TAR for Resident #3's pressure sore. During record review and interview on 02/13/23 at 3:15 p.m. the Director of Clinical Informatics reviewed Resident #3's computer and paper file. She said she did not find a physician order or treatments on the TAR for Resident #3's pressure sore. During record review and interview on 02/13/23 at 3:37 p.m. the VP of Clinical Operations said she did action plan 10/24/22 and did an action plan on skin. Fixed problem in the POR for skin. During an interview on 02/13/23 at 3:49 p.m. the Wound Care Doctor said when she did her rounds at the facility, she always had a nurse with her. She said she was reviewing her notes on Resident #3 for 9/14/22. The Wound Care Doctor said she did recommendations. She did not write actual orders. Her recommendation for Resident #3's treatment for the unstageable was hydrogel waver three times a week. She said with treatment and offloading it should have healed. She said the Venous ulcers would have resolved if they had been offloaded with or without treatment. She said her treatment recommendations for both heels, were hydrogel waver Unstageable. 3 times a week. She also recommended pressure relieving boot. The number one goal is to keep the foot off loaded. The Care Doctor said she did not remember the resident not having a dressing on his wounds when she saw hm. She said there was no reason for her to think his treatments were not completed as recommended. During an interview on 02/08/23 8:49 a.m. LVN N said she worked at the facility for [AGE] years. She said she remembered Resident #3 was admitted for therapy was diabetes. LVN N said she recalled sending Resident # 3 out to the hospital on 09/16/22. She said during therapy he had a change of condition. She said therapy had informed her Resident #3 could not assist in toileting or dressing himself. LVN N said she checked his vitals and noted an overall change. She said she contacted the NP and sent him out. LVN N said staff noted his change may have begun the night before, LVN N said she did not remember much about Resident #3, she did not work the floor regularly. During an interview on 02/09/23 at 9:50 DON said Resident # 3 was admitted with a pressure sore and was on antibiotics- for the wound on admission. (there was no documentation on this information) During an interview on 02/09/23 at 11:50 a.m. the PTA said she remembered Resident #3 was up and walking around. She said the day before he went to the hospital, he said he did not feel well and did not participate well with therapy that day, 09/15/22. The PTA said next day he was unable to dress himself and had a total ADL decline. The PTA said she talked to ADON, and they sent him out. She said she remembered he did have a pressure sore on his heel, and he wore a boot, but could not remember what kind. During an interview on 02/09/23 at 11:59 a.m. the Physician said there was a standard order for wound care. He said staff did not normally notify him of wound or pressure sore issues. He said he did not get wound care calls much with the Wound Care Doctor in place. They usually notify the Wound Doctor and she handled the wounds. During a telephone interview on 02/10/23 at 10:45 a.m. a family friend. They said prior to admission to the facility the [AGE] year-old man was very with it and was driving. They said when Resident #3 was admitted to the facility he had an area on his heel. The family friend said they had visited with him a few times during his stay at the facility. They came to see him one day and he was sick, he was not himself at all. They said he had on a boot that they removed the boot, and the sore on his heel was large, black, and draining. They said he did not have a bandage on the heel. The family friend said she had pointed out the area to the facility staff. They said that may have been the day he went to the hospital. During an interview on 02/13/23 at 11:40 a.m. LVN E said she did not remember Resident #3. She said he was not on her hall. LVN E said she sometimes did rounds with the Wound Care Doctor. She did not remember if Resident #3 had a wound or not. LVN E said she could not remember who the treatment nurse was during that time Resident #3 was in the facility or if they had a treatment nurse. During record review and interview on 02/13/23 at 4:00 p.m. LVN G said he did complete Resident #3's admission assessment dated [DATE]. He said when Resident #3 was admitted he had some redness on his lower extremities but no pressure sore. LVN G said he had written a note on 9/11/22 regarding Resident #3's pressure sore. He said he did not provide a treatment and did not know if there was an order or not. Resident #3 had some skin that was loose on his heel, and LVN G said he had just cleaned that area. He said he did not follow an order for that. LVN G said. the Wound Care Doctor must have seen him before because he remembered something about that. He said it had been a while and his memory was foggy. During an interview on 02/13/23 at 4:05 p.m. LVN E said she did not remember Resident #3. She said she did not remember if she did anything with him or not. (LVN E was identified by the DON as the person the named in the Wound Care Doctor documentation on 9/7/22 that LVN E was informed of the doctor's plan of care for Resident #3.) During an interview on 02/13/23 at 5:50 p.m. the administrator said she vaguely remember Resident #3. She knew he came from an assisted living. She said if they had a system problem it was due to poor documentation and the facility not following policy and procedures. During an interview on 02/15/230 at 3:43 p.m. the Regional Director of Therapy said she could not find an order for a boot for Resident #3. During an interview on 02/15/230at 3:58 p.m. CPTA said Resident #3 wore dress shoes. she thought he could put them on himself. She said the last few days he had a decline and required more assistance with everything. During an observation and interview on 02/15/230a t 3:58 p.m. the DON said they did not have inflatable pressure reduction boots. She said sometimes residents came for the hospital with their own. The DON said if Resident # 3 had an inflatable boot they were not provided by the facility. The DON said they used Prevalon heel protectors, they were cloth, washable, and went little over half way up the calf. She said they also the used the cloth heal protectors that stop at the ankle. She said if the residents had heel protectors they usually had an order for the boots. During an interview on 02/15/23 at 5:56 p.m., CNA P said she worked at the facility for [AGE] years. She said she remembered Resident # 3, he was good resident that was basically independent when he was first admitted . She said he did have a boot and she thought he brought a boot with him from home and it was plastic. She said she did not think the facility had that kind of boot. She said he would try to wear shoes all the time and they would have to remind him to keep his shoes off his feet. She said the sore on his heel got worse. CNA P said the last few days he was not able to put shoes on, he declined. She said a few days prior to hospitalization Resident #3 said his foot was hurting Resident #1 Record review of Resident #1's admission record with a print date of 02/07/23 indicated she was an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses were myocardial infraction, muscle weakness, lack of coordination, hypertension, end stage renal disease and hyperlipidemia. Record review of Resident #1's admission MDS dated [DATE] indicated her cognitive status was severely impaired (BIMS score 7). She required extensive assist with bed mobility, dressing, and toilet use of one-person, limited assistant to transfer with one person. Limited assistance with locomotion off the unit of one person. She was able to eat and drink with supervision and set help only. Record review on 02/07/23 revealed Resident #1 did not have a comprehensive care plan. Record review of Resident #1's weekly skin observation dated 12/5/22 indicated no skin issues. Record review of Resident #1's Braden Scale for Predicting Pressure Ulcer Risk indicated she had no sensory impairment, she had skin that was moist most of the time, she was chair fast, and slightly limited mobility, she had adequate nutrition, a potential problem for friction and shear. Her score was 16 ( 15-18 high risk) Record review of Resident #1's Nutrition Risk, Mini Nutrition assessment dated [DATE] indicated she weighed 150 pounds. She was on dialysis with no nutritional issues noted. Record review of Resident #1's Weekly Skin Observation dated 01/20/23 indicated a blister to the sacrum and a rash to the left gluteal fold. (last) Record review of nursing note dated 01/ 25/ 23 at 5:01 p.m. indicated resident number one was laying in bed open area noted to her buttocks will continue to monitor incontinent care. Signed by LVN M Record review of a nursing note dated 01/26/23 at 12:37 p.m. indicated a full assessment was performed on Resident #1. she was lying in bed on right side she appeared the lethargic but aroused to tactile stimuli the resident denied pain when asked but grimaced when repositioned in bed. There was a small area of MSD to the sacrum, zinc ointment applied and to apply every shift and as needed for incontinent episodes resident #3 tolerated without difficulty. this skilled nurse to monitor and meet needs as they arise. Signed by LVN F. Record review of nursing note dated 2/2/23 at 4:02 p.m. Resident #1 noted with areas to the right buttock and coccyx that appeared to be moisture associated. There was a small amount of serous exudate cleansed from wound, patted dry and applied Hydrocolloid dressing. Referral to Wound care signed by RN F. Record review of nursing notes dated 02/06/23 at 12:33 a.m. Resident awake in bed. Hydrocolloid dressing intact to coccyx, sacrum area. Pillows in place. Peg tube placement pending. Record review of nursing notes dated 02/06/23 at 11:45 a.m. Resident #1 Returned form dialysis center with flat affect. She did not respond to verbal stimuli but grimaces her face when turned and repositioned. Wounds to buttocks assessed and reported findings to Wound Care Doctor. Verbal orders were received to discontinue hydrocolloid to coccyx and begin to cleanse coccyx with wound cleaner, pat dry, apply alginate, cover with foam dressing daily. Signed by RN F Record review of Resident #1's computerized physicians order for 01/15/23 through 02/15/23 indicated an order dated 0/26/23 at 6 p.m. indicated Sin ointment to sacrum every shift and as needed. On an order dated 02/07/23 at 6:00 p.m. to cleanse left sacral wound #3 with wound cleanser, pat dry apply alginate and foam dressing daily. Cleanse right sacral wound #2 with wound cleanser, pat dry apply alginate and foam dressing daily. Cleanse superior scar wound #1 with wound cleanser, pat dry, apply alginate and foam dressing daily. Record review of Resident #1's Weekly Skin Observation dated 02/7/23 indicated a it was a full assessment for 02/03/23 indicated Resident #1 had MASD (moistures associated skin damage) on the sacrum that measured 2 by 2 by 0.1 And MASD to the right gluteal fold that measured 2 by 2 by 0.1. Hydrocolloid dressing in place, the skin is fragile noted to upper and lower buttocks referred to wound care. Record review of hospital records dated 2/7/23 at 3:10 p. m. indicated Resident #1 had a wound care consult due to multiple wounds. She had a deep tissue injury to the sacrum that measured 9 cm by 12 cm by 0.1 cm. she had a right thigh posterior deep tissue injury that was 2 cm by 10 cm by 0.1. cm. During an interview on 02/07/23 at 5:56 p.m. CNA L said she did not see a pressure sore on Resident #1 but they said she had one from the other staff, no one in particular. She said she did not work with her often. However the resident did not want turn roll, move, pick up head nothing During an interview on 02/07/23 at 6:00 p.m. CNA K said she saw a sore on Resident #1's right hip about a week before she left. She did not remember there being a bandage on the area and could not remember how big. She put her fingers together like a quarter size area. During an interview on 02/07/23 at 6:04 p.m. LVN M said she found Red open area on Resident #1's bottom. She said she sent a communication form to the treatment nurse/ RN F During an interview on 02/08/23 9:45 a.m. the ADON said LVN F's quit work on the morning of 02/07/23. She said LVN F's computer access was terminated due to her putting a skin assessment in the computer system on the night of 02/07/23. During an interview on 02/08/23 at 10:04 a.m. Administrator said Resident #1 did not have a skin assessment on 02/07/23 in the system. She said she had one that day because the RN F had put a skin assessment in after she asked her why they were not completed. The Administrator said they were looking at the computer last night and saw RN F had put a note in system after 5:00 p.m. During an interview on 02/08/23 at 11:12 the DON said LVN E called on Sunday, 02/05/23 and told her about pressure sores on Resident #1. The DON said she texted the wound care doctor on Sunday to see if she would look at the wounds on her regular visit on 02/07/23. During an interview on 02/08/23 at 1:25 p.m. LVN E said she saw some areas on Resident #1's bottom on Friday 2/3/23. She said there were 3 wounds. LVN E said one was about two centimeters and bleeding it was opened, there was one the right hip area, when she saw them on Friday, they were about quarter size. She said there was scar tissue beside the smaller one. She said she notified the treatment nurse RN F. Then on Sunday, 02/05/23 there was a Hydrocolloid bandage on the wound. She said she did not know if there was an order, she just put the same thing back on. She said Resident #1 had a BM and the bandage was dirty. LVN E said Resident #1's wounds were bigger and worse. she said they were about the size of a 50-cent piece. LVN E said at that time she called the DON and reported her findings. During an interview on 02/09/23 at 11:59 a.m. the Physician said that no one notified him of Resident #1's pressure sore. He said there is a standard order for wound care. However, they usually notify the Wound doctor and she handled things like that. He was not aware Resident #1 had a wound. During an interview on 02/09/23 at 12:10 p.m. Wound Care Doctor said first she heard about Resident #1's wounds was 2/5/23 about 8pm. She said the DON called or texted her and told her Resident #1's wounds were getting worse. The Wound Care Doctor said on Monday, 02/06/23 RN F called and told her Resident #1 had wounds and she told her to put alginate on the wounds. The Wound Care Doctor said she never saw the wounds. During a telephone interview on 2/9/23 at 12:16 p.m. RN F/treatment nurse said Resident #1's pressure sores were first brought to her attention Thursday, 02/02/23 by and aide. She said she sent a message to the resident 's physician and put a treatment in place. She said on 02/03/23 when Resident #1 came back from dialysis she reinforced the bandage. She wrote the late entry 02/07/23 because-she had put something in place. She said when she saw the areas on 02/03/23 they were not really pressure sores. RN F said when she got to work Monday, 02/06/23 the administrator told her the sores were big enough to put her fist in the wound. She said the administrator told her she had seen a picture of the wounds. According to RN F Resident #1 had 3 stage 2 wounds that measured 2.2 cm by 2/2 cm. RNF said she knew she was not eating because she was on the floor. Wound Care Doctor and she said they would do good with alginate. She said she was on the floor on 02/06/23 and received a call from dialysis saying they were sending Resident 1 back to the facility because she was too weak to attend the treatments. She assessed her and sent her out to the hospital. RN F said they all knew Resident #1 was not eating LVN G talked about it most every morning in the morning meeting. During an interview on 02/09/23 at 12:45 p.m. the Administrator said LVN E sent a picture to the DON. She had saw the picture. She may have exaggerated some, but it looked big on the picture. She used her fingers to indicate the wound was about the size of a small orange. During an interview on 02/09/23 at 12: 57 pm. The DON said she received a call and pictures of Resident #1's wounds on 02/05/23 from LVN E. She said just looking at the picture it was more than 2 cm wide and looked like it could have been unstageable. She had erased the picture from her phone. She had texted the Wound care doctor and asked her to see the resident on Wednesday. This was determined to be an Immediate Jeopardy (IJ) on 02/13/23 at 6:05 p.m. The facility Administrator, DON, VP of Clinical Operations, and Director of Clinical Informatics were notified. The Administrator was provided with the IJ template on 02/13/23 at 6:05 p.m. The plan of removal was accepted on 02/15/23 at 3:30 p.m. [Please accept the following plan of removal for F-686 Pressure Sores. 33. Notify V.P. of Clinical Operations of immediate Jeopardy status - o Onsite during notification 02/13/23 @6:05 P.M. 34. Notify Regional Director of operations of Immediate Jeopardy status - o Completed :02/13/23 @ 6:54 PM per V.P. of Clinical Operations 35. Notify facility PCP /Medical Director of Immediate Jeopardy status- o Completed :02/13/23 @ 6:43 PM 36. Resident #1 was readmitted to the facility on [DATE] @ 12:50 PM. Resident #1 was assessed / evaluated by licensed nursing staff. Resident #1 readmitted on Hospice services and is to receive comfort medications only. Resident #3 was evaluated by licensed nursing staff and was tr [TRUNCATED]

Based on observation, interview and record review the facility failed to maintain acceptable parameters for nutritional status such as usual body weight or desirable body weight range by failing to provide nutritional and hydration care and services to residents consistent with the resident's needs for 1 of 4 residents reviewed for weight loss (Resident #1). The facility failed to ensure Resident #1 was provided food, water, for about a 10-day period. The facility failed to ensure the dietician was notified and dietary recommendations were in place. The facility failed to follow their nutritional policy regarding weight loss. They failed to ensure the resident did not have skin breakdown due to poor nutrition. Resident #1 had a significant weight loss of 5.3 percent in one month and 9.6 percent in 3 months Resident #1 was sent to the hospital with diagnoses of malnutrition and dehydration. The facility failed to provide care to Resident #1 for about 10 days over multiple shifts and multiple staff were aware she was not eating and they put no interventions in place to prevent continued decline. An Immediate Jeopardy (IJ) situation was identified on 02/09/23 at 5:15 p.m. While the IJ was removed on 02/11/23 at 7:22 p.m., the facility remained out of compliance at actual harm with a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents as risk for decreased nutritional status, decline in health serious illness, or hospitalization . Findings included: Record review of Resident #1's admission record with a print date of 02/07/23 indicated she was an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses were myocardial infarction( heart attack), muscle weakness, lack of coordination, hypertension, end stage renal disease and hyperlipidemia. Record review of Resident #1's admission MDS dated [DATE] indicated her cognitive status was severely impaired (BIMS score 7). She required extensive assist with bed mobility, dressing, and toilet use of one-person, limited assistance to transfer with one person. Limited assistance with locomotion off the unit of one person. She was able to eat and drink with supervision and setup help only. Record review of Resident #1's Admission assessment dated [DATE] indicated she received dialysis 3 times a week. She weighed 150 pounds. She was incontinent of bowels and bladder and had no skin issues identified. She was totally dependent for bed mobility, transfers, personal hygiene, bathing, and dressing. Resident #1 required assistance of staff for eating. She used a wheelchair. She did not receive therapy. Record review of Resident #1's Nutrition Risk, Mini Nutrition assessment dated [DATE] indicated she weighed 150 pounds. She was on dialysis with no nutritional issues noted. Record review of nursing notes indicated: On 01/12/23 at 8:40 p.m. Resident #1 was lethargic unable to answer questions the physician was notified regarding her change in level of consciousness, and she was sent to the ER On 01/14/23 at 12:58 a.m. Resident #1 returned to the facility by ambulance she remained lethargic and unable to answer questions appropriately. On 01/15/23 9;38 a.m. Resident #1 was lethargic and could not swallow. Signed by MA H. On 01/15/23 at 3:07 p.m. Resident #1 was having difficulty swallowing food. A new order for swallow study was received. Signed by LVN G. On 01/17/23 at 12:11 a.m. Resident #1 was lying in bed sleeping no acute distress noted, and a new order to for swallow study related to appetite. Resident #1 ate less than 25% of her dinner, health shake offered and took 100 percent. signed by LVN M. On 01/18/23 at 7:00 p.m. the nurse assisted Resident #1 with supper. Her appetite remined poor. She consumed 25 percent of meal, accepted health shake, and drank about 75 percent. Continued generalized weakness. On 01/19 23 at 1:18 p.m. Resident #1's swallow study test was conducted per professional imaging. Record review of Dysphagia Consultation dated 01/19/23 indicated meal recommendations for Resident #1. Pleasure comfort feedings of pureed as accepted or tolerated, encourage more upright head posture, employ good oral care, cued cough to help clear upper airways, liquids nectar thick and pills are a choking risk crush medication. Feed slowly and carefully, hand over hand assistance, no straws, resident to be fed small bites and sips. SLP or trained staff only and monitor for adequate nutrition and hydration. Record review of Resident # 1's computerized physician orders for 01/15/23 to 02/15/223 indicated an order for puree diet, pureed texture, Nectar consistency due to swallowing difficulty. Record Review of nursing notes January 2023 notes indicated: On 01/19/23 at 4:31 p.m. Resident #1 received a new order to discontinue regular texture diet and thin liquids start. Texture and nectar thick liquids. recommended pleasure feeding small bites sips and foods recommendations were upright body and head positioning. Signed by LVN G. On 01/23/23 at 10:12 a.m. Novasource Renal give one bottle two times daily. Resident #1 was very lethargic. Signed by MA H On 01/24/23 at 8:28 a.m. Novasource renal give one bottle twice a day Resident #1 was lethargic and cannot swallow good signed by MA H. On 01/24/23 at 4:26 p.m. the Resident #1 was noted lying in bed facing up with head turn to the right, the skin was warm to touch but difficult to arouse. Her blood pressure was 97 / 56, pulse 80, and her O2 stats was 97. Respirations noted 14 and shallow. The NP was notified her recommendations to monitor the resident. The DON was notified they will continue to monitor notes signed by LVN G On 01/24/23 at 8:28 a.m. lethargic and cannot swallow good. Signed by MA H On 01/ 25/ 23 at 5:01 a.m. indicated Resident #1 was lying in bed sleeping at this time the resident is withdrawn she is refusing to eat . Signed by LVN M On 01/26/23 at 12:37 p.m. completed a full assessment was performed on resident #1. she was lying in bed on right side. She appeared the lethargic but aroused to tactile stimuli. The resident denied pain when asked but grimaced when repositioned in bed. There was a small area of MSD to the sacrum, zinc ointment applied. Apply the ointment every shift and as needed for incontinent episodes. Resident #1 tolerated without difficulty. The nurse would monitor and meet needs as they arise. Signed by LVN F. On 01/27/23 add 3:00 p.m. Resident #1 was back from dialysis weakness noted with decline. She took only a few sips of nectar water, noted poor balance and weakness. Resident #1 with a steady decline Max assist with all care and ADL. She only speaks a few words denied pain signed by LVN N. On 1/27/23 at 9:00 p.m. Resident # 1 was resting in bed with the head of the bed elevated she was noted with a global decline Signed by LVN Q On 01/28/10:21 a.m. Novasource renal not given Resident #1 unable to swallow. Signed by MA H On 01/30/23 at 1:37 a.m. Resident #1 lying in bed at this time sleeping with eyes closed. There was no acute distress noted. Resident #1 poor appetite noted. Signed by LVN M On 01/30/23 at 5:25 p.m. Resident #1 in bed with eyes closed. She exhibited generalized body weakness. Shallow respirations. At this am the nurse attempted to feed the resident but noticed the resident having difficulty in swallowing. Oral care performed, covid test conducted per dialysis request. Negative results. Signed by LVN G. Record review of Resident #1's ADL Nutrition sheet (amount eaten) for January 2023 indicated from 01/23/23 through 01/31/23 Resident #1 refused or did not eat except on 01/26/23 and 01/27/23 in the morning she ate 26 to 50 percent. On the evening of 01/25/23 she ate 51 to 75 percent. Record review of the facility weights indicated 12/30/22- 146.3 01/04/23- 146.3 1/12/23 - 147.6 1/20/23- 143.2 1/28/23 -137.1 Record review of the last dialysis sheet the facility presented dated 01/23/23 indicated Resident #1's weight was 61.9 kilometers. 61.9 x 2.2 equals 136.47 pounds. Record review of Resident #1's weights indicated for November 2022 her weight was 150.04 pounds, December 146.3 pounds, O1/20/23 143.2 on 02/01/23 her weight was 135.5 pounds. In 3 months, 9.6 percent. In one month, 5.3 percent; both significant weight loss. Record Review of nursing notes for February 2023 nursing notes revealed: On 02/1/23 at 4:19 p.m. Resident #1 received new order for G-tube placement per the facility physician and the dialysis physician. Pending appointment. Record review of an email provided by the DON dated 02/01/23 indicated the email was to the Dietician. The email stated please look at the following residents Resident #1 had a referral for a tube placement. Record Review of nursing notes for February 2023 nursing notes indicated: On 02/03/23 at 9:34 a.m. Resident #1 was unable to swallow. Signed by MA H. On 02/04/24 at 454 a.m. Resident #1 laying in bed sleeping currently. She is withdrawn. The resident was refusing to eat. Signed by LVN M. On 02/06/23 at 12:33 a.m. Resident awake in bed. Pillows in place. Peg tube placement pending. The resident appetite and fluid intake remained poor. The family visited on 02/05/23 and are aware of Resident #1's global decline. The resident continued dialysis three times a week. On 02/06/23 at 11:24 a.m. a call from the dialysis center stating Resident #1 was unstable to receive her treatment, and they were sending her back to nursing home. Signed by LVN E. On 02/06/23 at 11:45 a.m. Resident #1 Returned form dialysis center with flat affect. She did not respond to verbal stimuli but grimaces her face when turned and repositioned. Signed by RN F. On 02/06/23 at 12:05 p.m. during visual rounds, Resident #1 appeared lethargic with difficulty arousing. She did not respond to tactile or verbal stimuli. Three failed attempts to collect her blood pressure on the left wrist. Her heart rate was 78, temperature 96.8 and her respirations were 16. The physician was contacted regarding Resident #1's status and verbal orders were received to send her to the ER for evaluation and treatment. Record review of Resident #1's ADL Nutrition sheet (amount eaten) for February indicated from 02/01/23 through 02/06/23 the resident refused or did not eat except on the evening of 02/01/23 the resident ate 26-50 percent on the morning of 02/04/23 resident #1 ate 51 to 75 percent. Record review of Resident #1 hospital records dated 2/6/23 indicated the resident assessment plan was failure to thrive, the patient had not been eating or drinking for the past week. Would start on gentle fluids resuscitation the diagnosis likely dehydration and possible starvation. The EMS reported Resident #1 had a constant decline for the past couple of weeks. She last dialysis was two times. She was too weak. The physical exam indicated diagnosis of end stage renal disease related to high blood pressure in 2016. Encephalopathy progressing since 12/20/22 severe dehydration and malnutrition. The emaciated chronically ill female lost 10 kg=22.05 pounds in the past 3 to 4 months in no acute distress. Record review of the hospital records dated 02/06/23 indicated Resident #1's weight was 56.7 kilometers. 57.7 x 2.2 equals 125 pounds. During an interview on 02/07/23 at 10:32 a.m. CNA A said she worked at the facility since July 2022. She said Resident #1 had a swallowing problem. CNA A said she was told last week not to feed Resident #1 because she would choke. She said Resident #1 was a total care resident, she was incontinent, and on dialysis. CNA A did not want to talk to the Investigator. She said the nurse was the person to answer the questions. She said Resident #1 was supposed to get a feeding tube on today, 02/07/23. During an interview on 2/7/23 at 10:39 am. CNA B said she worked at the facility for 8 years. She said she had been off for two days. CNA B said Resident #1 was not eating the last few times she had worked with her. CNA B said she would try to feed Resident #1 and would start choking. Resident #1 was on thicken liquid and her choking got to the point they only gave her liquids. She said sometimes she would choke on the liquids as well. Then she was told not to give her anything because she would choke. During an interview on 02/07/23 at 11:47 a.m. LVN E said she worked at the facility for 3 years. She said on 02/06/23 dialysis called and said they were unable to complete dialysis on Resident #1 because she was too unstable. LVN E said Dialysis said she was too lethargic and sent her back to the facility. She said Resident #1 came back to the facility and was sent to the hospital on 02/06/23. LVN E said the treatment nurse RN F was the nurse that assessed Resident #1 and sent her to the hospital. LVN E said she did hear Resident #1 was not eating. She said on today, 02/07/23 Resident #1 had an appointment to have a feeding tube to be placed. LVN E said the nurse at the hospital told her on the phone Resident #1 was not a candidate for a feeding tube because she was too weak. She said they could not get Resident #1 to eat or drink for a least a week or two. LVN E said Resident #1 was not a DNR and she was not on hospice. She said the family would not change Resident #1's code status. LVN E said she had not personally contacted the physician regarding Resident #1 not eating or drinking. LVN E said the administrative staff were aware Resident #1's condition had declined to not eating anything. During an interview on 02/07/23 at 12:24 p.m. the Administrator said she thought the dialysis clinic sent Resident #1 back to the facility on [DATE] because she refused to allow them to allow them to dialysis her. The Administrator said she knew they had talked to the family about hospice, and the family did not want her to put her on hospice. The Administrator said she thought Resident #1 was supposed to have gotten the feeding tube today, 02/07/23. She said Resident #1 was in the hospital, and someone had mentioned the hospital said Resident #1 was not a candidate for the feeding tube. The Administrator said she was aware as she could be that Resident #1 was not eating well. She was not familiar with the medical aspect of resident care. During an interview on 02/07/23 at 1:00 p.m. the ADON said she worked at the facility for about three years. She said Resident #1's appetite steadily had decreased over the past month. She said Resident #1 was scheduled to have a feeding tube procedure on today, 02/07/23. She said they had tried to get an earlier appointment but were unable to. The ADON said she was aware Resident # 1 was not eating well, per the need for the feeding tube. She said she did believe she was eating a little something. The ADON said she did not think Resident #1 was not eating at all. During a telephone interview on 02/07/23 at 1:15 p.m. the DON she was currently on leave and her last day at work was 02/01/23. The DON the SW from dialysis called and wanted to know if Resident #1 was a DNR. She said the dialysis SW said they were having trouble with Resident #1 tolerating dialysis or receiving full treatment due to her weakness. The Nephrologist recommended putting her on Hospice. The DON said the dialysis SW said the family would not consent to Hospice. She said on 02/01/23 the dialysis SW said she had received consent from the family, the Nephrologist and the facility physician for Resident #1 to have feeding tube placed. She said at that time an appointment was scheduled for a gastrologist to do the feeding tube procedure on 02/07/23. The DON said as far as she knew Resident #1 was eating but not a whole lot. She said when Resident #1 ate less than 50 percent, the facility staff would give her a health shake or a sandwich. The DON said there were occasion when Resident #1 was at dialysis and her blood pressure would be too low to perform the procedure, and dialysis had to send Resident #1 back to the facility. During an interview on 02/07/23 at 1:55 p.m. the facility SW said Resident #1's family was hard to contact and they did not return her phone calls. The SW said the family did not want to stop dialysis and Resident #1 was still a full code. She said on 02/01/23 dialysis did the referral for a feeding tube. The SW said she was not a part of the referral. She said she felt they had done the referral for GI doctor because Resident #1 had gone downhill. The SW said she was in the morning meetings, and it was said Resident #1 was not eating very well. During a telephone interview on 02/07/23 at 2:23 p.m., Resident #1's Physician said in the old days a resident could send them straight to the ER to receive a feeding tube. He said now the hospital did not do that any longer. He said they had to schedule an appointment through a GI doctor to get a feeding tube placed. He said they got the first available appointment with GI doctor on 02/07/23. The Physician said potentially, they could have done a nasal gastric tube, but the patient reached and pulled the tube out regularly. He said it would not have done any good to prescribe an appetite stimulate if Resident #1 was not eating at all. He said he did not know until 02/06/23, that Resident #1 was not taking any of her meds and was not able to swallow at all for at least a week. He said if he had known he would have sent her to the hospital, and they would have likely gotten some IV fluids started on Resident #1. The Physician said Resident #1 was having swallowing difficulties before she came to the facility. The facility staff did not tell him Resident #1 was not eating, drinking, or taking her medications. He said what he was told was Resident #1 was not eating well. During an interview on 02/07/23 at 2:51 p.m. CMA/CNA I said LVN G told her not to give Resident #1 anything because she could not swallow. During an interview on 02/07/23 at 3:40 p.m. CNA K said she worked at the facility about 5 years. She said the last time she worked with Resident #1 was on Saturday, 02/04/23 and she was not eating at all. She said her mouth was open and the food would not stay in her mouth. She said the last time she fed Resident #1 was about a month ago and she was swallowing a little bit at that time. CNA K said she did not work with Resident #1 often. During a telephone interview on 02/07/23 at 3: 50 p.m. LVN G said Resident #1 could not eat or swallow anything due to her choking. He said it had been at least a week since she was able to swallow anything. He said they had placed Resident #1 on puree diet the later part if January, and even with diet change she only ate about 25 percent. LVN G said about a week ago an aide told him Resident #1 could not eat, she was choking on her food. He said he had gone down to the room to try and feed Resident #1 himself. He said he tried to get her to eat but she was choking. LVN G said he was able to get her to take half cup thickened liquids, but she had a hard time. He said on the following day Resident #1 was just holding food in her mouth and not drinking anything. The LVN said he asked the DON and she said they set up an appointment for tube feeding. He said the SW at Dialysis had talked to the dialysis doctor and the facility doctor and received a go ahead for a feeding tube. LVN G said at the first of January they sent Resident #1 sent to hospital and the hospital sent her right back. He said on one occasion he called the NP because Resident #1's BP was really low, and the NP said to just monitor her. The LVN said he reported in the morning meeting Resident was not eating or drinking. During an interview on 02/07/23 at 4:17 p.m. the Administrator and ADON said after reviewing the dietary recommendations for January they did not find anything regarding Resident #1. They said the last time the Dietician was in the building was 01/13/23. During an interview on 02/07/23 at 5:56 p.m. CNA L said Resident #1 would not eat but she had tried to feed her. She said Resident #1 was swallowing a little bit about a week ago. She said the Resident #1 appeared weak and lethargic. During an interview on 02/07/23 at 6:04 p.m. LVN M said she worked at the facility for two years. She said Resident #1 was lethargic and weak. She would take Resident #1's vitals, and they were normal. The LVN said most of time Resident #1's normal BP was low. The LVN said Resident #1 had declined with her eating and was very withdrawn. LVN M said there was nothing alarming that indicated she needed to send Resident #1 to the hospital. LVN M said Resident #1 would take a small amount of liquid. LVN M said that during shift change the DON said to monitor her. During an observation at the hospital on 02/08/23 at 7:35 a.m. Resident #1 was lying in bed on her left side with her head slanted in the pillow. She opened her eyes when her name was called but did not respond otherwise. She had an IV set up by her bed. During an interview on 02/08/23 at 8:30 a.m. the facility SW said she was told by staff in the morning meeting Resident #1 was not eating for at least a week. They had set an appointment for Resident #1 to receive a feeding tube for 02/07/23 but she went to the hospital on 02/06/23. The SW said she had tried to get in touch with the family several times because Resident #1 had a decline. The SW said she did get in touch with the family member one day last week to schedule a care plan meeting. The SW said the family said they did not want a DNR or to stop dialysis which seemed to be really hard on the Resident #1. During an interview on 02/08/23 at 8:49 a.m. LVN N said worked at the facility for [AGE] years. She said Resident #1 had an overall decline. She said Resident #1 could still say her name and say she did not want anything to eat, or if she was in pain. LVN N said Resident #1 began pocketing food at one time and not wanting to swallow. She said she had some aides come up and told her Resident #1 was not eating. She said over a week ago she had worked the evening shift and tried to get Resident #1 to drink. She said Resident #1 took a sip and turned her head. She said she worked with Resident #1 a few times she only worked the floor when they were short. The LVN said she had talked to Resident #1's family member one evening about 3 weeks ago. She said they talked about Resident #1 declining. LVN N said they talked Resident #1's not eating in morning meeting, and getting with the family about her code status, and her decline changes. During a telephone interview on 02/08/23 at 9:31 a.m. Resident #1's family member said the facility changed Resident #1's diet to puree and changed her medications to crushed. The family member said in the last couple of weeks they suggested doing a feeding tube and they were going to place the feeding tube on 02/07/23. The family member said they did not know she was not eating at all, she said Resident #1 was talking and now she is not. The family said first they said she failed the swallow study. She said Resident #1 did not like the food, but would eat the food the family brought. After the diet was changed to puree, she just stopped eating. The family member said during the last months they had been ill, and not come to visit often. The said in the last month Resident #1 had not been able to feed herself. During an interview on 02/08/23 at 10:43 a.m. the DON said when the dietician came, she looked at all weekly weights. When she was last here on 1/24/23 she did not look and Resident #1. The DON said she did the residents on dialysis and received weekly weights. The DON said on the morning of 2/1/23 an aide told her Resident #1 did not eat. The DON said on 2/1/23 she was provided the weight list and Resident #1 had lost weight. She said she contacted the dietician and asked if she could send a recommendation. She said she had informed the dietician via email Resident #1's weight was down 10 pounds from the previous weight. She said she had emailed the dietician and told her Resident #1 needed a consult. During a telephone interview on 02/08/23 at 11:07 a.m. the NP said she got a message on 2/6/23 that Resident #1 was sent to the hospital. She said she was aware Resident #1 had a decline, and the facility staff were trying to catch up with the family to see if they wanted to put her on hospice. She said Resident #1 was [AGE] years old and on dialysis, and dialysis was hard on the body. The NP said dialysis was designed to extend the life but not indefinitely; it was only a short term fix. She said Resident #1 had additional heart concerns. The family did not want to stop dialysis or make her a DNR. She said if she had known Resident #1 was not eating or drinking anything she would have sent her to the hospital. She said she remembered someone contacting her about Resident #1's low blood pressure but her blood pressure ran low. She said if she had known would have sent her out sooner. During an interview on 0/08/23 at11:12 the DON said she was not aware she did not take for over 10 days not eating for 10 days. During a telephone interview on 02/08/23 at 1:15 p.m. the Dietician said Resident #1 did not trigger for weight loss. The Dietician said the last weight she had was 143 and that was only a two-pound weight loss. The last time she was at the facility was 1/27/23. The Dietician said the DON sent an email that said the Resident #1 was going to be getting a feeding tube not she had weight loss. She said she had access to the system. If the weight was not in the system, she had no way of knowing there was a problem unless someone physically contacted her. She said with a pressure sore she was notified there was a change in condition, and she needed to see the resident for nutritional interventions. During an interview on 02/08/23 at 4:25p.m. the DON said Resident #1's weight for 2/1/23 had not been placed in the system. They just finished doing the weights. Resident #1 had not triggered for weights prior, and she did not know if she would trigger now. The DON said Resident #1's weights were up and down. She said they did not use dialysis weights. The DON said Resident #1's weight was 135 on 02/01/23. During an interview on 02/09/23 at 10:30 a.m. the DON conversation with the SW at dialysis but they were the facility sit up the swallow study. The DON said they had tried to talk to the family about stopping dialysis and changing Resident #1's. She said that was the conversation they had with dialysis. The next thing she knew it was putting in a peg tube. She said dialysis did not complain about Resident #1 losing weight. The DON said the family did not want to stop Resident treatment and wanted her to remain a full code. During an interview on 02/09/23 at 10:52 a.m. CNA C said that she used the dialysis weight and converted the kilograms to pounds. However, she did not appear to have the correct formula. She said on 2/1/23 she used the lift pad to weigh her on that day and she recorded that weight. Record review of the facility Weight Assessment and Intervention policy last revised September 2008 indicated. The nursing staff will measure resident weights on admission, the next day and weekly for two weeks thereafter. If there are no weight concerns weights will be monthly. Weight will be recorded . in individual medical record. Any weight change of 5 percent or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. The Dietician will respond withing 24 hours of receipt of written notification. The dietician will review the weight record by the 15th of each month. The threshold for significant up planned and undesired weight loss will be based on the following criteria. (where percentage of body weight less- usual weight - actual weight/usual weight x 100) one month is significant if 5 percent and if greater than 5 percent, is severe weight loss. For 3 months 7.5 percent is significant and if greater than 7.5, is severe weight loss. This was determined to be an Immediate Jeopardy (IJ) on 02/09/23 at 5:15 p.m. The facility Administrator, DON, ADON were notified. The Administrator was provided with the IJ template on 02/09/23 at 5:15 p.m. The plan of removal was accepted on 02/11/23 at 1:46 p.m. [Please accept the following plan of removal for F692-Nutrition: 1. Notify V.P. of Clinical Operations of immediate Jeopardy status - o Completed - 02/09/23 @5 :17 PM per DON 2. Notify Regional Director of operations of Immediate Jeopardy status - o Completed - 02/09/23@ 5:19 PM per V.P. of Clinical Operations 3. Notify facility Medical Directors of Immediate Jeopardy status- o Completed - Both notified on 02/09/23@ 8:15 PM/ 8:20 PM by ADON. 4. Notify Corporate Account manager for Dietary consultants and request onsite RD support. o Completed - 02/09/23@5:59 PM per V.P. of Clinical Operations. RD scheduled for 02/ 10/ 23. o RD onsite 02/10/23 @ 7:30 AM 5. Resident #1 was transferred to an appropriate medical setting on 02/06/23 for evaluation and treatment. Resident #1 remains hospitalized at the time of this report. 6. Residents skin assessments will be audited for completion and any identified skin areas. o Initiated: 02/10/23 @ 1:00 AM by DON. o Completed: 02/10/23@7:15 AM by DON. 7. Residents with identified skin concerns will be reviewed for treatment orders, care plan implementation and RD evaluation. Corrective actions will be completed for identified concerns. o Initiated: 02/10/23@ 7:45 AM by DON. o Completed: 02/10/23 @ 8:00pm 8. Residents' weights will be reviewed for completion and any significant variances identified. o Initiated: 02/10/23@ 5:00 AM by DON. o Completed: 2/10/23 @ 10:15am by Registered Dietician. 9. Residents with significant weight variances will be reviewed for RD evaluation, care plan implementation and notification to MD/PCP and responsible party. Corrective actions taken for identified significant weight loss variances (1 month - 5% or greater, 3 months - 7.5% or greater, 6 months - 10% or greater) will include notification to residents PCP/designee and responsible party by nurse management/ designee, care plans will be reviewed by nurse management/designee for weight loss and specific interventions implemented. Resident care plans will be reviewed/revised to include specific interventions for weight loss concerns by MDS Coordinator and/or nursing management. RD evaluations and recommendations will be reviewed with MD/PCP notified for consideration for implementation. The DON will be assigned to monitor the weight system for significant variances (1 month -5% or greater, 3 months- 7.5% or greater, 6 months - 10% or greater). The DON will monitor the PCC clinical dashboard, POC meal intake and any alerts less than 50%. The DON will notify the RD, PCP/designee, and RP of weight intake concerns via phone or electronically on a weekly basis. o Initiated: 2/10/23 @ 7:45 AM by DON/RD o Completed: 2/10/23 @ 8:30pm 10. Residents EMR will be reviewed for baseline care plan completion. No residents were identified to need a baseline care plan as a result of the audit. o Initiated: 2/10/23 @ 7:45 AM by DON/ RD. o Completed: 2/10/23 @ 10:45am by MDS Coordinator. 11. The facility DON was provided education by the V.P. of Clinical Operations on the following topics: a) Change in a residents' status - Discussion included review of Change in a Resident's condition or Status Policy & Procedure. Examples of changes in condition and notification expectations to MD/PCP and responsible party. Specific content of the change in a residents condition status policy were reviewed during the discussion. Three sections of this policy referenced significant changes in the

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 4 residents reviewed for care plans (Resident #1, Resident #3) Resident #1 had overall ADL decline due to poor nutrition, weight loss and pressure sores with no care plan interventions in place, and she was hospitalized . Resident #3 had a pressure sore that was not treated and caused an overall decline and hospitalization with no care plan interventions in place. The facility was cited for failure to develop and implement a comprehensive person-centered care plan on 08/17/22 during their annual survey. They were also cited on 12/07/22. The facility had an extended period and did not provide care plans as needed for continuity of resident care needs. An Immediate Jeopardy (IJ) situation was identified on 02/10/23 at 4:14 p.m. While the IJ was removed on 02/11/23 at 7:22 p.m., the facility remained out of compliance at actual harm with a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not having individual needs met, and decreased the quality of life. Findings included: Resident #1 Record review of Resident #1's admission record with a print date of 02/07/23 indicated she was an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses were myocardial infarction (heart attack, muscle weakness, lack of coordination, high blood pressure, end stage renal disease and hyperlipidemia. Record review of Resident #1's admission MDS dated [DATE] indicated her cognitive status was severely impaired (BIMS score 7). She required extensive assist with bed mobility, dressing, and toilet use of one-person, limited assistance to transfer with one person. Limited assistance with locomotion off the unit of one person. She was able to eat and drink with supervision and set help only. Record review of Resident #1's Admission assessment dated [DATE] indicated she received dialysis 3 times a week. She weighed 150 pounds. She was incontinent of bowels and bladder and had no skin issues identified. She was totally dependent for bed mobility, transfers, personal hygiene, bathing, and dressing. Resident #1 required assistance of staff for eating. She used a wheelchair. She did not receive therapy. Record review of Dysphagia ( difficulty swallowing) Consultation dated 01/19/23 indicated meal recommendations for Resident #1. Pleasure comfort feedings of pureed as accepted or tolerated, encourage more upright head posture, employ good oral care, cued to cough to help clear upper airways, liquids nectar thick and pills are a choking risk crush medication. Feed slowly and carefully, hand over hand assistance, no straws, resident to be fed small bits and sips. SLP or trained staff only and monitor for adequate nutrition and hydration. Record review of Resident #1 hospital records dated 2/6/23 indicated the resident assessment plan was failure to thrive. The patient had not been eating or drinking for the past week. Would start on gentle fluids resuscitation; the diagnosis likely dehydration and possible starvation. The EMS reported Resident #1 had a constant decline for the past couple of weeks. She last dialysis was two times in the last week. She was too weak to complete the treatment. She had not been taking her medications. The physical exam indicated diagnosis of end stage renal disease related to high blood pressure in 2016. Encephalopathy progressing since 12/20/22 severe dehydration and malnutrition. The emaciated chronically ill female lost 10 kg=22.05 pounds in the past 3 to 4 months in no acute distress. Record review on 02/07/23 revealed Resident #1 did not have a comprehensive care plan. Record review of Resident #3's Admission record with a print date of 02/07/23 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis was congestive heart failure, respiratory failure, diabetes, hypertension, kidney disease, and reduced mobility and coordination. The record indicated Resident #3 was discharged on [DATE] with 17 days stay to an acute hospitalization . Record review of Resident #3's Admission assessment dated [DATE] indicated the resident was admitted to the facility from an ALF due to edema to the bilateral LE with high blood pressure. He was alert times 4. Resident #3 had poor balance and unsteady gait. He was continent of bowel and bladder. His skin assessment revealed right inner arm bruising, lower left leg rear vascular, lower right leg vascular ( areas caused by decreased blood flow), left gluteal fold redness, and right gluteal fold. His bed mobility, transfers were assisted by staff, and he used a wheelchair. Record review of Resident #3's Baseline Care Plan dated 08/30/22 indicated he was setup help only with eating. Resident #3 required one person assist with personal hygiene, toilet use, dressing, bathing, bed mobility, and transfers. He required the use of a wheelchair. Resident #3 current skin integrity issues were bruises and vascular to bilateral LE. Record review revealed Resident #3 did not have a Comprehensive Care Plan. Record review of a Wound Evaluation and Management Summary( Wound Doctor Note) dated 09/07/22 reflected The chief complaint was multiple wounds. He had an unstageable DTI( deep tissue injury) of the right heel for at least 7 days duration. There is light serous drainage. Focused Wound Exam (site 1) Unstageable DTI of right heal partial thickness, Etiology pressure Unstageable DTI within and around the wound with a duration of 7 days, the size of the wound 5cm by 5 cm the surface area is 25cm, exudate was light serous. The dressing plan was hydrogel wafer apply three times per week for 30 days. Plan of care reviewed and addressed with facility staff. The recommendations were to off load wound, reposition per facility protocol, sponge boot, Prevalon boot(cushioned bottom that floats the heel off the surface of the matters. A Sage boot.), Zinc sulphate 220 mg by mouth for 14 days, Vitamin C 500 mg twice daily and multivitamin once daily. Discussed the etiology of wound, offloading, repositioning, prevalon boot, nutrition, vitamin supplementation with treatment nurse Record review of Resident #3 clinical record reveled he did not have a facility physician orders to treat his wounds, and no treatment administration record that indicated his wounds were being treated. He did not have an order for a pressure reducing boot. During an interview on 02/07/23 at 3:20 p.m. the Corporate MDS Nurse said LVN J said they had gotten tags in the past regarding residents not having care plans. The Corporate MDS Nurse said they cannot work any faster to get them caught up. She said they hired one staff and she quit so they have not really had any staff since August 2022, and they are doing the best they can. LVN J said some of the older residents had paper care plans in their paper chart. They are currently updating all the care plans to the system. She said if a resident did not have a care plan in the system and they did not have a paper chart, they did not have a care plan in place. She said Resident #1 and Resident # 3 did not have care plans at the current time. Resident #3 was discharged but they would work on getting Resident #1's care plan completed today. During an interview on 02/07/23 at 4:00 p.m. the ADON and Administrator said they did not have a care plan for Resident #3. The Administrator said they have some paper charts at the nurse's station, and they are working to get all care plans uploaded into their computer system. The ADON said Resident #3 was discharged and he was not on the list for his care plan to be updated. The Administrator said she was aware the facility had care plans that were not current. The administrator said they had some staffing issues with the MDS nurses but hopefully they had staff. During an interview on 02/08/23 9:45 a.m. the ADON said Care plans on Resident #1 was completed last night by the Corporate MDS nurse. She said Residents #3 did not have valid a care plan. Review of the facility policy on Care Plans, Comprehensive Person Center dated December 2016 indicated . A comprehensive, person centered care plan that included measurable objectives and time tables to meet the residents' physical, psychosocial and functional needs is developed and implemented for each resident . The care plan interventions are derived from a through analysis of the information gathered as part of the comprehensive assessment. The facility was notified of the IJ in Comprehensive Care plans on 03/06/23 at 12:00 p.m. via email. The facility provided a plan of removal on 2/11/23 that addressed the development of Baseline Care Plans and Comprehensive Care Plans. [POR for F656 and 692 1. Residents with significant weight variances will be reviewed for RD evaluation, care plan implementation and notification to MD/PCP and responsible party. Corrective actions taken for identified significant weight loss variances (1 month - 5% or greater, 3 months - 7.5% or greater, 6 months - 10% or greater) will include notification to residents PCP/designee and responsible party by nurse management/ designee, care plans will be reviewed by nurse management/designee for weight loss and specific interventions implemented. Resident care plans will be reviewed/revised to include specific interventions for weight loss concerns by MDS Coordinator and/or nursing management. o Initiated: 2/10/23 @ 7:45 AM by DON/RD o Completed: 2/10/23 @ 8:30pm 2. Residents EMR will be reviewed for baseline care plan completion. No residents were identified to need a baseline care plan as a result of the audit. o Initiated: 2/10/23 @ 7:45 AM by DON/ RD. o Completed: 2/10/23 @ 10:45am by MDS Coordinator. 3. The facility DON was provided education by the V.P. of Clinical Operations on the following topics: a) Change in a residents' status - Discussion included review of Change in a Resident's condition or Status Policy & Procedure. Examples of changes in condition and notification expectations to MD/PCP and responsible party. Specific content of the change in a residents condition status policy were reviewed during the discussion. Three sections of this policy referenced significant changes in the resident physical/emotional/mental condition and defined significant change of condition as a major decline or improvement in the residents status that : i. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); ii. Impacts more than one area of the resident's health status; iii. Requires interdisciplinary review and/or revision to the care plan; and iv. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. The policy provided interpretation and implementation guidance for the nurse to record in the residents' EMR information relative to changes in the residents medical/mental condition or status. Refer to attached Policy and Procedure. Other relevant information contained in the policy referenced notification to residents attending physician or physician on call when there had been a need to alter the resident's medical treatment significantly. b) Baseline Care Plan - Discussion of timeframe and procedure for completion. The Baseline care plan policy indicated that a baseline plan of care to meet the resident's immediate needs should be developed for each resident within 48 hrs of admission. The baseline care plan is to assure that the resident's immediate care needs are met and maintained. The policy indicated areas to review to develop the baseline care plan to meet the residents immediate care needs including dietary and physician orders. The baseline care plan will be used until the comprehensive assessment and interdisciplinary person-centered care plan is developed. The policy indicates the process for communicating the baseline care plan summary content to the resident and their representative. The summary content can include resident's medications, dietary instructions, and initial goals of the residents. Refer attached Policy and Procedure. o Initiated: 02/10/23 @ 11:00 pm by V.P. Clinical Operations. o Completed: 02/10/23 @ 11:45 PM by V.P Clinical Operations o Initiated: 02/10/23@ 6:45 AM By V.P. Clinical Operations o Completed: 2/10/23@ 3:00pm a) Baseline Care Plan - The Baseline care plan auto flags in EMR on the Resident's admission assessment. The charge nurse must initiate and complete within 48 hours after admission. Print the Resident's baseline care plan, Order Summary and review with the Resident and/or responsible party. After review the nurse will obtain signature(s) of the resident /responsible party and the nurse is to sign the care plan after completed. Nurse will then place in organizer file for medical records to scan. Refer to Policy and Procedure. o Initiated: 02/10/23 @ 6:45 AM By V.P. Clinical Operations o Completed: 2/10/23 @ 3:00pm by V.P. Clinical Operations The Interdisciplinary care plan team will be provided education by the V.P. of Clinical] On 02/11/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews on 2/11/23 between 5:25 p.m. and 6:41 p.m. facility staff: LVN E 6a to 6p LVN R 6p to 6a CNA S 6a to 2p LVN T 6a to 6p CNAU 10 p to 6 a LVN M 6pto 6a CNA V 2p to 10 p CNA P 2p to 10 p and 10p to 2 a CNA W 2p to 10 p LVN X 6a to 6p Indicated they were knowledgeable regarding the importance of developing and implementing care plans for the administrative staff. They were able to provide information an refer to policies they were educated on during the in-services they received. The administrative staff to include the DON and ADON were knowledgeable as well. The facility also provided an audit of care plans that indicated all care plans were up to date as of 2/10/23. Review of two additional residents care plans indicated care plans were updated. The facility completed and updated care plan of Resident #1 after her return to the facility. The Administrator, DON and ADON, were informed of the Immediate Jeopardy on 3/6/23 at 12:00p.m. The facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from neglect for 2 of 7 residents reviewed for neglect ( Resident #1 and Resident #3). The facility had system failures in that they failed to: 1. Ensure Resident #1 had nutritional interventions in place such as a way to provide nutrition. 2. Ensure Resident #1 had pressure sore interventions in place such as physician notification and treatment of the wounds. 3. Ensure Resident #3 had interventions in place to prevent the development and worsening of pressure sores. 4. Ensure care plans were developed, in place and implemented for Resident #1 and Resident #3's needs. 5. Ensure the dietician was consulted and dietary interventions were in place for Resident #1 that required nutritional interventions of weight loss, and pressure sores for Resident #1 and #3. 6. Ensure physicians were contacted with a change of condition in Resident #1 and a pressure sore for Resident #3. 7. Ensure wound orders and treatments were in place for resident #3. 8. Ensure their policies and procedures regarding nutrition and pressure sores were followed. 9. Ensure residents were assessed timely regarding pressure sores and ensure documentation was accurate regarding the care and services they required for Resident #1 and Resident #3. An Immediate Jeopardy (IJ) situation was identified on 02/13/23 at 6:05 p.m. While the IJ was removed on 02/15/23 at 6:32 p.m., the facility remained out of compliance at actual harm with a potential for more than minimal harm at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for negative outcomes including death. Findings included: Record review of Resident #1's admission record with a print date of 02/07/23 indicated she was an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses were myocardial infarction, muscle weakness, lack of coordination, hypertension, end stage renal disease and hyperlipidemia. Record review of Resident #1's admission MDS dated [DATE] indicated her cognitive status was severely impaired (BIMS score 7). She required extensive assist with bed mobility, dressing, and toilet use of one-person, limited assistant to transfer with one person. Limited assistance with locomotion off the unit of one person. She was able to eat and drink with supervision and setup help only. Record review of Resident #1's baseline care plan dated 8/30/22 indicated she was a setup help only with eating. She required one person assist with personal hygiene, bed mobility, transfer, and toilet use. She used a wheelchair for a mobility device. The care plan indicated she was alert and cognitively intact. She was occasional incontinent of bowel and bladder. Record review on 02/07/23 revealed Resident #1 did not have a comprehensive care plan. Record review of Resident #1's Nutrition Risk, Mini Nutrition assessment dated [DATE] indicated she weighed 150 pounds. She was on dialysis with no nutritional issues noted. Record review of Dysphagia(swallowing difficulty) Consultation dated 01/19/23 indicated meal recommendations for Resident #1. Pleasure comfort feedings of pureed as accepted or tolerated, encourage more upright head posture, employ good oral care, cued cough to help clear upper airways, liquids nectar thick and pills are a choking risk crush medication. Feed slowly and carefully, hand over hand assistance, no straws, resident to be fed small bits and sips. SLP or trained staff only and monitor for adequate nutrition and hydration. On 01/19/23 at 4:31 p.m. Resident #1 received a new order to discontinue regular texture diet and thin liquids start. Texture and nectar thick liquids. recommended pleasure feeding crushed medications small bites sips and foods recommendations were upright body and head positioning. Signed by LVN G. Record Review of Resident #1's MAR for January 2023 indicated Resident #1 received medications on a regular basis until 01/23/23. Review of the MAR indicated the medications were not given because the resident refused, or they were on hold: Aspirin 81 mg one time a day - for myocardial infraction- was not given from 01/23/23 through 01/31/23 Atorvastatin Calcium 40 mg one by mouth at bedtime for Hyperlipidemia- was given 01/26/23 and 01/31/23 only Folic Acid 400 mg one daily for supplement was not given from 01/23/23 through 01/31/23 Isosorbide Mononitrate ER 30 mg one time daily for hypertension she was not given from 01/23/23 through 01/31/23 Sensipar Tablet 30 MG one time daily for renal disease given on 01/26/23 and 01/31/23 only Metoprolol tartrate 25 mg for hypertension was not given from 01/23 through 01/31/23 Novasourse Renal two times daily was given on 01/26/23 and 01/31/23 on the evening shift only Ticagrelor tablet 90 MG two times daily for blood thinner was not given from 01/23 through 01/31/23 Tums tablet chewable 500 MG three times daily for Calcium supplement was given on 01/26/23 and 01/31/23 on the evening shift only. She also received it on 01/30/23 at the 2p.m. Megestrol Acetate 40mg by mouth four times a day for appetite was given on 0//26/23 at 2 p.m. and 9 p.m. and on 01/27/23 at 9:00 p.m. Record Review of Resident #1's MAR for February 2023 indicated she was not given any medications from 02/01/23 through 02/06/23. Her medications were not given because she refused, or they were on hold. Record review of Resident #1's ADL Nutrition sheet (amount eaten) for January 2023 indicated from 01/23/23 through 01/31/23, Resident #1 refused or did not eat except on 01/26/23 and 01/27/23 in the morning she ate 26 to 50 percent. On the evening of 01/25/23 she ate 51 to 75 percent. Record review of Resident #1's ADL Nutrition sheet (amount eaten) for February indicated from 02/01/23 through 02/06/23 the resident refused or did not eat except. On the evening of 02/01/23 the resident ate 26-50 percent on the morning of 02/04/23 resident #1 ate 51 to 75 percent. Record review of the Resident #1's facility's weights indicated: 12/30/22- 146.3 01/04/23- 146.3 1/12/23 - 147.6 1/20/23- 143.2 1/28/23 -137.1 In 3 months, 9.6 percent. In one month, 5.3 percent both significant weight loss. Record review of the last dialysis sheet dated 01/23/23 the facility presented indicated Resident #1's weight was 61.9 kilometers. (136.47 pounds). Record review of an email provided by the DON dated 02/01/23 indicated the email was to the Dietician. The email stated please look at the following residents Resident #1 had a referral for a tube placement. Record Review of nursing notes for February 2023 nursing notes revealed: On 02/01/23 at 8:49 a.m. Resident #1 refused her medications signed by MA H On 02/01/23 at 4:19 p.m. Resident #1 received new order for G-tube placement per the facility physician and the dialysis physician. Pending appointment. On 02/2/23 at 8:02 a.m. Resident #1 refused medications On 2/2/23 at 4:02 p.m. Resident #1 noted with areas to the right buttock and coccyx that appeared to be moisture associated. There was a small amount of serous exudate cleansed from wound, patted dry and applied Hydrocolloid dressing. Referral to Wound care signed by RN F On 02/03/23 at 9:34 a.m. Resident #1 was unable to swallow. Signed by MA H On 02/04/24 at 454 a.m. Resident #1 laying in bed sleeping currently. She is withdrawn. The resident was refusing to eat, refusing to take medication and had an open area noted to her buttocks. Signed by LVN M On 02/04/23 at 10:11 a.m. medications not administered. Resident #1 was unable to swallow. MA H On 02/05/23 at 10:00 a.m. medications not administered. Resident #1 was unable to swallow. MA H On 02/05/23 at 7:43 p.m. medications not administered. Resident #1 was unable to swallow. LVN Q On 02/06/23 at 12:33 a.m. Resident awake in bed. Hydrocolloid dressing intact to coccyx, sacrum area. Pillows in place. Peg tube placement pending. The resident appetite and fluid intake remained poor. The family visited on 02/05/23 and are aware of Resident #1's global decline. The resident continued dialysis three times a week. On 02/06/23 at 11:24 a.m. a call from the dialysis center stating Resident #1 was unstable to receive her treatment, and they were sending her back to nursing home. Signed by LVN E. On 02/06/23 at 11:39 a.m. Resident #1 refused medications. Signed by MA H. Record revie of nursing notes dated 02/06/23 at 11:45 a.m. Resident #1 Returned from dialysis center with flat affect. She did not respond to verbal stimuli but grimaces her face when turned and repositioned. Wounds to buttocks assessed and reported findings to Wound Care Doctor. Verbal orders were received to discontinue hydrocolloid to coccyx nd begin to cleanse coccyx with wound cleaner, pat dry, apply alginate, cover with foam dressing daily. Signed by RN F On 02/06/23 at 11:45 a.m. Resident #1 Returned from the dialysis center with flat affect. She did not respond to verbal stimuli but grimaces her face when turned and repositioned. Wounds to buttocks assessed and reported findings to Wound Care Doctor. Verbal orders were received to discontinue hydrocolloid to coccyx and begin to cleanse coccyx with wound cleaner, pat dry, apply alginate, cover with foam dressing daily. Signed by RN F On 02/06/23 at 12:05 p.m. during visual rounds, Resident #1 appeared lethargic with difficulty arousing. She did not respond to tactile or verbal stimuli. Three failed attempts to collect her blood pressure on the left wrist. Her heart rate was 78, temperature 96.8 and her respirations were 16. The physician was contacted regarding Resident #1's status and verbal orders were received to send her to the ER for evaluation and treatment. Record review of Resident #1 hospital records dated 2/6/23 indicated the resident assessment plan was failure to thrive. The patient had not been eating or drinking for the past week. Would start on gentle fluids resuscitation; the diagnosis likely dehydration and possible starvation. The EMS reported Resident #1 had a constant decline for the past couple of weeks. She last dialysis was two times in the last week. She was too weak to complete the treatment. She had not been taking her medications. The physical exam indicated diagnosis of end stage renal disease related to high blood pressure in 2016. Encephalopathy progressing since 12/20/22 severe dehydration and malnutrition. The emaciated chronically ill female lost 10 kg=22.05 pounds in the past 3 to 4 months in no acute distress. During an interview on 02/07/23 at 11:47 a.m., LVN E said she worked at the facility for 3 years. She said on 02/06/23 dialysis called and said they were unable to complete dialysis on Resident #1 because she was too unstable. LVN E said dialysis said she was too lethargic and sent her back to the facility. She said Resident #1 came back to the facility and was sent to the hospital on 02/06/23. LVN E said the treatment nurse, RN F, was the nurse that assessed Resident #1 and sent her to the hospital. LVN E said she did hear Resident #1 was not eating. She said on 02/07/23, Resident #1 had an appointment to have a feeding tube placed. LVN E said the nurse at the hospital told her on the phone Resident #1 was not a candidate for a feeding tube because she was too weak. She said the staff could not get Resident #1 to eat or drink for a least a week or two. LVN E said Resident #1 was not a DNR and she was not on hospice. She said the family would not change Resident #1's code status. LVN E said she had not personally contacted the physician regarding Resident #1 not eating or drinking. LVN E said the administrative staff were aware Resident #1's condition had declined to not eating anything. During an interview on 02/07/23 at 12:24 p.m. the Administrator said she thought the dialysis clinic sent Resident #1 back to the facility on [DATE] because she refused to allow them to complete dialysis. The Administrator said she knew they had talked to the family about hospice, and the family did not want her to put her on hospice. The Administrator said she thought Resident #1 was supposed to have gotten the feeding tube, 02/07/23. She said Resident #1 was in the hospital, and someone mentioned the hospital said Resident #1 was not a candidate for the feeding tube. The Administrator said she was aware as she could be that Resident #1 was not eating well. She was not familiar with the medical aspect of resident care. During a telephone interview on 02/07/23 at 1:15 p.m., the DON stated she was on leave, at that time, and her last day at work was 02/01/23. The DON the SW from dialysis called and wanted to know if Resident #1 was a DNR. She said the dialysis SW said they were having trouble with Resident #1 tolerating dialysis or receiving full treatment due to her weakness. The Nephrologist recommended putting her on hospice. The DON said the dialysis SW said the family would not consent to Hospice. She said on 02/01/23, the dialysis SW said she received consent from the family, the Nephrologist, and the facility physician for Resident #1 to have feeding tube placed. She said at that time, an appointment was scheduled for a gastrologist to do the feeding tube procedure on 02/07/23. The DON said, as far as she knew, Resident #1 was eating but not a whole lot. She said when Resident #1 ate less than 50 percent, the facility staff would give her a health shake or a sandwich. The DON said there were occasion when Resident #1 was at dialysis and her blood pressure would be too low to perform the procedure, and dialysis had to send Resident #1 back to the facility. During a telephone interview on 02/07/23 at 2:23 p.m., Resident #1's Physician said in the old days a resident could send them straight to the ER to receive a feeding tube. He said now the hospital did not do that any longer. He said they had to schedule an appointment through a GI doctor to get a feeding tube placed. He said they got the first available appointment with GI doctor on 02/07/23. The Physician said potentially, they could have done a nasal gastric tube, but the patient reached and pulled the tube out regularly. He said it would not have done any good to prescribe an appetite stimulate if Resident #1 was not eating at all. He said he did not know until 02/06/23, that Resident #1 was not taking any of her meds and was not able to swallow at all for at least a week. He said if he had known he would have sent her to the hospital, and they would have likely gotten some IV fluids started on Resident #1. The Physician said Resident #1 was having swallowing difficulties before she came to the facility. The facility staff did not tell him Resident #1 was not eating, drinking, or taking her medications. He said what he was told was Resident #1 was not eating well. During an interview on 02/07/23 at 3:20 p.m., LVN J -MDS nurse said Resident #1 did not have a current care plan. She said they were working on getting care plans into the system. LVN J said they had gotten tags in the past regarding residents not having care plans. She said she could not work any faster to get them caught up. She said they hired one staff and she quit so they have not really had any staff since August 2022, and they are doing the best they can. She said some of the older residents had paper care plans in their chart. They are currently updating all the care plans to the system. She said if a resident did not have a care plan in the system and they did not have a paper chart, they did not have a care plan in place. During a telephone interview on 02/07/23 at 3:50 p.m., LVN G said Resident #1 could not eat or swallow anything due to her choking. He said it had been at least a week since she was able to swallow anything. He said they had placed Resident #1 on puree diet the later part if January, and even with diet change she only ate about 25 percent. LVN G said about a week ago an aide told him Resident #1 could not eat, she was choking on her food. He said he had gone down to the room to try and feed Resident #1 himself. He said he tried to get her to eat but she was choking. LVN G said he was able to get her to take half cup thickened liquids, but she had a hard time. He said on the flowing day Resident #1 was just holding food in mouth and not drinking anything. The LVN said he asked the DON and she said they set up an appointment for tube feeding. He said the SW at Dialysis had talked to the dialysis doctor and the facility doctor and receive a go ahead for a feeding tube. LVN G said at the first of January they sent Resident #1 to the hospital and the hospital sent her right back. He said on one occasion he called the NP because Resident #1' BP was really low, and the NP said to just monitor her. The LVN said he reported in the morning meeting, Resident was not eating or drinking. However, he never called the doctor. During an interview on 02/07/23 at 6:04 p.m. LVN M said she worked at the facility for two years. She said Resident #1 was lethargic and weak. She would take Resident #1's vitals, and they were normal. The LVN said most of time, Resident #1's normal BP was low. The LVN said Resident #1 had decline with her eating and was very withdrawn. LVN M said there was nothing alarming that indicated she needed to send Resident #1 to the hospital. LVN M said Resident #1 would take a small amount of liquid. She said that she never called doctor. LVN M said that during shift change DON said to monitor her. During an interview on 02/08/23 at 8:49 a.m., LVN N said she worked at the facility for [AGE] years. She said Resident #1 had an overall decline. She said Resident #1 could still say her name and say she did not want anything to eat, or if she was in pain. LVN N said Resident #1 began pocketing food at one time and not wanting to swallow. She said she had some aides come up and told her Resident #1 was not eating. She said over a week ago she had worked the evening shift and tried to get Resident #1 to drink. She said Resident #1 took a sip and turned her head. LVN N said the MA told her Resident #1 would not swallow meds even when crushed. She said they could not get her to swallow. LVN N said she never called the Physician. She said she worked with Resident #1 a few times she only worked the floor when they were short. The LVN said she had talked to Resident #1's daughter one evening about 3 weeks ago. She said they talked about Resident #1 declining. LVN N said they talked Resident #1's not eating in morning meeting, and getting with the family about her code status, and her decline changes. The hospital records also indicated Resident #1 had multiple wounds. During a telephone interview on 02/08/23 at 11:07 a.m., the NP said she got a message on 2/6/23 that Resident #1 was sent to the hospital. She said she was aware Resident #1 had a decline, and the facility staff were trying to catch up with the family to see if they wanted to put her on hospice. The NP said she did not know that Resident #1 was not taking any of her mediations. The NP said she was aware the resident refused medications on occasion. She said Resident #1 was [AGE] years old and on dialysis, and dialysis was hard on the body. The NP said dialysis was designed to extend the life but not indefinitely; it was only a short term fix. She said Resident #1 had additional heart concerns. The family did not want to stop dialysis or make her a DNR. She said if she had known Resident #1 was not eating or drinking anything, she would have sent her to the hospital. She said she remembered someone contacting her about Resident #1's low blood pressure but her blood pressure ran low. She said if she had known, she would have sent her out sooner. During an interview on 02/09/23 at 11:59 a.m. the Physician said that no one notified him of Resident #1's pressure sore. He said there is a standard order for wound care. However, they usually notify the Wound doctor and she handled things like that. He was not aware Resident #1 had a wound. During an interview on 02/09/23 at 12:10 p.m. Wound Care Doctor said first she heard about Resident #1's wounds was 2/5/23 about 8pm. She said the DON called or texted her and told her Resident #1's wounds were getting worse. The Wound Care Doctor said on Monday, 02/06/23 RN F called and told her Resident #1 had wounds and she told her to put alginate on the wounds. The Wound Care Doctor said she never saw the wounds. During a telephone interview on 02/08/23 at 1:15 p.m. the Dietician recommendation were made in December. She said Resident #1 did not trigger for weight loss. The Dietician said the last weight I have is 143 on 01/20/23 and that was only a two-pound weight loss. The last time I was at the facility was 1/27/23. The Dietician said the DON sent an email that said the Resident #1 was going to be getting a feeding tube not she had weight loss. She said she had access to the system. If the weight was not in the system, she had no way of knowing there was a problem unless someone physically contacted her. She said with a pressure sore she was notified there was a change in condition, and she needed to see the resident for nutritional interventions. During a telephone interview on 2/9/23 at 12:16 p.m. RN F/treatment nurse said Resident #1's pressure sores were first brought to her attention Thursday, 02/02/23 by an aide. She said she sent a message to the resident's physician and put a treatment in place. She said on 02/03/23 when Resident #1 came back from dialysis she reinforced the bandage. She wrote the late entry 02/07/23 because-she had put something in place and wanted it known that she had done her job, even if she had quit. She said when she saw the areas on 02/03/23 they were not really pressure sores. RN F said when she got to work Monday, 02/06/23 the administrator told her the sores were big enough to put her fist in the wound. She said the administrator told her she had seen a picture of the wounds. According to RN F, Resident #1 had 3 stage 2 wounds that measured 2.0 cm by 2.0 cm. RN F said she knew she was not eating because she had to work on the floor as a charge nurse. The Wound Care Doctor and she said they would do good with alginate. She said she was on the floor on 02/06/23 and received a call from dialysis saying they were sending Resident #1 back to the facility because she was too weak to attend the treatments. She assessed her and sent her out to the hospital. RN F said they all knew Resident #1 was not eating for at least a week. LVN G talked about it most every morning in the morning meeting. Resident #3 Record review of Resident #3's Admission record with a print date of 02/07/23 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis was congestive heart failure, respiratory failure, diabetes, high blood pressure kidney disease, and reduced mobility and coordination. The record indicated Resident #3 was discharged on [DATE]. Record review of Resident #3's admission MDS dated ,d+[DATE]//22 indicated his cognitive status was moderately impaired. His bed mobility was extensive assist with two people. His ability to transfer was limited assistance with one person. He was able to walk in the room with the supervisor of one person. Resident #3's functional abilities indicated he required supervision or touching assistance to put on or take off socks and shoes. He required the set-up help of one staff. Record review of Resident #3's Admission assessment dated [DATE] indicated the resident was admitted to the facility from and ALF due to edema to the bilateral LE with high blood pressure. He was alert times 4. Resident #3 had poor balance and unsteady gait. He was continent of bowel and bladder. His skin assessment revealed right inner arm bruising, lower left leg rear vascular, lower right leg vascular, left gluteal fold redness, and right gluteal fold. His bed mobility, transfers were assisted by staff, and he used a wheelchair. Record review of Resident #3's Baseline Care Plan dated 08/30/22 indicated he was setup help only with eating. Resident #3 required one person assist with personal hygiene, toilet use, dressing, bathing, bed mobility, and transfers. He required the use of a wheelchair. Resident #3 current skin integrity issues were bruises and vascular to bilateral LE. Record review indicated Resident #3 did not have a Comprehensive Care Plan. Record review of Resident #3's skin assessment dated [DATE] indicated no skin issues noted. There was no other skin assessments. Record review of Resident #3's MAR and TAR dated September 2022 showed no documentation of pressure sores or any indication of treatments completed. The MAR indicated Resident #3 received Zinc 50 mg, Vitamin C 500 mg, and B complex starting on 09/27/22. the was no indication the Prostat( protein supplement) was given or on the MAR. There were no orders for treatment of Resident #3's wounds. Record review of a Wound Evaluation and Management Summary (Wound Doctor Note) dated 09/07/22 revealed the chief complaint was multiple wounds. Resident #3 had an unstageable DTI of the right heel for at least 7 days duration. The exam for Peripheral Vascular( narrowed blood vessels that reduce blood flow the limbs), examination of left lower extremities with moderate edema and foot warm, examination of the right lower extremities indicated moderate edema(swollen) foot warm, wound present. Pedal pulses( pulse of blood between the big toe and second toe) to left and right dorsalis pedis( pulse on the lateral extensor tendon of the great toe) detected by portable doppler ( ultrasound used to estimate the blood flow through the vessels. Focused Wound Exam (site 1) Unstageable DTI of right heal partial thickness, Etiology pressure Unstageable DTI within and around the wound with a duration of 7 days, the size of the wound 5cm by 5 cm the surface area is 25cm, exudate was light serous( a thing watery fluid that is produced in response to local inflammation.). The dressing plan was hydrogel wafer apply three times per week for 30 days. Plan of care reviewed and addressed. The recommendations were to off load wound, reposition per facility protocol, sponge boot, Prevalon boot (cushioned bottom that floats the heel off the surface of the matters. A Sage boot.), Zinc sulphate 220 mg by mouth for 14 days, Vitamin C 500 mg twice daily and multivitamin once daily. Site two was a venous wound ( wound with abnormal vein function) of the right superior shin partial thickness and site 3 venous wound of the right, inferior shin partial thickness. Record review of Resident #3's Wound Evaluation and Management Summary dated 09/14/22 indicated Wound care assessment and evaluation was performed. Resident #3 had an unstageable DTI of the left posterior, lateral heel and for at least 1 day's duration. There was no exudated. Site 1- Unstageable DTI of the right heel, partial thickness, etiology pressure, size 6 cm by 7 cm the surface area measured 42 cm the duration is greater than 13 days. Wound progression deteriorated. Dressing hydrogel wafer apply three times per week. The plan was off load, reposition per facility protocol. Sponge boot, prevelon boot. Site 4 Unstageable DTI to left posterior, lateral heel, etiology pressure unstageable DTI . size 1.0 x 1.9 dept not measurable treatment plan the same as site 1. Record review of a nursing note dated 9/11/22 at 1:03 p.m. indicated Resident #3 continued with skilled services for strengthening and conditioning. He continued with wound treatment to the right heel. The resident required assistance with transfers to the bathroom, all needs met at that time. signed by LVN G. (the only nursing note that mentioned wound care.) Record review of Physical Therapy note dated 09/15/22 indicated nursing advised PT Resident #3 should not ambulate any more due to the opening of wound on right heel. Bed mobility was performed. Resident #3 regressed overall due to the wound on the right heel, continued with PT as advised by nursing and Wound Care Doctor. Record review of Physical Therapy notes dated indicated 09/16/22 Resident #3 stated that he felt weak and tired but would try to do his best. Bed mobility performed. Resident #3 was regressing with all mobility tasks since the worsening of wound on right heal. Record review of Occupational Therapy notes indicated on 09/16/22 Resident #3 verbalized pain that limited his functional activities. The resident required increased assistance with ADL performance. Resident #3 said the pain exacerbates with standing. The resident described that pain with movement as 5/10, constant in the heel. With increased aching. Nursing notified and discussed sending the patient to the hospital due to change in condition. Record Review of Resident #3's hospital records dated 09/16/22 indicated hospital problems were the Primary Right Foot Infection with acute kidney disease. His diagnosis acute renal failure, unspecified, pressure injury of skin of right foot, unspecified injury stage. This [AGE] year-old presented to the emergency department due to generalized weakness and right foot wound. The patient stated generalized weakness for about 3 months and progressively worsening. The patient stated chronic right heel wound. The patient was without redness, and no drainage to the right foot wound the wound was covered and had a compressive boot. Resident #3 arrived form nursing home with inflatable heel boot to relieve pressure. Labs revealed acute kidney injury with creatinine elevated from base line. All labs were review on 09/16/22 at 2:13 p.m. acute coronary syndrome, pneumonia, urinary tract infection, deconditioning, anemia, electrolyte disturbance, pulmonary embolism, COPD , asthma, foot wound, foot ulcer, osteomyelitis, sepsis and congestive heart failure. Patient with bilateral foot wound right with dusky black appearance noted at the right heel. The patient with DP Pt pulse in bilateral legs. Patient able to move legs at will. No sensory deficit. Motor strength 5 out of 5 for bilateral lower extremities. Record review of Resident #3's hospital Discharge Course dated 09/26/22 indicated Resident #3 resided at the nursing facility came to the hospital with right diabetic foot wound. Resident #3 received IV antibiotics during the hospital stay along with two debridement's. His medical status gradually worsened during the hospital stay. Resident #3 had a poor prognosis given his advanced age, and diagnoses. Resident #3 was discharged with hospice services. During record review and interview on 02/13/23 at 3:00 p.m., the DON could not find a physician order or treatments for pressure sores on the TAR for Resident #3's pressure sore. During record review and interview on 02/13/23 at 3:15 p.m. the Director of Clinical Informatics reviewed Resident #3's computer and paper file. She said she did not find a physician order or treatments on the TAR for Resident #3's pressure sore. During an interview on 02/09/23 at 11:59 a.m., the Physician said there was a standard order for wound care. He said staff do not normally notify him of wound or pressure sore issues. He said he did not get wound care calls much with the Wound Care Doctor in place. They usually notified the Wound doctor and she handled the wounds. During an interview on 02/13/23 at 3:49 p.m., the Wound Care Doctor said when she did her rounds at the facility, she always had a nurse with her. She said she was reviewing her notes on Resident #3 for 09/14/22. The Wound Care Doctor said she did recommendations. She did not write actual orders. Her recommendation for Resident #3's unstageable be treated with hydrogel waver three times a week. She said with treatment and offloading it should have healed. She said the Venous ulcers would have resolved if they had been offloaded with or without treatment. She said when she saw

Based on interview and record review the facility failed to immediately consult with the resident's physician when there was significant change in the resident's physical, mental, or psychosocial status for 2 of 7 residents reviewed for notification of changes. (Resident #1 and #3) The facility failed to notify the resident's physician when resident #1 stopped eating or taking medications for about 10 days. The facility failed to notify the resident's physician when Resident #1 and #2 developed pressure sores. An Immediate Jeopardy (IJ) situation was identified on 02/10/23 at 4:14 p.m. While the IJ was removed on 02/11/23 at 7:22 p.m., the facility remained out of compliance at actual harm with a scope of a isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems This failure could place residents at risk of their physicians not being aware of the resident conditions and delay treatments for the resident conditions. Findings included: Record review of Resident #1's admission record with a print date of 02/07/23 indicated she was an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses were myocardial infarction (heart attack), muscle weakness, lack of coordination, hypertension, end stage renal disease and hyperlipidemia. Record review of Resident #1's admission MDS dated [DATE] indicated her cognitive status was severely impaired (BIMS score 7). She required extensive assist with bed mobility, dressing, and toilet use of one-person, limited assistant to transfer with one person. Limited assistance with locomotion off the unit of one person. She was able to eat and drink with supervision and setup help only. There was no significant change MDS. Record review of Resident #1's computerized Physician orders indicated on 1/19/23 a puree diet, pureed texture, nectar consistency. An order dated 12/07/22 for Novasourse Renal two times daily. Record review of Dysphagia(difficulty swallowing) Consultation dated 01/19/23 indicated meal recommendations for Resident #1. Pleasure comfort feedings of pureed as accepted or tolerated, encourage more upright head posture, employ good oral care, cued cough to help clear upper airways, liquids nectar thick and pills are a choking risk crush medication. Feed slowly and carefully, hand over hand assistance, no straws, resident to be fed small bits and sips. SLP or trained staff only and monitor for adequate nutrition and hydration. Record Review of Resident #1's MAR for January 2023 indicated Resident #1 received medications on a regular basis until 01/23/23. Review of the MAR indicated the medications were not given due to the resident refused, or they were on hold. Aspirin 81 mg one time a day - for myocardial infarction- was not given from 01/23/23 through 01/31/23 Atorvastatin Calcium 40 mg one by mouth at bedtime for Hyperlipidemia- was given 01/26/23 and 01/31/23 only Folic Acid 400 mg one daily for supplement was not given from 01/23/23 through 01/31/23 Isosorbide Mononitrate ER 30 mg one time daily for hypertension she was not given from 01/23/23 through 01/31/23 Sensipar Tablet 30 MG one time daily for renal disease given on 01/26/23 and 01/31/23 only Metoprolol tartrate 25 mg for hypertension was not given from 01/23/23 through 01/31/23 Novasource Renal two times daily was given on 01/26/23 and 01/31/23 on the evening shift only Ticagrelor tablet 90 MG two times daily for blood thinner was not given from 01/23/23 through 01/31/23 Tums tablet chewable 500 MG three times daily for Calcium supplement was given on 01/26/23 and 01/31/23 on the evening shift only. She also received it on 01/30/23 at the 2p.m. Megestrol Acetate 40mg by mouth four times a day for appetite was given on 01/26/23 at 2 p.m. and 9 p.m. and on 01/32/23 at 9:00 p.m. Record review of Resident #1's ADL Nutrition sheet (amount eaten) for January 2023 indicated from 01/23/23 through 01/31/23 Resident #1 refused or did not eat except on 01/26/23 and 01/27/23 in the morning she ate 26 to 50 percent. On the evening of 01/25/23 she ate 51 to 75 percent. Record Review of Resident #1's MAR for February 2023 indicated from 02/01/23 through 02/06/23 indicated she was not given any medications. Her medications were not given because she refused, or they were on hold. Record review of Resident #1's ADL Nutrition sheet (amount eaten) for February 2023 indicated from 02/01/23 through 02/06/23 the resident refused or did not eat except on the evening of 02/01/23 the resident ate 26-50 percent and on the morning of 02/04/23 resident #1 ate 51 to 75 percent. Record review of Resident #1's hospital records dated 2/6/23 indicated the resident assessment plan was failure to thrive, the patient had not been eating or drinking for the past week. The plan was to start on gentle fluids resuscitation the diagnosis likely dehydration and possible starvation. The EMS reported Resident #1 had a constant decline for the past couple of weeks. She last dialysis was two times ago. She was too weak to have the procedure. She had not been taking her medications. The physical exam indicated diagnosis of end stage renal disease related to high blood pressure in 2016. Encephalopathy progressing since 12/20/22 severe dehydration and malnutrition. The emaciated chronically ill female lost 10 kg=22.05 pounds in the past 3 to 4 months in no acute distress. Record review on 02/07/23 revealed Resident #1 did not have a comprehensive care plan. Record Review of Resident #1's clinical record indicated no physician notification of her status for not for eating, or taking meds. During an interview on 02/07/23 at 11:47 a.m. LVN E said she worked at the facility for 3 years. LVN E said on 02/06/23 dialysis called and said they were unable to complete dialysis because Resident #1 too unstable. LVN E said Dialysis said she was too lethargic and sent her back to the facility. LVN E said Resident #1 came back to the facility and was sent to the hospital on 02/06/23. LVN E said the treatment nurse RN F was the nurse that assessed Resident #1 and sent her to the hospital. LVN E said she did hear Resident #1 was not eating. She said on today, 02/07/23 Resident #1 had an appointment to have a feeding tube placed. LVN E said the nurse at the hospital told her on the phone Resident #1 was not a candidate for a feeding tube because she was too weak. LVN E said they could not get Resident #1 to eat or drink for at least a week or two. LVN E said Resident #1 was not a DNR and she was not on hospice. She said the family would not change Resident #1's code status. LVN E said she had not personally contacted the physician regarding Resident #1 not eating or drinking. LVN E said the administrative staff were aware Resident #1's condition had declined to the resident not eating anything. During a telephone interview on 02/07/23 at 2:23 p.m. Resident #1's Physician said in the old days a resident could send them straight to the ER to receive a feeding tube. He said now the hospital did not do that any longer. He said they had to schedule an appointment through a GI doctor to get a feeding tube placed. He said they got the first available appointment with GI doctor on 02/07/23. He said it would not have done any good to prescribe an appetite stimulant if Resident #1 was not eating at all. He said he did not know until yesterday, 02/06/23 that Resident #1 was not taking any of her meds and was not able to swallow at all for at least a week. He said if he had known he would have sent her to the hospital, and they would have likely gotten some IV fluids started on Resident #1. The Physician said Resident #1 was having swallowing difficulties before she came to the facility. The facility staff did not tell him Resident #1 was not eating, drinking, or taking her medications. He said what he was told was Resident #1 was not eating well until she was sent to the hospital on 02/06/23. During a telephone interview on 02/07/23 at 3: 50 p.m. LVN G said Resident #1 could not eat or swallow anything due to her choking. He said it had been at least a week since she was able to swallow anything. He said they had placed Resident #1 on puree diet the later part if January, and even with diet change she only ate about 25 percent. LVN G said about a week ago an aide told him Resident #1could not eat, she was choking on her food. He said he had gone down to the room to try and feed Resident #1 himself. He said he tried to get her to eat but she was choking. LVN G said he was able to get her to take a half cup of thickened liquids, but she had a hard time. He said on the following day Resident #1 was just holding food in her mouth and not drinking anything. The LVN said he asked the DON and she said they set up an appointment for tube feeding. He said the SW at Dialysis had talked to the dialysis doctor and the facility doctor and received a go ahead for a feeding tube. LVN G said at the first of January they sent Resident #1 to the hospital and the hospital sent her right back. He said on one occasion he called the NP because Resident #1's BP was really low, and the NP said to just monitor her. The LVN said he reported in the morning meeting for at least the last week that Resident was not eating or drinking. However, he never called the doctor. During an interview on 02/07/23 at 6:04 p.m. LVN M said she worked at the facility for two years. She said Resident #1 was lethargic and weak. She would take Resident #1s vitals, and they were normal. The LVN said most of time Resident #1's normal BP was low. The LVN said Resident #1 had declined with her eating and was very withdrawn. LVN M said there was nothing alarming that indicated she needed to send Resident #1 to the hospital. LVN M said Resident #1 would take a small amount of liquid. She said that she never called the doctor. LVN M said that during shift change the DON said to monitor her. During an interview on 02/08/23 at 8:49 a.m. LVN N said she worked at the facility for [AGE] years. She said Resident #1 had an overall decline. She said Resident #1 could still say her name and say she did not want anything to eat, or if she was in pain. LVN N said Resident #1 began pocketing food at one time and not wanting to swallow. She said she had some aides come up and told her Resident #1 was not eating. She said over a week ago she had worked the evening shift and tried to get Resident #1 to drink. She said Resident #1 took a sip and turned her head. LVN N said the MA told her Resident #1 would not swallow meds even when crushed. She said they could not get her to swallow. LVN N said she never called the Physician. She said she worked with Resident #1 a few times and she only worked the floor when they were short. The LVN said she had talked to Resident #1's family member one evening about 3 weeks ago. She said they talked about Resident #1 declining. LVN N said they talked about Resident #1's not eating in morning meeting, and getting with the family about her code status, and her decline changes. The hospital records also indicated Resident #1 had multiple wounds. Record review of Resident #1's Weekly Skin Observation dated 02/7/23 indicated a it was a full assessment for 02/03/23 indicated Resident #1 had MASD (moistures associated skin damage) on the sacrum that measured 2 by 2 by 0.1 And MASD to the right gluteal fold that measured 2 by 2 by 0.1. Hydrocolloid dressing in place, the skin is fragile noted to upper and lower buttocks referred to wound care. Record review of Resident #1's computerized physicians order for 01/15/23 through 02/15/23 indicated an order dated 01/26/23 at 6 p.m. indicated Zinc ointment to sacrum every shift and as needed. On an order dated 02/07/23 at 6:00 p.m. to cleanse left sacral wound #3 with wound cleanser, pat dry apply alginate and foam dressing daily. Cleanse right sacral wound #2 with wound cleanser, pat dry apply alginate and foam dressing daily. Cleanse superior scar wound #1 with wound cleanser, pat dry, apply alginate and foam dressing daily. Record review of hospital records dated 2/7/23 at 3:10 p. m. indicated Resident #1 had a wound care consult due to multiple wounds. She had a deep tissue injury to the sacrum that measured 9 cm by 12 cm by 0.1 cm. she had a right thigh posterior deep tissue injury that was 2 cm by 10 cm by 0.1. cm. During a telephone interview on 02/09/23 at 11:59 a.m. Resident #1's Physician said that no one notified him of Resident #1's pressure sore. He said there is a standard order for wound care. However, they usually notify the Wound doctor and she handled things like that. He was not aware Resident #1 had a wound. During an interview on 02/09/23 at 12:10 p.m. the Wound Care Doctor said first she heard about Resident #1's wounds was 2/5/23 about 8pm. She said the DON called or texted her and told her Resident #1's wounds were getting worse. The Wound Care Doctor said on Monday, 02/06/23 RN F called and told her Resident #1 had wounds and she told her to put alginate on the wounds. The Wound Care Doctor said she never saw the wounds. During a telephone interview on 2/9/23 at 12:16 p.m. RN F/treatment nurse said Resident #1's pressure sores were first brought to her attention Thursday, 02/02/23 by an aide. She said she sent a message to the resident 's physician and put a treatment in place. She said on 02/03/23 when Resident #1 came back from dialysis she reinforced the bandage. She wrote the late entry 02/07/23 because she had put something in place. She said when she saw the areas on 02/03/23 they were not really pressure sores. RN F said when she got to work Monday, 02/06/23 the administrator told her the sores were big enough to put her fist in the wound. She said the administrator told her she had seen a picture of the wounds. According to RN F Resident #1 had 3 stage 2 wounds that measured 2.2 cm by 2/2 cm. RN F said she knew she was not eating because she was on the floor. Wound Care Doctor and she said they would do good with alginate. She said she was on the floor on 02/06/23 and received a call from dialysis saying they were sending Resident #1 back to the facility because she was too weak to attend the treatments. She assessed her and sent her out to the hospital. RN F said they all knew Resident #1 was not eating LVN G talked about it most every morning in the morning meeting. Resident #3 Record review of Resident #3's Admission record with a print date of 02/07/23 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis was congestive heart failure, respiratory failure, diabetes, hypertension, kidney disease, and reduced mobility and coordination. The record indicated Resident #3 was discharged on [DATE] with 17 days stay to an acute hospitalization . Record review of Resident #3's Admission assessment dated [DATE] indicated the resident was admitted to the facility from an ALF due to edema( swelling) to the bilateral LE with high blood pressure. He was oriented to time, place and situation. Resident #3 had poor balance and unsteady gait. He was continent of bowel and bladder. His skin assessment revealed right inner arm bruising, lower left leg rear vascular, lower right leg vascular, left gluteal fold redness, and right gluteal fold. His bed mobility, transfers were assisted by staff, and he used a wheelchair. Record review of Resident #3's Baseline Care Plan dated 08/30/22 indicated he was setup help only with eating. Resident #3 required one person assist with personal hygiene, toilet use, dressing, bathing, bed mobility, and transfers. He required the use of a wheelchair. Resident #3's current skin integrity issues were bruises and vascular to bilateral LE. Record review indicated Resident #3 did not have a Comprehensive Care Plan. Record review of Resident #3's clinical record revealed he saw the Wound Care Doctor on two occasions. However, there was no facility physician doctor's order, facility assessment, or facility treatment documentation of the wound. Record review of Resident #3's Wound Evaluation and Management Summary dated 09/14/22 indicated Wound care assessment and evaluation was performed today. Resident #3 had an unstageable DTI of the left posterior, lateral heel and for at least 1 day's duration. There is no exudated. Site 1- Unstageable DTI of the right heel, partial thickness, etiology pressure, size 6 cm by 7 cm the surface area measured 42 cm the duration is greater than 13 days. Wound progression deteriorated. Dressing hydrogel wafer apply three times per week. The plan was off load, reposition per facility protocol. Sponge boot, prevelone boot. Site 4 Unstageable DTI to left posterior, lateral heel, etiology pressure unstageable DTI . size 1.0 x 1.9 dept not measurable treatment plan the same as site 1. Record Review of Resident #3's hospital records dated 09/16/22 indicated hospital problems were the Primary Right Foot Infection with acute kidney disease. His diagnosis acute renal failure, unspecified, pressure injury of skin of right foot, unspecified injury stage. This [AGE] year-old presented to the emergency department due to generalized weakness and right foot wound. The patient stated generalized weakness for about 3 months and progressively worsening. The patient stated chronic right heel wound. The patient was without redness, and no drainage to the right foot wound the wound was covered and had a compressive boot. Resident #3 arrived form nursing home with inflatable heel boot to relieve pressure. Labs revealed acute kidney injury with creatinine elevated from base line. All labs were review on 09/16/22 at 2:13 p.m. acute coronary syndrome, pneumonia, urinary tract infection, deconditioning, anemia, electrolyte disturbance, pulmonary embolism, COPD , asthma, foot wound, foot ulcer, osteomyelitis, sepsis and congestive heart failure. Patient with bilateral foot wound right with dusky black appearance noted at the right heel. The patient with DP Pt pulse in bilateral legs. Patient able to move legs will. No sensory deficit. Motor strength 5 out of 5 for bilateral lower extremities. Record review of Resident #3's hospital Discharge Course dated 09/26/22 indicated a past history of coronary artery disease, chronic systolic heart failure, stage 3 chronic kidney disease, essential hypertension, prostate cancer, hyperlipidemia who currently resided at the nursing facility came to the hospital with right diabetic food wound. Resident #3 received IV antibiotics during the hospital stay along with two debridement's. His medical status gradually worsened during the hospital sta. Resident #3 had a poor prognosis given his advanced age, and diagnoses. Resident #3 was discharged with hospice services. During record review and interview on 02/13/23 at 3:00 p.m. the DON could not find a physician order or treatments for pressure sores on the TAR for Resident #3's pressure sore. During record review and interview on 02/13/23 at 3:15 p.m. the Director of Clinical Informatics reviewed Resident #3's computer and paper file. She said she did not find a physician order or treatments on the TAR for Resident #3's pressure sore. Record review of Resident #3's clinical record did not reveal any physician notification or physician orders for wound care. During a telephone interview on 02/09/23 at 11:59 a.m. Resident #3's Physician said there is a standard order for wound care. He said staff do not normally notify him of wound or pressure sore issues. He said he did not get wound care calls much with the Wound Care Doctor in place. They usually notify the Wound doctor, and she handled the wounds. During an interview on 02/13/23 at 3:49 p.m. the Wound Care Doctor said when she did her rounds at the facility, she always had a nurse with her. She said she was reviewing her notes on Resident #3 for 09/14/22 The Wound Care Doctor said she did recommendations. She did not write actual orders. Her recommendation for Resident #3's unstageable was hydrogel wafer three times a week. She said with treatment and offloading and it should have healed. The Wound Care Doctor said the Venous ulcers would have resolved if they had been offloaded with or without treatment. She said when she saw Resident #3 on 09/14/22 one of the venous ulcers had resolved. She said her treatment recommendations for both heels, were hydrogel wafer Unstageable. 3 times a week. She also recommended pressure relieving boot and the number one goal is to keep the foot off loaded. The Wound Care Doctor said she did not remember the resident not having a dressing on his wounds when she saw hm. She said there was no reason for her to think his treatments were not completed as recommended. This was determined to be an Immediate Jeopardy (IJ) on 02/10/23 at 4:15 p.m. The facility Administrator, DON, VP of Clinical Operations, and Director of Clinical Informatics were notified. The Administrator was provided with the IJ template on 02/10/23 at 4:15 p.m. The plan of removal was accepted on 02/11/23 at 1:46 p.m. Please accept the following plan of removal for F580-Notify of Changes: 1. Notify V.P. of Clinical Operations of immediate Jeopardy status - o Completed - 02/10/23 @ 4:00pm 2. Notify Regional Director of operations of Immediate Jeopardy status - o Completed - 02/10/23 @ 4:15pm per V.P. of Clinical Operations 3. Notify facility Medical Directors of Immediate Jeopardy status- o Completed - Both notified on 02/10/23 @ 4:35 PM/ 4:50 PM by DON. 4. Resident #1 was transferred to an appropriate medical setting on 02/06/23 for evaluation and treatment. Resident #1 remains hospitalized at the time of this report. 5. Residents' weights will be reviewed for completion and any significant variances identified. o Initiated: 02/10/23@ 5:00 AM by DON. o Completed: 2/10/23 @ 10:15am by Registered Dietician. 6. Residents with significant weight variances (1 month - 5% or greater, 3 months- 7.5% or greater, 6 months-10% or greater) will be identified by DON/designee. MD/PCP and responsible party will be notified. If the resident's MD/PCP does not respond the charge nurse will notify the medical director. o Initiated: 2/10/23 @ 7:45 AM by DON/RD o Completed: 2/10/23 7. The facility DON was provided education by the V.P. of Clinical Operations on the following topics: a) Change in a residents' status - Discussion included review of Change in a Resident's condition or Status Policy & Procedure. Examples of changes in condition and notification expectations to MD/PCP and responsible party. Specific content of the change in a resident's condition status policy were reviewed during the discussion. Three sections of this policy referenced significant changes in the resident physical/emotional/mental condition and defined significant change of condition as a major decline or improvement in the resident's status that: i. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); 11 . Impacts more than one area of the resident's health status; iii . Requires interdisciplinary review and/or revision to the care plan; and iv. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. The policy provided interpretation and implementation guidance for the nurse to record in the residents' EMR information relative to changes in the residents medical/mental condition or status. Refer to attached Policy and Procedure. Other relevant information contained in the policy referenced notification to residents attending physician or physician on call when there had been a need to alter the resident's medical treatment significantly. b) Charting and Documentation - Discussed expectations for completion of nursing documentation in Resident EMR and use of facility 24-Hour report to identify residents with changes in condition /status to facilitate communication and continued monitoring. Refer to Policy and Procedure. c) Implementation of Physician Orders/Appointments - Discussed importance of communication with MD/PCP on order content and any concerns with appointment dates. Appointment process changed for nurses to make and coordinate appointments. d) If the resident's MD/PCP does not respond the charge nurse will notify the medical director. o Initiated: 02/10/23 @ 11:00 pm by V.P. Clinical Operations o Completed: 02/10/23 @ 11:45 PM by V.P Clinical Operations 8. Licensed Nursing Staff will be provided education by the DON/Designee on the following topics: Change in a resident's Condition or Status - The Nurse will promptly notify the Resident's MD/PCP and responsible party of changes in the Resident's medical/mental condition and/or status. i. Examples of change in condition: Incident, weight loss, pressure injuries {new or worsened), refusal of medications or treatments, difficulty 'swallowing, decreased food and fluid intake, skin concerns, pain not relieved by medications or other interventions, critical lab values, vital signs not in baseline range for the Resident, abnormal diagnostic results, change in diet or liquid and significant change consistency change in resident's physical, mental or psycho-social status and /or adverse reactions to medications and /or significant treatments. ii. The facility will utilize the following weight loss parameters to identify significant weight loss variances (1 month - 5% or greater, 3 months- 7.5% or greater, 6 months-10% or greater) that will be monitored by nursing management for notification to residents MD/PCP and responsible party. iii. If the resident's MD/PCP does not respond the charge nurse will notify the medical director. iv. Refer to Policy & Procedure . o Initiated: 02/10/23@ 6:45 AM By V.P. Clinical Operations o Completed: 2/10/23 @ 3:00pm Charting and Documentation-The Nurse is to complete documentation in the Resident's EMR to indicate Nursing evaluation/assessment findings, notification to PCP and responsible party, interventions and orders and response to treatments/interventions. New orders, incidents, appointments, and changes in Resident's condition will be placed on the 24-Hour Report to facilitate communication and continued monitoring. Residents with diet modifications will be monitored by licensed nurses for responses to diet modifications and recorded in the residents' EMR. Any concerns related to the new diet modifications will be communicated to PCP by licensed nursing staff. The nurse will continue to monitor and document on the residents indicated on the 24-Hour report until Nursing Management indicates resident no longer needs follow up monitoring. Refer to Policy and Procedure. o Initiated: 02/10/23@ 6:45 AM By V.P. Clinical Operations o Completed: 2/10/23@ 3:00pm by V.P. Clinical Operations 9. Staff who were not on duty will be notified to come to the facility for education by the DON/designee. No staff will be allowed to work on the floor until education have been completed. o Administrator, DON, and MDS Coordinator will monitor for employee completion of required education topics o Administrator, DON, MDS Coordinator and HR Director will conduct audits of current facility employees and indicate completion dates for required education. Staff are being notified to report to facility for education completion via phone and texts. o Notifications started on 02/09/23 @ 8:00AM and are continuing 02/10/23. o Administrator and DON will continue to audit, notify and provide education items until all employees have completed the requirement. o Initiated: 02/10/23@ 6:45 AM By V.P. Clinical Operations o Completed: 2/10/23@ 3:00pm by V.P. Clinical Operations 10. Facility Administrator and the DON were provided education on compliance and monitoring procedures by the V.P of Clinical Operations.] On 02/11/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews on 2/11/23 between 5:25 p.m. and 6:41 p.m. facility staff: LVN E 6a to 6p LVN R 6p to 6a CNA S 6a to 2p LVN T 6a to 6p CNAU 10 p to 6 a LVN M 6pto 6a CNA V 2p to 10 p CNA P 2p to 10 p and 10p to 2 a CNA W 2p to 10 p LVN X 6a to 6p Record review of in services and staff interviews indicated they were knowledgeable regarding identifying residents with a change in condition and when to notify the physician. They were able to provide information and refer to policies they were educated on during the in-services they received. The administrative staff to include the DON and ADON were knowledgeable as well. The Administrator, DON and ADON, were informed the Immediate Jeopardy was removed on 02/11/23 at 7:22 p.m. The facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accidents (Resident #2.) The facility failed to ensure Resident #2 was properly secured into her wheelchair during transport. The van seat belt did not hold the Resident in place when the brakes of the van were applied. Resident #2 slid out of the wheelchair resulting in a broken tibia(shin bone) and fibula(calf bone) which continued to caused her pain weeks later. The facility failed to provide documentation staff were properly trained prior to the incident on how to secure residents for transport. The facility failed to ensure a new van did not have any issues with the seatbelt prior to transportation of a resident that had upper body and lower body impairment. This failure could place residents that are transported on the facility van at risk for harm. Findings included: Record review of Resident #2's face sheet with a print date of 02/07/23 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Unspecified fracture of shaft of left fibula, unspecified fracture of the lower end of left tibia dated 01/26/23 she also had diagnosis of diabetes, protein calorie malnutrition, anemia, hypertension heart with chronic kidney failure, lack of coordination, Surgical amputation, and legal blindness. Record review of Annual MDS dated [DATE] indicated her cognitive status was intact (BIMS score of 15.) The MDS indicated Resident #2 required extensive assistance with bed mobility of two people, she was totally dependent with transfers and required two-person assistance. The resident required total dependence for locomotion in her room, and she was totally dependent with one person assistance. Record review of Resident #2's care plan dated 02/03/23 indicated she had a problem of ADL self-care performance deficit related to right above the knee amputation, cognitive deficit, and legally blind. The resident required mechanical lift and total assistance of staff with transfers. The resident required extensive assistance by staff to turn and reposition in bed. Resident #2 had a problem of limited physical mobility related to right above the knee amputation, new fracture of the left tibia and fibula. Revised on 02/06/23. The resident is No-weight bearing. Resident #2 had a problem of being on pain medication related to neuropathy and new fractures of left ankle. The interventions were to monitor for pain, side effects, and effectiveness of medications. Record review of Resident #2's computerized physician orders for 01/05/23 through 02/05/23 indicated Resident #2 had an order for Hydrocodone -Acetaminophen 5-325 mg with an active date of 01/29/23. An order for Tylenol 325 mg. An order for 1/4 side rails for increased mobility and repositioning with an active date of 6/28/22. An order for fall precautions with an active date of 06/24/22. Record review of an incident report dated 1/26/23 indicated a report was received by transportation aide that Resident #2 slid on the floor of the transport vehicle. The resident was unable to be lifted and placed back into the wheelchair by staff members and EMS was summoned and the resident taken to the hospital. Review of a hospital x ray report dated 01/26/23 at 2:15 p.m. indicated x-ray of left ankle 3 views. The impression was severe osteopenia ( lower than normal bone mass or bone density), left tibia fracture through the distal fibula, which appears essentially nondisplaced. Record review of Resident #2's MAR for January 2023 indicated she had orders for tramadol HCL 50 mg to give by mouth every 6 hours as needed for moderate pain. The MAR indicated she did not receive it during the month of January. An order for Tylenol tablet 325 give two tabs every 6 hours for pain. The MAR indicated she received it on 01/27/23, 01/30/23 and 01/31/23. Record Review of a nursing note dated 01/26//23 at 5:35 p.m. indicated Resident #2 arrived at the facility by emergency transportation. She was in stable condition, alert and oriented to person, place, and condition her left leg was splinted and elevated for comfort. The resident reported general discomfort with the left LE with movement. She denied an at rest. The resident said she received tramadol at the hospital, and it remained effective at this time. Record review of Resident #2's MAR for February 2023 indicated she did not receive the Tramadol or Tylenol during February. She had an order for Hydrocodone- acetaminophen 5-325 mg one tablet by mouth every 6 hours as needed for pain. The MAR indicated she received it 10 times between 02/01/23 to 02/07/23. Record review of the facility provider report dated 01/26/23 indicated statements form the resident, and staff involved. It contained in-services for the transportation staff CNA C and CNA D on wheelchair and rider securement procedures and checklists, securing a wheelchair for van transport, and a You Tube video on proper securement of residents on vans in wheelchairs. There was no documentation provided that indicated CNA D was trained on the procedures prior to 01/26/23. During an interview on 02/07/23 at 10:39 am. CNA B said Resident #2 had a fall on the van. She said Resident #2 complained of pain after the fall and continued to complain of pain since the fall. During an interview on 02/07/23 at 11:00 a.m. Resident #2 said that she was in pain. Resident #2 said she remembered that she was on the van, they did not buckle her in. They were going down the street and the van stopped suddenly. Her feet went up and so did the wheelchair. She said after that she did not know what happened except, she was on the floor in pain. The EMS came and got her off the floor and took her to the hospital. She said she was in pain now. During an interview on 02/07/23 at 11:10 a.m. CNA C said on 01/26/23 when Resident #2 fell on the van, they were not using the regular van. It was a van they had inherited from a sister facility, and the van only held one person at a time. She said the wheelchair did not have a seat belt only the van seat belt was in question. There was also no place for staff to sit in the back with the resident. CNA C said she knew Resident #2 said she did not have a seat belt on because she had told everyone she did not. CNA C said Resident #2's wheelchair was strapped down before she got to the van, and Resident #2 had the van seat belt buckled over her lap. CNA C said the strap was not on Resident #2. CNA C said CNA D was driving the van and she was just the ride along for assistance with Resident #2. Resident #2 had seat belt across the waist. She said Resident #1 rocked back and forth. She had asked her to stop and normally when she is able to ride in the back with her,. CNA C said she would be able to pat on Resident #2 and calm her down enough to get her to stop rocking. However, on this trip there was not enough room in the back of the van for her to sit close to Resident #2. They stopped at the light and according to CNA C it was not a sudden stop. The wheelchair did not move. CNA C said the van seat belt must have loosened and Resident #2 slid under the seat belt to the floor. She said Resident #2 only had one leg and it was hurt during the incident. CNA C said CNA D had to keep going to get out of the intersection. They got out and tried to go into the back of the van but was blocked by the wheelchair. Resident #2's back was resting against the chair. CNA C said Resident #2's leg turned to the side. She kept saying her back she did not say her leg. During an interview on 02/07/23 at 11:28 a.m. CNA D said she was the van driver one and a half years ago, and the facility did not currently have a van driver. She said she received training on operation of the van and van transportation of residents in the past. She filled in for the driver, and her current [NAME] was staffing coordinator. She said the van was new to the facility, but she had driven it a few times that week. CNA D said on 1/26/23 she loaded Resident #2 on the van and used the anchor system and anchored down her wheelchair. CNA D said she locked the chair and did the slid test. Tried to slide the wheelchair back and forth to make sure it was secure. CNA D said she put the van waist belt seat belt on Resident #2. She did not use the shoulder restraints. It would not go all the way across. CNA D said Resident#2 had a tic or something. She would rock way forward almost to her knees, with hands together, rocking back and forth. CNA D said Resident #2 was rocking so far forward she could not see her in the rear mirror. She said she and CNA C asked Resident # 2 to stop rocking but she did not. CNA D said Resident #2 was on a Hoyer lift pad, and the pad tends to slide a little. When she stopped at a red light Resident #2 slid out of the wheelchair to the floor. CNA D said she had to maneuver out of traffic and wait until safe to pull off the road. According to CNA D Resident #2 did not have very much room to fall, and her back was up against the wheelchair seat. CNA D said the way Resident #2 was positioned in the back of the van on the floor. They had to take the wheelchair out so she could lean on the side of the van. The seat belt was still clasped but it was loose. She said CNA C called 911 and she called the DON. The van was like a minivan and could only carry one wheelchair. She said CNA C would usually sit in the back with Resident #2 but there was no room. CNA D said seat belt was still closed but had become loose. CNA D said she put the seat belt on Resident #2 and tightened it. However, somehow it was loose enough for Resident #2 to slide under. She said it could have been because she was rocking, but it was not supposed to do that. CNA D said they still do not have a van driver, but she had not driven the van since 1/26/23. They were using an outside company for transportation of residents. During an interview on 02/07/23 at 11:47 a.m. LVN E said today was the first day she had worked with Resident #2 in a while. She said Resident #2 complained of pain in her back and leg. During a telephone interview on 02/07/23 at 12:01 pm. the VP of Clinical Operations said the Physical plant director of their company did an inspection of the van that was involved in the incident on 01/26/23. She said the facility took the van to a place where it was purchased for them to inspect as well. The VP said they took the van out of commission. They have not transported anyone via facility van since 01/26/23. They had contracted an outside company do the transports at this time. During an interview on 02/07/23 at 12:24 p.m. the Administrator said they received a van from a sister facility on 1/19/23 and had a mechanical inspection completed to be able to put insurance on the van. She said 01/23/23 was the first time they had used that van, and there were no incidents until 01/26/23. The Administrator said since the incident occurred on 1/26/23 with Resident #2 they had not transported residents to their appointments. They had used an outside company for resident transport to appointments. She said they wanted to make sure the van was safe for transport before using it again. They had sent the van to the manufacture to make sure there was no malfunctioning of the wheelchair attachments. The Administrator said the van driver walked out in January and they used CNA D to drive the van because she had been trained and that was her former position. The Administrator said a spokesman for the company said it would not have made a difference if had used a shoulder strap or not, they needed a personal seatbelt on the wheelchair in order to hold the person in the seat. The Administrator said that CNA C and CNA D said in statements Resident #2 had on seat belt, and she had interviewed them twice. She said they both received in-services and had video training specific for the van. The Administrator said Resident #2 said she was not buckled in but both staff said that she was. She said the seat belt was composed of two separate parts with one for the waist and one for the shoulder. The Administrator said CNA D said she had not used the shoulder strap because it did not fit right, it would have come across the resident's face. During an observation and interview on 02/07/23 at 4:55 the AIT said he had taken the facility van today to have it checked out by the manufacturing company. He said the technician said there was nothing wrong with the van. Observation of the van showed there was only room for one wheelchair in the back. There were four tie downs for the wheels of the wheelchair and a waist seat belt. There was an attachment for the shoulder strap that attached to the waist restraint. The AIT revealed a clasp on the seat belt used to loosen and tighten the seat belt. He said apparently the belt had become loose somehow during transport of Resident #2. The AIT showed how if the clasp was pressed on both ends the seat belt would loosen. During an interview on 02/07/23 at 5:15 p.m. Resident #2 she was a little Shakey at first about riding in a van. She said she did not blame anyone for falling out of the chair, it was just an accident. During an interview on 02/07/23 at 6:04 p.m. LVN M said Resident #2 was in more pain since she fell on the van. She said the only thing Resident #2 had for to take for pain was tramadol. LVN M said she got an order for hydrocodone for pain, because Resident #2 needed something stronger. During an interview on 02/08/23 at 8:49 a.m. LVN N said she worked at the facility for [AGE] years. She said Resident #2 complained of more pain since the van accident. During an interview on 02/08/23 at 3:00 p.m. the Administrator said she could not find the training for that showed where CNA D was trained. She said the manufacturer said there was nothing wrong with the securement belt. She said the AIT said Resident #2 could have put her arms under the belt and could have loosened the belt. She said something occurred that should not have. The Administrator said they have suspended transporting residents. During an interview on 02/09/23 at 10:00 a.m. the Administrator said they do not have a policy for who should and should not ride the van. She said they have discussed the issue but had not taken it to QA meeting as of yet. QA had not met this month. During an interview on 02/09/23 at 11:40 a.m. the COTA director of therapy said Resident #2 did not like exercise or to get out of bed. She had been screened several times but always refused therapy. The COTA said because Resident #2 had fallen on 01/26/23 they had screened her again and she refused. She said Resident #2 did have trunk control issues in that she rocked her upper body back and forth when she was out of bed which was not often. She said Resident #2 rocked as a comfort measure. The COTA said Resident #1 had only one leg and did not use it to walk or propel herself. During an telephone interview on 2/15/23 11:31 a.m. a family member said Resident #2 was still in pain. They said she was having pain in her back and her ankle as well. They said Resident #2 went to the doctor yesterday and set her up to see a pain management doctor. The family member said they knew the facility staff said they had buckled Resident #2 into the seat that day. However, his family member did not lie. They said Resident #2 said they did not buckle her into the wheelchair.

Based on observation, interview, and record review, the facility did not ensure all treatment and care was provided to residents, based on the comprehensive assessment of the resident and in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents reviewed for quality of care. (Resident #1) The facility did not monitor an open wound on Resident #1's sacral area daily and did not accurately assess the resident's wound. The facility did not prevent the development and worsening of Resident #1's sacral wound. The resident developed an open moisture associated wound on her sacral area that was initially identified as pressure ulcers on 8/31/20. Staff noticed drainage and odor from the wound prior to the resident being discharged to the hospital. The resident had a stage 3 pressure ulcer on her sacral area upon admission to the hospital. This failure could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries. Findings included: A face sheet dated 9/17/2020 indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. She was discharged [DATE]. An MDS assessment dated [DATE] indicated Resident #1 had moderate cognitive impairment, was dependent on two staff for bed mobility, transfers, dressing, and was dependent on one staff for toilet use. She was always incontinent of bowel and bladder. She was at risk for developing pressure ulcers and had no identified pressure ulcers present on this assessment. A departmental note dated 8/31/2020 written by LVN B indicated Resident #1 had a new wound identified as a stage 2 pressure ulcer on her coccyx and a stage 1 pressure ulcer on her right upper buttock. The note indicated the wound was staged by the MDS nurse (an RN) and the wound care nurse was made aware and assessed the wound. During an interview on 9/17/2020 at 5:25 p.m., RN G said she observed Resident #1's wounds on 8/31/2020. She said the wound on Resident #1's sacrum was small, and the wound bed had no top skin layer, which was why she staged it as a stage 2 pressure ulcer. She said the wound on Resident #1's buttock was small with intact skin and was red, non-blanchable, which is why she staged it at a stage 1 pressure ulcer. She said she did not document her measurements of the resident's pressure ulcers and that the treatment nurse was responsible for getting the treatment orders. During an interview on 9/18/2020 at 10:20 a.m., the DON said she expected wound measurements to be documented when obtained for new wounds or any reassessed wounds. She said measurements should have been documented on Resident #1's pressure injury when it was discovered on 8/31/2020. A departmental note written by the treatment nurse dated 9/1/2020 indicated Resident #1 had a new order for a wound care physician to evaluate and treat her wounds. The coccyx wound was noted to be pink and moist with over 80% yellow slough and moderate amount of serosanguinous drainage noted. A new treatment was ordered to apply calcium alginate to the wound bed and cover with a dry protective dressing. The right buttock wound was noted to be dry with yellow tissue to the center and was to be treated with zinc ointment daily and as needed after incontinent care. A care plan dated 9/2/2020 indicated Resident #1 had a moisture associated wound to her left upper buttocks and on 9/9/2020 it combined to her sacral wound. A care plan dated 9/2/2020 indicated Resident #1 had a moisture associated wound to her sacrum with interventions including treatment to the area per her physician orders, observe and document any signs of infection, and re-evaluate the wound at least every 2 weeks for appropriateness of treatment orders if no signs of healing was noted. The care plan indicated the resident would be turned and repositioned at least every 2 hours to alleviate pressure, use padding to prevent skin/skin contact, and incontinent care would be provided every 2 hours and as needed. The care plan indicated the resident would be referred to the wound care physician and the dietician. An initial wound evaluation and management summary report dated 9/2/2020 from the wound care physician indicated Resident #1 had a wound to her sacrum that was present over 3 days duration. It showed signs of healing and was 4.5cm x 3.5cm x 0.1 cm. It had light serous drainage with 70% dermis (skin) present (open wound, not intact skin). She had a wound to her left upper buttock that was present over 3 days duration. It showed signs of a healing moisture associated skin damage and was 0.4cm x 0.6cm x 0.1cm with light serous drainage. A wound healing progress report for Resident #1 completed by the treatment nurse indicated on 9/2/2020 her moisture associated wound on her sacrum was identified and measured 4.50cm x 3.50cm. On 9/9/2020, her wound measured 4.0cm x 5.0cm. During an interview on 9/16/2020 at 1:24 p.m., the wound care physician said Resident #1 had a macerated moisture associated wound to her bottom/sacral area. She said when she last observed it on 9/9/20, the wound did not show any signs of infection and she described it as wet skin with rivers or folds in the skin. A departmental note written by the treatment nurse dated 9/3/2020 indicated Resident #1 was seen by the wound care physician and the current treatment to the resident's wounds were discontinued. The note indicated a new treatment for [REDACTED]. Both areas were noted with light serosanguinous drainage with the peri-wound skin intact. Resident #1's sacrum wound was noted with 70% dermis skin and the left upper buttocks was noted with 100% dermis skin. A skin inspection report dated 9/4/20 for Resident #1 indicated on 9/4/2020 her skin was not intact with an existing wound. No other description of the wound was noted. A wound evaluation and management summary report dated 9/9/2020 from the wound care physician indicated Resident #1's wound to her sacrum was present over 10 days duration. It showed signs of healing and was 4.0cm x 5.0cm x 0.1 cm. It had light serosanguinous drainage with 70% dermis present. Her wound to her left upper buttock was combined with her sacrum wound presenting as one wound. A departmental note dated 9/10/2020 indicated Resident #1 was seen by the wound care physician. The note indicated the wound to her left upper buttock combined with the sacral wound to present as one wound. A treatment was ordered to cleanse the wound with wound cleanser, pat dry, and apply a foam silicone border dressing 3 times a week and as needed. The note indicated the moisture associated wound to Resident #1's sacrum had deteriorated in size since last assessment. Physician orders [REDACTED].#1 had an order started 9/11/2020 to cleanse a moisture associated wound on her sacrum with wound cleanser, pat dry, and apply a silicone foam border dressing 3 times a week and as needed. A weekly skin inspection report for Resident #1 dated 9/1/2020-9/17/2020, indicated on 9/4/2020 her skin was not intact with an existing wound. On 9/11/2020 her skin was not intact with an existing wound. No other details were present on the report. The 24-hour reports for 200 hall on 9/11/2020 indicated Resident #1 moved from the 400 hall to the 200 hall. The 24-hour reports for 200 hall from 9/11/2020-9/14/2020 did not indicate Resident #1 had wounds. The treatment records for September 2020 indicated Resident #1 received her ordered treatment of [REDACTED]. A Transfer Summary Report [REDACTED]. The report indicated she was receiving preventative skin care, but the report did not describe the resident's current wound status. During an interview on 9/16/2020 at 2:41 p.m., LVN A said she was the nurse taking care of Resident #1 when the resident was sent to the hospital. She said she sent her to the hospital because of her change of status in respirations and cognition. She said she had not been eating or drinking well. She said she was not aware Resident #1 had wounds. During an interview on 9/16/2020 at 1:30 p.m., the treatment nurse said she performed Resident #1's treatment prior to her being sent to the ER. She said the wound was not open like a pressure ulcer would be. During an interview on 9/17/2020 at 1:59 p.m., CNA E said Resident #1's wound had an odor coming from it. She said the treatment nurse was aware of the odor. She said she assisted the treatment nurse with the wound change on 9/14/2020 and there was drainage on the dressing. She said she was not able to see the wound during the treatment. During an interview on 9/17/2020 at 1:50 p.m., CNA D said she took care of Resident #1 on the day she was transferred to the ER. She said she knew Resident #1 had a small wound on her bottom but had never seen the wound because of it being covered with a dressing. She said they were in-serviced to keep Resident #1 off her back unless she was eating. A hospital record dated 9/15/2020 indicated Resident #1 had a sacral stage 3 pressure ulcer that was present on admission. A wound care consult was ordered. A hospital wound care consult dated 9/16/2020 indicated Resident #1 had a 5 to 6 cm unstageable sacral pressure ulcer with eschar present. A plan was initiated for the consulting physician to be notified when Resident #1 was more stable to undergo surgery for [REDACTED]. During an interview on 9/16/2020 at 12:58 p.m., Resident #1's family member indicated she was transferred to the local ER because of a change in condition. He said the ER staff changed Resident #1's brief within an hour of her arriving to the hospital where they discovered she had a large open wound on her bottom. He said he was not aware of the wound or when it started. He said the hospital was wanting to do surgery on the wound but was not sure if she could survive the surgery. During an interview on 9/16/2020 at 3:28 p.m., the COTA said Resident #1 had a change of condition that started 9/11/2020. She said the treatment nurse had come in on 9/14/2020 and told her she needed to document on the wound, so she could notify the wound doctor of some changes, but she was unsure if she treated the wound. She said she reported to CNAs who were present (but she could not recall who) that the wound was smelling but staff told her they were handling it. During an interview on 9/17/2020 at 10:33 a.m., CNA C said she cared for Resident #1 when she was on 400 hall, and she had not noticed an odor to the wound but had seen the dressing saturated with drainage before. She said the dressing had obvious drainage on it and it was not urine or feces. During an interview on 9/17/2020 at 11:15 a.m., the treatment nurse said she was never notified of Resident #1's wound having any odors. She said the wound had gotten bigger but was not open like a pressure ulcer or showing signs of infection. During an interview on 9/17/2020 at 2:32 p.m., the DON said she expected any changes in wounds to be documented and reported to the resident's physician and responsible party. She said if a resident had an odorous wound it should be documented and followed up on. During an interview on 9/17/2020 at 3:04 p.m., RN F said she was the charge nurse the weekend before Resident #1 was sent out. She said she did not remember Resident #1's wounds being reported to her and did not know Resident #1 had wounds. She said she did not observe Resident #1's skin over the weekend. She said she performs wound care if the nurses ask her to, otherwise the nurses are responsible for performing scheduled wound care. During an interview on 9/17/2020 at 4:24 p.m., CNA D said she provided Resident #1 with a bed bath on 9/14/2020. She said the dressing was intact to Resident #1's sacral region. She said the nurse did tell her they changed the dressing later that day. She said the CNAs were not told if a resident had any wounds. During an interview on 9/17/2020 at 4:30 p.m., LVN A said she was not told Resident #1 had a wound and it was not on the 24-hour report sheet the staff used to communicate needs on. She said she expected to be informed of any resident wounds by the treatment nurse. She said if she would have known about Resident #1's wound, she would have observed the wound and the dressing during her shifts. During an interview on 9/17/2020 at 4:39 p.m., the treatment nurse said she was not responsible for staging pressure injuries (ulcers) because she was an LVN. She said a facility RN staged Resident #1's original pressure ulcer on 8/31/2020. She said the wound care physician saw Resident #1 on 9/2/2020 and changed the wound on her coccyx from a pressure injury to MASD because it was not on a pressure point. She said the staff originally put zinc on it, which was why the wounds were not open or yellow when observed by the wound care physician. She said she documented wound changes on the day of the scheduled skin assessment and not when new areas developed. She said during the second week of September, Resident #1's wounds on her sacral area and buttock came together on the sacrum because of deterioration. She said Resident #1's skin was moist and had small cracks in it from being moist. She said the facility did not initiate a low air loss mattress because the wound was not a pressure wound. She said on 9/14/2020, Resident #1's wound had open cracks in it, but nothing alarmed her, and she did not see any signs of it being a pressure wound. She said if a resident had wounds they were to stay on the 24-hour report and be documented on until it was resolved. During an interview on 9/17/2020 at 5:05 p.m., the DON said she expected documentation on the 24-hour report to be continued for 72 hours for new wounds. She said she expected the direct care staff assigned to the residents to be aware of any wounds and be observant of those issues. She said she expected the treatment nurse to understand the sacrum area was a pressure area. She said the treatment nurse was trained in wound care. She said if an area was identified on the skin inspection report, then an assessment on the visual body map and the wound assessment report should be made on the same day. The DON said she did not see the wound. During an interview on 9/18/2020 at 10:05 a.m., the treatment nurse said she did not go through formal training when she took the treatment nurse position last month. She said she had resources she could refer to if she needs them for wounds. She said the facility would refer a resident to the wound care physician if a wound was believed to be a pressure injury. An undated facility policy titled Charting and Documentation indicated: .1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records .6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment An undated facility policy titled Prevention of Pressure Ulcers/Injuries indicated: .4. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries .b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc,); Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e/ Reposition resident as indicated on the care plan . An undated facility policy titled Pressure Ulcers/Injuries Overview indicated: .Pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. Pressure ulcer/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue . Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown or tan in color; and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist; can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed . Stage 2 pressure ulcer: Partial-thickness skin loss with exposed dermis .granulation tissue, slough and eschar are not present . Stage 2 Pressure Ulcer: full-thickness skin loss- the stage 3 pressure ulcer appears as full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or escar may be visible but does not obscure the depth of tissue loss The National Pressure Injury Advisory Panel (NPIAP) accessed at https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf on 9/29/2020 indicated: .Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury The NPIAP form titled Pressure Injury Prevention Points accessed at https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/1a._pressure-injury-preventi.pdf on 9/30/20 indicated: .Inspect the skin at least dailyfor signs of pressure injury, especially nonblanchable [DIAGNOSES REDACTED] .

Based on observation, interview, and record review, the facility did not ensure treatment was provided, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing for 1 of 6 residents reviewed for pressure injuries (ulcers). (Resident #1) The facility did not prevent the development and worsening of an open wound on Resident #1's sacral area. The resident developed an open moisture associated wound on her sacral area that was initially identified as pressure ulcers on 8/31/20. Staff noticed drainage and odor from the wound prior to the resident being discharged to the hospital. The facility was not monitoring the area daily to ensure the prevention of a stage 3 pressure ulcer. The resident had a stage 3 pressure ulcer on her sacral area upon admission to the hospital. The facility did not monitor the resident's sacral wound and did not accurately assess the resident's wound. This failure could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries. Findings included: A face sheet dated 9/17/2020 indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. She was discharged [DATE]. An MDS assessment dated [DATE] indicated Resident #1 had moderate cognitive impairment, was dependent on two staff for bed mobility, transfers, dressing, and was dependent on one staff for toilet use. She was always incontinent of bowel and bladder. She was at risk for developing pressure ulcers and had no identified pressure ulcers present on this assessment. A departmental note dated 8/31/2020 written by LVN B indicated Resident #1 had a new wound identified as a stage 2 pressure ulcer on her coccyx and a stage 1 pressure ulcer on her right upper buttock. The note indicated the wound was staged by the MDS nurse (an RN) and the wound care nurse was made aware and assessed the wound. During an interview on 9/17/2020 at 5:25 p.m., RN G said she observed Resident #1's wounds on 8/31/2020. She said the wound on Resident #1's sacrum was small, and the wound bed had no top skin layer, which was why she staged it as a stage 2 pressure ulcer. She said the wound on Resident #1's buttock was small with intact skin and was red, non-blanchable, which is why she staged it at a stage 1 pressure ulcer. She said she did not document her measurements of the resident's pressure ulcers and that the treatment nurse was responsible for getting the treatment orders. During an interview on 9/18/2020 at 10:20 a.m., the DON said she expected wound measurements to be documented when obtained for new wounds or any reassessed wounds. She said measurements should have been documented on Resident #1's pressure injury when it was discovered on 8/31/2020. A departmental note written by the treatment nurse dated 9/1/2020 indicated Resident #1 had a new order for a wound care physician to evaluate and treat her wounds. The coccyx wound was noted to be pink and moist with over 80% yellow slough and moderate amount of serosanguinous drainage noted. A new treatment was ordered to apply calcium alginate to the wound bed and cover with a dry protective dressing. The right buttock wound was noted to be dry with yellow tissue to the center and was to be treated with zinc ointment daily and as needed after incontinent care. A care plan dated 9/2/2020 indicated Resident #1 had a moisture associated wound to her left upper buttocks and on 9/9/2020 it combined to her sacral wound. A care plan dated 9/2/2020 indicated Resident #1 had a moisture associated wound to her sacrum with interventions including treatment to the area per her physician orders, observe and document any signs of infection, and re-evaluate the wound at least every 2 weeks for appropriateness of treatment orders if no signs of healing was noted. The care plan indicated the resident would be turned and repositioned at least every 2 hours to alleviate pressure, use padding to prevent skin/skin contact, and incontinent care would be provided every 2 hours and as needed. The care plan indicated the resident would be referred to the wound care physician and the dietician. An initial wound evaluation and management summary report dated 9/2/2020 from the wound care physician indicated Resident #1 had a wound to her sacrum that was present over 3 days duration. It showed signs of healing and was 4.5cm x 3.5cm x 0.1 cm. It had light serous drainage with 70% dermis (skin) present (open wound, not intact skin). She had a wound to her left upper buttock that was present over 3 days duration. It showed signs of a healing moisture associated skin damage and was 0.4cm x 0.6cm x 0.1cm with light serous drainage. A wound healing progress report for Resident #1 completed by the treatment nurse indicated on 9/2/2020 her moisture associated wound on her sacrum was identified and measured 4.50cm x 3.50cm. On 9/9/2020, her wound measured 4.0cm x 5.0cm. During an interview on 9/16/2020 at 1:24 p.m., the wound care physician said Resident #1 had a macerated moisture associated wound to her bottom/sacral area. She said when she last observed it on 9/9/20, the wound did not show any signs of infection and she described it as wet skin with rivers or folds in the skin. A departmental note written by the treatment nurse dated 9/3/2020 indicated Resident #1 was seen by the wound care physician and the current treatment to the resident's wounds were discontinued. The note indicated a new treatment for [REDACTED]. Both areas were noted with light serosanguinous drainage with the peri-wound skin intact. Resident #1's sacrum wound was noted with 70% dermis skin and the left upper buttocks was noted with 100% dermis skin. A skin inspection report dated 9/4/20 for Resident #1 indicated on 9/4/2020 her skin was not intact with an existing wound. No other description of the wound was noted. A wound evaluation and management summary report dated 9/9/2020 from the wound care physician indicated Resident #1's wound to her sacrum was present over 10 days duration. It showed signs of healing and was 4.0cm x 5.0cm x 0.1 cm. It had light serosanguinous drainage with 70% dermis present. Her wound to her left upper buttock was combined with her sacrum wound presenting as one wound. A departmental note dated 9/10/2020 indicated Resident #1 was seen by the wound care physician. The note indicated the wound to her left upper buttock combined with the sacral wound to present as one wound. A treatment was ordered to cleanse the wound with wound cleanser, pat dry, and apply a foam silicone border dressing 3 times a week and as needed. The note indicated the moisture associated wound to Resident #1's sacrum had deteriorated in size since last assessment. Physician orders [REDACTED].#1 had an order started 9/11/2020 to cleanse a moisture associated wound on her sacrum with wound cleanser, pat dry, and apply a silicone foam border dressing 3 times a week and as needed. A weekly skin inspection report for Resident #1 dated 9/1/2020-9/17/2020, indicated on 9/4/2020 her skin was not intact with an existing wound. On 9/11/2020 her skin was not intact with an existing wound. No other details were present on the report. The 24-hour reports for 200 hall on 9/11/2020 indicated Resident #1 moved from the 400 hall to the 200 hall. The 24-hour reports for 200 hall from 9/11/2020-9/14/2020 did not indicate Resident #1 had wounds. The treatment records for September 2020 indicated Resident #1 received her ordered treatment of [REDACTED]. A Transfer Summary Report [REDACTED]. The report indicated she was receiving preventative skin care, but the report did not describe the resident's current wound status. During an interview on 9/16/2020 at 2:41 p.m., LVN A said she was the nurse taking care of Resident #1 when the resident was sent to the hospital. She said she sent her to the hospital because of her change of status in respirations and cognition. She said she had not been eating or drinking well. She said she was not aware Resident #1 had wounds. During an interview on 9/16/2020 at 1:30 p.m., the treatment nurse said she performed Resident #1's treatment prior to her being sent to the ER. She said the wound was not open like a pressure ulcer would be. During an interview on 9/17/2020 at 1:59 p.m., CNA E said Resident #1's wound had an odor coming from it. She said the treatment nurse was aware of the odor. She said she assisted the treatment nurse with the wound change on 9/14/2020 and there was drainage on the dressing. She said she was not able to see the wound during the treatment. During an interview on 9/17/2020 at 1:50 p.m., CNA D said she took care of Resident #1 on the day she was transferred to the ER. She said she knew Resident #1 had a small wound on her bottom but had never seen the wound because of it being covered with a dressing. She said they were in-serviced to keep Resident #1 off her back unless she was eating. A hospital record dated 9/15/2020 indicated Resident #1 had a sacral stage 3 pressure ulcer that was present on admission. A wound care consult was ordered. A hospital wound care consult dated 9/16/2020 indicated Resident #1 had a 5 to 6 cm unstageable sacral pressure ulcer with eschar present. A plan was initiated for the consulting physician to be notified when Resident #1 was more stable to undergo surgery for [REDACTED]. During an interview on 9/16/2020 at 12:58 p.m., Resident #1's family member indicated she was transferred to the local ER because of a change in condition. He said the ER staff changed Resident #1's brief within an hour of her arriving to the hospital where they discovered she had a large open wound on her bottom. He said he was not aware of the wound or when it started. He said the hospital was wanting to do surgery on the wound but was not sure if she could survive the surgery. During an interview on 9/16/2020 at 3:28 p.m., the COTA said Resident #1 had a change of condition that started 9/11/2020. She said the treatment nurse had come in on 9/14/2020 and told her she needed to document on the wound, so she could notify the wound doctor of some changes, but she was unsure if she treated the wound. She said she reported to CNAs who were present (but she could not recall who) that the wound was smelling but staff told her they were handling it. During an interview on 9/17/2020 at 10:33 a.m., CNA C said she cared for Resident #1 when she was on 400 hall, and she had not noticed an odor to the wound but had seen the dressing saturated with drainage before. She said the dressing had obvious drainage on it and it was not urine or feces. During an interview on 9/17/2020 at 11:15 a.m., the treatment nurse said she was never notified of Resident #1's wound having any odors. She said the wound had gotten bigger but was not open like a pressure ulcer or showing signs of infection. During an interview on 9/17/2020 at 2:32 p.m., the DON said she expected any changes in wounds to be documented and reported to the resident's physician and responsible party. She said if a resident had an odorous wound it should be documented and followed up on. During an interview on 9/17/2020 at 3:04 p.m., RN F said she was the charge nurse the weekend before Resident #1 was sent out. She said she did not remember Resident #1's wounds being reported to her and did not know Resident #1 had wounds. She said she did not observe Resident #1's skin over the weekend. She said she performs wound care if the nurses ask her to, otherwise the nurses are responsible for performing scheduled wound care. During an interview on 9/17/2020 at 4:24 p.m., CNA D said she provided Resident #1 with a bed bath on 9/14/2020. She said the dressing was intact to Resident #1's sacral region. She said the nurse did tell her they changed the dressing later that day. She said the CNAs were not told if a resident had any wounds. During an interview on 9/17/2020 at 4:30 p.m., LVN A said she was not told Resident #1 had a wound and it was not on the 24-hour report sheet the staff used to communicate needs on. She said she expected to be informed of any resident wounds by the treatment nurse. She said if she would have known about Resident #1's wound, she would have observed the wound and the dressing during her shifts. During an interview on 9/17/2020 at 4:39 p.m., the treatment nurse said she was not responsible for staging pressure injuries (ulcers) because she was an LVN. She said a facility RN staged Resident #1's original pressure ulcer on 8/31/2020. She said the wound care physician saw Resident #1 on 9/2/2020 and changed the wound on her coccyx from a pressure injury to MASD because it was not on a pressure point. She said the staff originally put zinc on it, which was why the wounds were not open or yellow when observed by the wound care physician. She said she documented wound changes on the day of the scheduled skin assessment and not when new areas developed. She said during the second week of September, Resident #1's wounds on her sacral area and buttock came together on the sacrum because of deterioration. She said Resident #1's skin was moist and had small cracks in it from being moist. She said the facility did not initiate a low air loss mattress because the wound was not a pressure wound. She said on 9/14/2020, Resident #1's wound had open cracks in it, but nothing alarmed her, and she did not see any signs of it being a pressure wound. She said if a resident had wounds they were to stay on the 24-hour report and be documented on until it was resolved. During an interview on 9/17/2020 at 5:05 p.m., the DON said she expected documentation on the 24-hour report to be continued for 72 hours for new wounds. She said she expected the direct care staff assigned to the residents to be aware of any wounds and be observant of those issues. She said she expected the treatment nurse to understand the sacrum area was a pressure area. She said the treatment nurse was trained in wound care. She said if an area was identified on the skin inspection report, then an assessment on the visual body map and the wound assessment report should be made on the same day. The DON said she did not see the wound. During an interview on 9/18/2020 at 10:05 a.m., the treatment nurse said she did not go through formal training when she took the treatment nurse position last month. She said she had resources she could refer to if she needs them for wounds. She said the facility would refer a resident to the wound care physician if a wound was believed to be a pressure injury. An undated facility policy titled Charting and Documentation indicated: .1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records .6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment An undated facility policy titled Prevention of Pressure Ulcers/Injuries indicated: .4. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries .b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc,); Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e/ Reposition resident as indicated on the care plan . An undated facility policy titled Pressure Ulcers/Injuries Overview indicated: .Pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. Pressure ulcer/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue . Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown or tan in color; and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist; can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed . Stage 2 pressure ulcer: Partial-thickness skin loss with exposed dermis .granulation tissue, slough and eschar are not present . Stage 2 Pressure Ulcer: full-thickness skin loss- the stage 3 pressure ulcer appears as full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or escar may be visible but does not obscure the depth of tissue loss The National Pressure Injury Advisory Panel (NPIAP) accessed at https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf on 9/29/2020 indicated: .Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury The NPIAP form titled Pressure Injury Prevention Points accessed at https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/1a._pressure-injury-preventi.pdf on 9/30/20 indicated: .Inspect the skin at least dailyfor signs of pressure injury, especially nonblanchable [DIAGNOSES REDACTED] .

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 6 residents reviewed for accidents. (Resident #1) The facility did not prevent Resident #1 who had a history of [REDACTED]. Resident #1 was found approximately 50-100 feet away from the facility driveway on the shoulder of a busy highway where the speed limit was 60 miles per hour and no sidewalks. The facility was not aware the resident was missing until the social worker arrived at the facility. An Immediate Jeopardy (IJ) situation was determined to have existed on 6/21/2020 to 7/7/20. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of accidents, injury, or death. Findings included: A face sheet dated 6/21/2020 indicated Resident #1 was [AGE] years old, was admitted [DATE], and had [DIAGNOSES REDACTED]. An elopement risk assessment dated [DATE] indicated Resident #1 was identified as an elopement risk. A quarterly MDS dated [DATE] indicated Resident #1 was moderately impaired cognitively, wandered daily during the look back period, and required supervision of one staff for locomotion off of her unit. A care plan updated 6/13/2020 indicated Resident #1 would wander at times. The interventions included to monitor the resident's whereabouts frequently, encourage resident to not go outside unsupervised, and have a wander guard system in place. An elopement risk book kept at the nurses' station indicated Resident #1 and 9 other residents were identified as elopement risks. A safe smoking evaluation dated 6/21/2020 indicated Resident #1 must be supervised by staff, volunteer, or family member at all times when smoking. A staff assignment sheet dated 6/21/2020 indicated CNA A was responsible for the 11:00 a.m. smoking break. A witness statement completed by the staffing coordinator dated 6/21/2020 indicated she brought Resident #1 outside for a smoke break at the front of the building where CNA A was waiting. The statement indicated she placed Resident #1's wheelchair next to CNA A and prior to re-entering the building the staffing coordinator reminded CNA A to extinguish Resident #1's cigarette. The statement indicated she was unaware Resident #1 was left outside after the break. A witness statement completed by the SW dated 6/21/2020 indicated she was driving to work when she located Resident #1 on the shoulder of the highway in front of the facility in her wheelchair. The statement indicated she pulled over and notified the facility of the resident being on the side of the highway and she stayed with Resident #1 until staff came to retrieve the resident. A departmental note dated 6/21/2020 indicated Resident #1 was located by the social worker (SW) on the highway by the facility and the staff retrieved the resident and performed an assessment. The resident was placed on 15-minute checks. During an interview on 7/10/20 at 3:22 p.m., the administrator said Resident #1 was discharged with family shortly after the incident on 6/21/20. She said Resident #1 eloped to the end of the driveway and she was about 6 feet from a major highway. The administrator said anyone at the facility's entrance could see the end of driveway and if a resident was at end of driveway staff would be able to see them. She acknowledged no staff knew Resident #1 had eloped until they received a phone call from the SW stating Resident #1 eloped. During an interview on 7/10/20 at 3:32 p.m., LVN B said she was a nurse and did not actually see what happened, she said she was returning from her break on 6/21/20 and was parking her car during the incident. She said Resident #1 was a known wanderer and should have been supervised. During an interview on 7/10/20 at 3:35 p.m., CNA C said herself, CNA A and LVN B were the three staff outside with the residents during smoke break. She said there were several other residents outside. She said on the day of the incident a staff member had returned to facility with ice cream that had started melting and requested CNA A to take the ice cream inside and put away in freezer. CNA C said she punched in the door code for CNA A to go inside since her hands were full. She said CNA A proceeded inside and did not make any other staff aware that she was leaving the smoke area or the residents. CNA C said while she was at the door, another supervisor requested she go remove a brief from a resident's room, so she also went inside the facility and left the residents outside unattended. She said she did not notify other staff to watch the residents for her. She said during the time when Resident #1 eloped from the smoking area, no staff were present. She said she was not aware Resident #1 eloped until the SW called and notified the facility. During an observation and interview on 7/15/2020 at 8:50 a.m., the administrator said CNA A was the one responsible for the residents on the 11:00 a.m. smoke break. She said at the time of the elopement, the facility's line of sight was obscured due to the placement of the facility van and the support columns on the awning. She said at the time Resident #1 was found, there were no staff outside. She said Resident #1 was discharged home with family on 6/24/2020 because she ultimately wanted to go home. She said Resident #1 was found at the doorway 2 more times after the incident, between the 15-minute checks, but was able to be redirected. She said the family agreed it was in Resident #1's best interest to be discharged home. The administrator pointed out the area where Resident #1 was located to the surveyor and she indicated Resident #1 was on the shoulder of the highway closest to the facility approximately 50-100ft from the driveway near a mailbox. During an interview on 7/15/2020 at 9:03 a.m., the staffing coordinator said she took Resident #1 outside for a cigarette on the day she eloped on 6/21/20. She said there were other residents outside and 2 other staff members present. She said she placed Resident #1's wheelchair next to CNA A because of how they interacted together. She said all the staff helped monitor the smoke break, but it was ultimately CNA A's responsibility to get all the residents back inside. She said she did not tell CNA A she was going back inside but reminded her to extinguish Resident #1's cigarette before they all came inside. She said after she came into the facility she did not witness any staff or residents come in after her. She said she was down the hallway when the staff alerted her Resident #1 was outside on the road. She said she asked CNA A if she had brought Resident #1 in after the smoke break and CNA A responded, you're not going to blame that on me, she is not my resident. She said the facility in-serviced the staff on elopement and smoking after the incident. During an interview on 7/15/2020 at 9:34 a.m., the SW said she was scheduled to work 6/21/2020 and when she arrived she noticed Resident #1 outside on the shoulder of the highway (to the left of the driveway) but was headed back towards town (towards the driveway). She said Resident #1 was unable to explain what she was doing. She said traffic was known to speed down the highway, so she used her car as a barrier with her hazard lights on, so the resident would not get injured. She said she notified the facility while she was outside with the resident and within a minute multiple staff were outside to get the resident. She said she notified the administrator of the incident because she was the abuse coordinator. The SW said she had been in-serviced on elopement. She said Resident #1 eventually discharged home because the family did not want her transferred to another facility further away that had a secured unit. During an interview on 7/15/2020 at 10:35 a.m., the administrator said all the other residents who were outside smoking were able to get themselves inside and did not need assistance. She said Resident #1 was the only resident who smoked and needed assistance because she was a wander risk. She said that all residents require supervision during smoke breaks due to safety. She said after the incident they moved the smoking area to the back of the facility and changed all the door codes. During an interview on 7/15/2020 at 10:57 a.m., CNA D said all the residents who smoked besides Resident #1 were able to come and go for the smoke breaks without needing assistance. She said Resident #1 was the only one who required supervision outside due to her elopement risk. During an observation on 7/15/20 at 12:00 p.m., the speed limit sign indicated the speed was 60 miles per hour on the highway where Resident #1 was found. During an interview on 7/15/2020 at 12:15 p.m., the administrator said she expected staff to ensure Resident #1 was brought in after her smoke break due to her wandering and elopement risk. She said CNA A should have brought Resident #1 inside since she was responsible for the residents on that smoke break. She said LVN B was not on the clock and was taking a break and CNA C was also on a break and not responsible for the residents at that time. During an interview on 7/15/2020 at 12:23 p.m., CNA C said she stepped outside to take a phone call and there were residents outside, but several had already begun to re-enter the facility. She said she remembered the staffing coordinator telling CNA A to extinguish Resident #1's cigarette because it was getting close to the filter. She said the staffing coordinator went inside. She said the nurse came up with some ice cream, so she opened the door to have CNA A take it inside. She said she did not know if CNA A returned outside to ensure the residents were inside. She said staff are designated to take residents out to smoke and that it is on the CNA assignment sheet at the bottom. During an interview on 7/15/2020 at 1:07 p.m., the administrator said after Resident #1 eloped they did large and small group in-services related to elopement and wandering residents. The facility had staff locate the elopement risk book at the nurses' station. She said she did informal 1-on-1 in-services with CNA A, LVN B, CNA C, and the staffing coordinator. She said they suspended CNA A on 6/21/20 and terminated her on the 6/24/20 because of attendance issues. She said CNA A had not returned to work after being suspended. She said if a resident was a smoker and in the elopement book then they were to be in direct supervision which was essentially within 5 feet of the resident and with a direct line of sight. She said other residents who smoked and were not an elopement risk could have a staff member outside with them, but they do not have to be right next to the smoker. She said that all staff knew where the elopement book was located and if they had a wander guard bracelet they were to be directly supervised when outside of the facility. A facility policy titled Wander and Elopement dated 10/1/07 indicated: .the facility will provide preventive interventions as necessary to help ensure the safety of the resident identified and the safety of other residents residing in the facility An undated facility policy titled Wandering, Unsafe Resident indicated: .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement An undated facility policy titled Smoking Policy- Residents indicated: . 10. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking The administrator, DON, and company Vice President were notified on 7/15/2020 at 3:15 p.m., a past non-compliance situation had been identified due to the above failures. It was determined these failures placed residents in an IJ situation on 6/21/20 to 7/7/20. The facility implemented the following interventions: -assessment of Resident #1, -initiation of 15-minute checks for Resident #1 and her eventual discharge, -completion of in-services regarding Elopement Investigation, Wandering & Elopement, and Wandering/Unsafe Residents; -suspension of CNA A, -placing the elopement incident on the facility's quality assurance program, and -moving the designated smoking area to the back of the facility on 7/7/2020. These interventions were completed based on 7 staff (Administrator, DON, SW, 1 LVN, and 2 CNAs) interviewed to ensure these interventions had been completed. Staff were able to appropriately define abuse, identify the abuse coordinator, and said they would immediately notify the administer or DON of any abuse allegations

Based upon observation, interview, and record review, the facility failed to ensure the necessary treatment and services consistent with professional standards of practice, to promote healing and to prevent new ulcers from developing was provided for 1 of 8 residents reviewed for pressure injury. (Resident # 29) The facility did not accurately assess and notify the physician of changes to Resident #29's excoriation to the buttocks. Resident #29 developed 3 facility acquired stage 2 pressure injuries on her sacral area and on each buttock. The facility did not accurately assess, notify the physician, and provide treatment to the new areas. The failure could place 76 residents who received preventative skin care at risk for developing new pressure injuries and 3 residents with pressure injuries at risk for a decline in existing pressure injuries. Findings Included: Physician orders [REDACTED].#29, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #29 required extensive assistance with bed mobility. The Resident had severe cognitive impairment with no behavioral symptoms. Resident #29 was incontinent of bowel and bladder and required total assistance with hygiene and bathing. Resident #29 had a feeding tube and received 51% or more of calories from [MEDICATION NAME] feeding daily. The resident was at risk for development pressure injuries. The MDS indicated Resident #29 did not have any pressure injuries. A revised care plan dated 1/24/18 indicated Resident #29 had a potential for alteration of skin integrity related to restricted mobility and incontinence and was to have skin assessments weekly and as needed. A revised care plan dated 3/7/18 indicated Resident #29 had excoriation to the buttocks. The goal for Resident #29 was for the area to heal without complications over the next 90 days. The care plan indicated treatments were to be performed as ordered and if no improvement after 2 weeks notify the physician, monitor areas for increased breakdown and signs and symptoms of infection and report to physician, keep the physician and responsible party informed of the resident's progress, and apply [MEDICATION NAME] to buttocks every shift. A wound assessment report dated 3/7/18 indicated Resident #29 had irritation/excoriation, light pink with mild irritation on her sacrum measuring 5.0 cm long x 5.0 cm wide. Skin inspection reports dated 3/7/18, 3/8/18, 3/14/18, 3/23/18, 3/28/18, 3/30/18, and 4/18/18 and 4/20/18 indicated Resident # 29s skin was intact. Skin inspection reports dated 3/09/18, 3/16/18, 4/04/18, 04/06/18, and 04/13/18 indicated Resident #29's skin was not intact-existing (no description or measurement of non-intact skin was documented). During an interview on 4/25/18 12:00 p.m., RN C said no one had notified her that Resident #29's skin was assessed as not intact on 3/09/18, 3/16/18, 4/04/18, 04/06/18 or 04/13/18. During an observation on 4/25/18 at 9:51 a.m., Resident #29 had an excoriated (damage to or removed part of the skin) area the approximate size of a grapefruit on the sacrum area and left and right buttocks. Inside the excoriated area, the resident had 3 small stage 2 pressure injuries, one on the sacrum and one on the left and right buttock. During an interview on 4/25/18 at 9:55 a.m. and 10:22 a.m., CNA D said she reported any changes in a resident's skin to the charge nurse or wound care nurse immediately. CNA D indicated she provided care for Resident #29 yesterday (4/24/18). CNA D said she did not think there were any openings on Resident #29's bottom yesterday. She indicated that sometimes it looks like it is open and sometimes it doesn't. CNA D said she did not report any changes in Resident #29's skin to anyone today. During an interview on 4/25/18 at 9:55 a.m. and 10:22 a.m., CNA E said she reported any changes or problems with a resident's skin to the charge nurse or wound care nurse immediately. CNA E said she provided care for Resident #29 yesterday 4/24/18. CNA E said she believed Resident #29's buttocks looked the same today as yesterday, but said she could not really tell the difference when the resident's bottom was open and when it was not. She indicated it is open sometimes and closed sometimes. CNA E indicated she did not report any change in Resident #29's skin to anyone today. During an interview on 4/25/18 at 10:00 a.m., RN C, the facility wound care nurse, indicated Resident #29 had excoriation on her buttocks. RN C indicated she was not aware of any pressure injuries or open areas on Resident #29. RN C said she tracked pressure injuries and documented them in the computer which kept a list of residents with pressure injuries. RN C indicated Resident #29 was not on that list. RN C indicated she was notified of any changes in resident's skin by the charge nurses and/or CNAs. RN C indicated she had not been notified of any skin changes for Resident #29. During an observation and interview on 4/25/18 at 10:09 a.m., RN C said the last time she assessed Resident #29's buttock on 3/7/18 the area was excoriated. RN C assessed Resident #29's buttock and indicated the excoriated area had changed. RN C indicated Resident #29 now had 3 stage 2 pressure injuries. RN C indicated on 3/7/18 she received an order to apply [MEDICATION NAME] to buttocks every shift until the area was healed. RN C indicated the charge nurses were responsible for completing weekly skin assessments. RN C indicated she monitored daily to make sure skin assessments were completed weekly. RN C indicated she just started daily monitoring of the weekly skin assessments this Monday. She indicated when she was notified of a new wound, she assessesed the area, including measurements and notified the physician for treatment orders. RN C indicated if a treatment was not effective after two weeks, she would re-evaluate and get a new order. RN C indicated she monitored effectiveness of a treatment by looking at skin assessments and looking at the resident. RN C indicated she had not measured the excoriated area on Resident #29 since 3/7/18. RN C indicated a wound care physician came in weekly and saw residents that were referred to him by the facility. The RN said Resident #29 had not been referred to the wound care physician for assessment. During an interview on 4/25/18 at 10:45 a.m., LVN F said she applied [MEDICATION NAME] to residents buttocks this morning. LVN F indicated she saw two open areas on Resident #29's buttocks. She indicated she had not seen the open areas prior to this morning. LVN F indicated she would normally put the information into the computer and let the wound care nurse know. LVN F indicated she did not measure the areas or report the areas to the wound care nurse or physician because she had not had time. LVN F said nurses filled out the weekly skin assessments on residents. LVN F indicated the charge nurses did not measure wounds or injuries when they completed the weekly skin assessment. LVN F indicated the charge nurse would measure a new pressure injury or other skin defect sometimes if the wound care nurse was not available. LVN F indicated she had not measured the excoriated area on Resident #29 when completing any of the weekly skin assessments. During an interview on 4/25/18 at 12:35 p.m. the Corporate Nurse indicated that technically the facility did not have to measure anything other than pressure injury. She said the nursing staff and wound care nurse determined if any skin defect, other than pressure injuries were improving by looking at it when completing weekly skin assessments. The Corporate Nurse indicated the current charting system did not ask for measurements or the type of wound on the weekly skin assessments. The Corporate Nurse indicated the nursing staff needed clarification on what was intact and not intact skin. She said some staff were mistakenly identifying excoriation as not intact. The Corporate Nurse indicated she would expect nursing staff to document and report pressure injuries as soon as possible after identifying. She said the wound care nurse was there Monday through Friday and nursing staff were expected to report any skin concerns to the wound care nurse. The Corporate Nurse indicated on the weekends the charge nurse would measure, document and get orders for any new wounds. She said she was not sure how the wound care nurse was notified of skin issues that occurred on the weekend. Wound assessment reports dated 4/25/18, completed by RN C indicated Resident #29 had 3 stage 2 pressure ulcers. *Left buttock pressure ulcer measured 1.0 x 1.0 x 0.00cm. *Right buttock pressure ulcer measured 0.5 x 0.6 x 0.0 cm. *Sacrum pressure ulcer measured 0.6 x 0.5 x 0.0 cm. A wound care specialist initial evaluation dated 4/25/18 indicated Resident # 29 had a wound on the left buttock greater than 1 day that measured 1cm x 1.8 cm x 0.1, a wound on the right buttock, greater than 1 day that measured 0.5cm x 0.1mc X 0.1. He indicated the reported area on the sacrum had healed. The wound care specialist indicated Resident #29 also had moisture associated [MEDICAL CONDITION] (a general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture). A pressure ulcer/skin breakdown policy revised (MONTH) 2014 indicated Assessment and Recognition. 2. .the nurse shall describe and document /report the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue Treatment/Management 1. The physician will authorize pertinent orders related to wound treatments, including wound cleansing, debridement approaches, dressings and application of topical agents if indicated for type of skin alteration. Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive or non-healing wounds. The website, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages, accessed 5/4/18 indicated: . Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions) . The CMS 672 dated 4/23/18 indicated 76 residents received preventative skin care 3 residents had pressure injuries.

Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistance devices were provided to prevent an accident for 1 of 5 residents reviewed for accidents. (Resident #1) The facility did not replace Resident #1's grab bar on his bed after a room change. While attempting to get out of the bed without the grab bar, Resident #1 fell and sustained a right hip fracture. This failure contributed to Resident #1's right hip fracture. This failure could place 56 residents who required assistance devices at risk for injury. Findings included: The face sheet dated 6/12/2017 indicated Resident #1, admitted [DATE], and re-admitted [DATE]. He was [AGE] years old with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident # 1's cognition was intact with adequate hearing, clear speech, and clear comprehension. Resident #1's bed mobility was limited assistance of 1 person, resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight-bearing assistance. His transfer was self- performance with limited assistance, support provided by 1 person assistance. His range of motion was impaired on one side. He was always continent of bowel and occasional incontinent of bladder. He received physical therapy on 05/08/17 ongoing for 5 days for 279 minutes. A plan of care dated 6/5/17 indicated Resident #1 had a problem of a history of and potential for falls. The goal was for the resident to be free from falls. A care plan dated 06/05/17 indicated Resident #1 had grab bars for mobility. An approach was staff to monitor frequently for needs. A daily physical therapy progress note dated 5/25/17 indicated Resident #1 required minimum assistance with transfers, but he was unable to transfer his center of gravity enough forward to transfer safely alone. A Resident Incident Report dated 6/9/17 at 5:01 a.m., indicated Resident #1 had a Significant Injury/Event. The report indicated the resident was found on the floor on his right side complaining of pain to the right hip and right groin. The report indicated the resident was transferring from the bed to his wheelchair without assistance and heard a pop. The report indicated the resident was transferred to the hospital. The report documented bowel and bladder was a medical risk factor possibly related to the fall. A Provider Investigation Report dated 6/12/17 indicated Resident #1 sustained a fall on 6/9/17 which resulted in a hip and leg fracture. The report indicated the resident fell while attempting to transfer self to his wheelchair. The report documented the resident's sister contacted the facility on 6/12/17 and said she believed the resident's fall was caused by the lack of side rails on the resident's bed. The provider action taken was the nursing administration in-serviced staff on items related to room transfers, including but not limited to: adaptive equipment. The attached investigation summary indicated the grab bars were not on the resident's bed when the resident attempted to transfer himself from the bed to the wheelchair. The summary indicated the resident was able to transfer himself unassisted from his bed to his wheelchair prior to the incident on 6/9/17; and he had successfully transferred himself during his stay. A witness statement dated 6/9/17 completed by CNA F indicated Resident #1 was found on the floor and said he was trying to get into his chair and tumbled over. An Operative Report dated 6/12/17 indicated Resident #1 had surgery on 6/12/17. The preoperative and postoperative [DIAGNOSES REDACTED]. A hospital discharge summary signed 6/13/17 indicated Resident #1 admitted to the hospital on [DATE] and discharged on [DATE]. The summary indicated the resident had a fall from the bed that lead to a hip fracture. The resident had a [DIAGNOSES REDACTED]. During an interview on 6/26/17 at 3:38 p.m., Resident #1 said he did not remember the incident on 6/9/17. He said prior to the incident he would transfer himself from the bed to the wheelchair using his grab bar. He said no one had told him not to use the bar to transfer himself. He said facility staff knew he used the bar to transfer himself. He said now he had to use his call light to have staff come and reposition him in the bed and transfer him since he was no longer able to transfer himself. During an interview on 06/20/17 at 9:41 a.m., the administrator said Resident #1 fell on Friday (6/9/17) morning at 5 am. She said on 6/8/17 he was upset with another resident that was across the hall from him and they offered him to move to a different room. The administrator said they moved Resident #1 into another room along with his clothes, television, and a few personal items, but not his bed. The administrator said the bed in the new room did not have mobility bars. During an interview on 06/20/17 at 1:57 p.m., the ADON said Resident #1 had grab bars because of his right sided weakness. The ADON said, prior to the incident, the resident used the grab bar to sit up and sit on the side of the bed. During an interview on 06/20/17 at 2:00 p.m., CNA A said prior to the incident, Resident #1 definitely used the grab bar to sit up on the side of the bed and to get in his wheelchair. The CNA said prior to accident Resident #1 could transfer himself using the grab bar. During an interview on 06/20/17 at 2:10 p.m., LVN B said prior to the incident, Resident #1 used the grab bars to sit up, get up out of bed, and transfer to his wheelchair. She said she had seen him transfer himself to his wheelchair using the grab bar. During an interview and observation on 6/20/17 at 10:57 a.m., Resident #1 was in bed. The bed had a grab bar. The resident said he could get himself up and get into his wheelchair. During an observation on 06/20/17 at 2:45 p.m., CNAs C and D transferred Resident #1 with a Hoyer lift with the assistance of occupational therapist (OT) E holding Resident #1's injured leg. Resident #1 yelled out Oh and hip as he was being moved. OT E said Resident #1 was having leg spasms pretty bad in his injured leg. During an interview on 06/20/17 at 11:13 a.m., the ADON stated Resident #1 can no longer ambulate since the fall. She said prior to his fall, he could walk short distances and was able to walk into the bathroom after leaving his wheelchair at the door. A facility 802 indicated 56 residents required assistance devices.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided, based on the comprehensive assessment, to prevent new pressure ulcers from developing for 3 of 11 residents reviewed for pressure ulcers. (Residents #s 7 and 11) The facility did not provide pressure relief to prevent pressure ulcers from developing for Resident #7 and did not identify 2 pressure ulcers until after surveyor intervention. The resident had a healed stage 2 pressure ulcer on her buttock. She developed 2 avoidable stage 2 pressure ulcers on her buttocks. The facility did not provide pressure relief to prevent Resident #11 from developing 3 new facility acquired pressure ulcers and did not identify the areas until after surveyor intervention. The resident was at risk of developing pressure ulcers and was admitted with an unstageable area on her sacrum. He developed an avoidable deep tissue injury (DTI) on his right buttock and 2 stage 2 pressure ulcers on his inner ankles. This failure could place 91 residents who received preventive skin care at risk for the development of new or worsening pressure ulcers. Findings included: 1. Physician orders [REDACTED].#11 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. A Stat 3000 low air loss mattress at a setting of 4 was to be maintained on his bed. The resident was to receive weekly head to toe skin assessments to be documented in the wound manager. A quarterly MDS dated [DATE] indicated Resident #11 had intact cognition, was able to understand, and was understood. He required extensive assist of 2 for bed mobility and transfers, was incontinent of bowel, and a Foley catheter was in place. He had limited range of motion in both lower extremities. The assessment indicated the resident was at risk for developing a pressure ulcer. The resident had one unstageable with slough/eschar and one unstageable deep tissue. A care plan with a review date of 3/29/17 indicated Resident #11 had a potential for alternation of skin; an intervention was to turn and reposition every 2 hours and as needed. A care plan with a review date of 3/30/17 indicated Resident #11 had an unstageable pressure ulcer on his sacral area. Interventions included to turn the resident at least every 2 hours to alleviate pressure to the pressure ulcer area and use padding to prevent skin/skin contact. A Braden Risk Assessment Report dated 5/1/17 indicated Resident #11 was at mild risk for developing pressure ulcers. A Skin Inspection Report dated 5/22/17 indicated skin not intact-Existing. There were no new areas identified. The most recent wound assessment report dated 5/18/17 indicated Resident #11 had a stage 4 pressure ulcer on his sacrum measuring 8.0 cm x 8.50 cm x 0.0 with a rolled wound border, wound tunneling, and undermining. The wound bed was covered with 90% percent granulation tissue and 10% eschar. There was no documented wound depths. During an observation on 5/22/17 at 9:47 a.m., Resident #11 was positioned on his back on a low air loss mattress. Resident #11 asked the CNA to move and reposition his legs. During an observation and interview on 5/22/17 at 12:19 p.m., Resident #11 was on his back in his bed on a low air loss mattress with the head of bed elevated greater than 30 degrees. A pillow was under his legs, but the bottom of his heels were not off loaded. The inner aspect of his heels were touching and rotated to the left. Resident #11 said he was paralyzed. During an observation on 5/22/17 at 1:00 p.m., Resident #11 was on his back with feet positioned together on a pillow. During an observation on 5/22/17 at 2:00 p.m. Resident #11 had a pillow under his upper right back; however, his buttocks remained on the bed. During an observation on 5/22/17 at 3:20 p.m., Resident #11 was positioned on his back with pillows under his legs. During an observation and interview on 5/23/17 at 8:25 a.m., Resident #11 was positioned on his back with a pillow under his right upper back. He said he was turned every 2 hours when staff were not too busy. During an observation on 5/23/17 at 2:35 p.m., the wound care nurse provided Resident #11 with wound care. Resident #11 had the following pressure ulcers: *a new DTI on his right lower buttock that was dark purple in color and measured 0.5cm x 0.7cm; *Stage 2 on the inner right ankle measuring 2.0 cm x 2.0 cm; *Stage 2 on the inner left ankle measuring 1.3 cm x 1.5 cm. During an interview on 5/23/17 at 2:35 p.m., the wound care nurse said she did not identify the new right lower buttock DTI or the new stage 2 pressure ulcers on his inner ankles when she dressed a new abrasion from tape on the resident's right buttock this morning. She said she did not know she could measure pressure ulcers if there was any slough in the wound bed and was not measuring the depth of open stage 2 ulcers because the MDS did not require a depth. Wound Assessment Reports dated 5/23/17 indicated the following new pressure ulcers were identified after surveyor intervention: *Right lower buttock (ischium) unstageable due to suspected deep tissue injury; described as indurated, red, and measured 0.50cm x 0.70cm. *Left Heel inner aspect, stage 2; described as indurated with distinct borders, measured 1.30 cm x 1.50 cm. *Right heel inner aspect, stage 2: described as indurated with distinct borders, measured 2.0cm x 2.0 cm. During an interview on 5/23/17 at 4:17 p.m., Resident #11 said he was not being checked for incontinence every 2 hours and was not being turned off his back. During an interview on 5/24/17 at 2:15 p.m. CNA W said she turned and repositioned Resident #11 every 2 hours when she worked on 5/23/17 on the day shift. She said she provided incontinent care for Resident #11 that day (5/23/17), but never uncovered his feet or placed a pillow or pressuring relieving device between his ankles, knees, or under his legs. CNA W said she was never told to offload or place pressure relieving devices between his ankles. She said Resident #11 usually requested her to move his legs if they were painful and she never saw the wound on his buttocks or sacral area because they were usually covered with a dressing. During an interview on 5/24/17 at 8:05 a.m. the wound care nurse said she consulted with a RN wound representative from a nationally and internationally recognized certification agency for treatment and staging of wounds. She said if she had questions, she consulted the DON and have her look at the wounds to clarify staging. She said she did not measure the depth of wounds that were stage 2 because the MDS did not ask for a depth. 2. Physician orders [REDACTED].#7 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #7 had unclear speech and was moderately impaired cognitively. She was usually understood and sometimes understands others. She required extensive assistance of 2 people for bed mobility, transfers, and toileting. She received enteral feeding for nutrition. The assessment indicated the resident was incontinent of bowel and had a Foley catheter. Resident #7 was determined to be at risk for the development of pressure ulcers. She had a healed stage 2 pressure ulcer on prior assessment with no current identified pressure ulcers. She had a pressure reducing device on her bed. A care plan with a review date of 3/20/17 indicated Resident #7 was at risk for alteration in skin integrity with approaches that included turn and reposition every 2 hours and as need, protect skin from moisture, weekly skin assessment, use pressure reduction devices and mattress as needed. During an observation and interview on 5/22/17 at 10:00 a.m., Resident #7 was in bed with the head of bed elevated 30 degrees on a foam pressure reduction mattress with bolsters. A pillow was positioned under her left upper back and her buttocks were not off loaded. LVN X said Resident #7 did not have skin breakdown. During an observation on 5/22/17 at 12:25 p.m., Resident #7 was on her back with the head of bed elevated 30 degrees. A pillow was under her left upper back with no offloading for her buttocks. During an observation on 5/22/17 at 3:25 p.m., Resident #7 was on her back with the head of bed elevated 30 degrees. During an observation and interview on 5/22/17 at 11:10 a.m., CNA Y turned Resident #7 off her back onto her right side without assistance of another staff. She pulled the draw sheet dragging Resident #7's buttock across the bed and positioned her on her right side. CNA Y said she would normally have assistance, but staff were at lunch. Resident #7 had pressure ulcer on her left buttock with a yellow center and a second pressure ulcer on her right buttock near her sacral area. The CNA said she had been putting barrier cream on the areas and that was how they always looked. The ADON said the area kept reopening and referred to the area as shears. During an interview on 5/23/17 at 11:25 a.m., the DON said Resident #7 had a shear on her buttocks that healed about 3 weeks ago and kept reopening. The DON said turning and positioning should be performed by two staff every 2 hours and she expected staff to obtain assistance to prevent dragging and shearing. The DON said residents should be turned to offload boney prominences and not just leaned by a pillow. During an interview on 5/24/17 at 7:50 a.m. CNA Y said she had been just propping pillow under Resident #7's upper back and should have been positioning her so her buttocks were not on the bed. During an observation on 5/24/17 at 8:24 a.m. Resident #7 was positioned on her right side with her buttocks offloaded. The resident was now on a low air loss mattress with bolsters. The wound care nurse measured the pressure ulcers. Measurements completed by the wound care nurse were as follows: *Left inner buttock - Stage 2 measuring 2.0 cm x 1.6 cm and at surveyor request measured the depth at less than x <0.1 cm with red wound base. *Right upper buttock - Stage 2 measuring 0.3 cm x 0.4cm x <0.1cm with red wound base. The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 6/1/17 indicated Pressure Injury: .A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. A Pressure Ulcer/Skin Breakdown-Clinical Protocol dated March 2014 indicated the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressures sores; for example, immobility, recent weight loss, and history of pressure ulcer(s) .the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue . A Pressure Ulcer Risk assessment dated [DATE] indicated pressure ulcers are usually formed when a resident remains in the same position for and an extended period of time causing increased pressure or a decrease of circulation to that area, which destroys the tissues. Pressure ulcer risk assessment are done on admission .with significant changes . skin assessed weekly or more frequently if indicated .staff will perform routine skin inspections with daily care and nurses will assess if skin changes are identified. The CMS 672 dated 5/22/17 indicated 91 residents were receiving preventive skin care and 5 residents had pressure ulcers.

Based on interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 of 4 residents reviewed for neglect. (Resident #1) Transport Aide A did not properly secure Resident #1 in his wheelchair while he was transported in the facility van. Resident #1 received rib fractures after a fall that occurred during transport in the van. This failure could place 20 residents who required transport in the facility van at risk for harm or death. Findings included: A resident face sheet dated 06/28/16 indicated Resident #1 was a [AGE] year old male admitted on [DATE]. A Physician order [REDACTED].#1's [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #1 did not have any behavior problems. He was cognitively intact. The resident required extensive assistance with one person physical assistance with bed mobility, transfers, dressing, and toilet use. A Plan of Care with a review date of 03/02/16 indicated Resident #1 had a problem of an activity tray on his wheelchair at time. Interventions listed included activity tray to be in place as ordered and visual checks every 2 hours. A Provider Investigation Report dated 06/30/16 indicated Resident #1 was injured on 06/24/16 during transport in the facility van. The report indicated the resident received 2 skin tears to the left arm, and rib fractures. An Investigative Summary attached to the report regarding the incident that occurred Friday 6/24/16, and completed by the DON, documented .hospital records revealed that Resident #1 told them he had fallen out of the chair backwards. The resident said he fell backwards out of the wheelchair. During an interview on 07/06/16 at 11:27 a.m. Transport Aide A said on 6/24/16, Resident #1 fell out of his wheelchair while she was transporting him back to the facility following an appointment. She said on the way to the facility the resident asked her to stop at a store. Transport Aide A said she left Resident #1 in the van alone while she went into the store, then continued toward the facility. The aide said she was driving on a straight road when she heard a loud sound and heard Resident #1 call for help. The aide said she did not know how the resident got out of his wheelchair. The aide said the lap buddy was no longer on the wheelchair. A departmental note dated 06/24/16 at 3:23 p.m. documented Resident #1 sustained a skin tear to his left elbow, and left forearm. A hospital Medical Imaging report dated 06/27/16 indicated Resident #1 had multiple left posterior rib fractures. A departmental note dated 06/26/16 at 9:57 p.m. documented Resident #1 was returned to the facility by emergency medical services transportation from a hospital stay following the injury on 06/24/16 at 4:00 p.m. During an interview on 07/06/16 at 10:20 a.m., RN B said Resident #1 was no longer at the facility. The RN indicated the resident was discharged to the hospital. During an interview on 07/06/16 at 1:10 p.m. Transport Aide A said she did not check to see if Resident #1 was secure before leaving the store parking lot. She said she did not know if she was required to check. During an observation and interview on 07/06/16 at 11:50 a.m. Transport Aide A demonstrated where Resident #1 was found in the van when he fell out of his wheelchair. She indicated the resident was on the floor in the space between the wheelchair and seat, which was approximately 12 inches wide. The transport aide said the resident's lap buddy was found on the rear left side of the van next to Resident #1's wheelchair. During an observation and demonstration on 07/06/16 at 1:17 p.m., Transport Aide A could not secure the seatbelt that went across a demo resident's (Resident #2) chest while securing the resident on the van in a wheelchair that had a lap buddy. Resident #2 continually placed the strap back across his shoulder and chest area due to the strap not fitting snuggly. The administrator said the seatbelt was not locking properly. She indicated she did not know why the seatbelt would not lock. She indicated the locking apparatus on the seatbelt would be checked before using the van again. She said when she checked the seatbelt on 06/27/16, the seatbelt was working properly. During an interview on 7/8/16 at 2:04 p.m. Transport Aide A said she transported 20 residents on the facility van.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment based on the comprehensive assessment was provided to prevent the development and worsening of pressure ulcers for 3 of 3 residents reviewed for pressure ulcers. (Residents #6, 5 & 8) The facility did not provide appropriate pressure relief for 24 days, document accurate assessments, or initiate the chain of command when the physician assistant did not assess or provide appropriate orders for pressure ulcer deterioration. Resident #6 was admitted to the facility without pressure ulcers. Resident #6 developed a Stage IV pressure ulcer to his right hip, an unstageable pressure ulcer to his left hip, and Stage IIs to his coccyx, right upper buttock, and left outer ankle. The resident's right hip pressure ulcer deteriorated and exhibited signs of infection. The nurse did not contact the physician when the physician assistant did not assess the wounds for 8 days after the first sign of infection. Resident #6 developed osteo[DIAGNOSES REDACTED] (infection of the bone) and gangrene (death of body tissue due to a lack of blood flow or a bacterial infection) to the hips. Resident #6 was admitted to the hospital for wound infection [MEDICAL CONDITION]. LVNs A, D and E did not know how to set the low air loss mattress according to the weight for Resident #s 5 and 8. An Immediate Jeopardy situation was identified on 04/04/2016 at 9:15 a.m. The Immediate Jeopardy was removed on 04/04/2016 at 4:30 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure may have contributed to Resident #6's admission to the hospital for wound infections [MEDICAL CONDITION]. This failure could place 6 residents who had pressure ulcers at risk for developing new pressure ulcers and decline of existing pressure ulcers, to include osteo[DIAGNOSES REDACTED]. Findings included: 1. Physician orders [REDACTED].#6, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #6 required extensive assistance with bed mobility, transfers, and personal hygiene. The MDS indicated Resident #6 required extensive assistance with toileting and was incontinent of bowel and bladder. The resident had moderate problems in the area of mental status and no behavior problems. Resident # 6 had multiple pressure ulcers at the time of this assessment. A Braden Risk assessment dated [DATE] indicated Resident #6 was high risk for developing skin pressure ulcers due to mobility, inadequate nutrition, and sensory impairment. Right Hip Pressure Ulcer A care plan with a problem onset date of 09/26/2015 indicated Resident #6 had a Stage II pressure ulcer to the right hip. Interventions included were to observe and document any signs and symptoms of infection, notify physician, and responsible party of changes, the resident ' s pressure ulcer was to be re-evaluate at least every 2 weeks for appropriateness of treatment orders if no signs of healing, turn and reposition at least every two hours to alleviate pressure to area(s), use padding to prevent skin to skin contact and use a low air mattress on the bed. A MAR dated October 2015 indicated Resident #6 received a low air loss mattress to bed every shift. The MAR indicated the start date was 10/21/15. The Wound Assessment Report (WAR) for Resident #6's right hip pressure ulcer indicated 09/26/2015 - Stage II (0.50cm x 0.50cm x 0.10cm) new wound WAR dated 10/6/2015 - Stage II (0.70cm x 0.50cm x 0.05cm) new wound WAR dated 10/13/2015 - Stage II (0.70cm x 0.50cm x 0.05cm) deteriorated WAR dated 10/20/2015 - Stage II (0.90cm x 0.60 x cm0.03cm) deteriorated WAR dated 10/27/2015 - Stage II (0.80xcm x 0.60cm x 0.03cm) unchanged WAR dated 11/3/2015 - Stage II (1.00cm x 1.00cm x 0.01cm) unchanged WAR dated 11/10/2015 - Stage II (1.00cm x 1.00cm x 0.01cm) improved; right hip pressure ulcer #1 was improving but the right hip pressure ulcer #2 was deteriorating A departmental note dated 11/11/2015 indicated Resident #6 ' s right hip pressure ulcer #2 deteriorated and had no odor. WAR dated 11/17/2015 - Stage II (0.50cm x 0.60cm x 0.01cm) improved; new treatment orders received. A departmental note dated 11/17/2015 indicated the right hip pressure ulcer was resolving with no signs of infection. A physician's telephone order dated 11/20/15 indicated an order for [REDACTED]. WAR dated 11/24/2015 - Stage III (3.00 cm x 2.50 cm x 0.10 cm) improved with moderate serosanguineous (serum and blood) drainage. The wound went from a Stage II to a Stage III with moderate serosanguineous drainage. The assessment indicated a new treatment order was received. A departmental note dated 11/24/2015 indicated all wounds had improved and the right hip was a Stage III with decrease in drainage with no odor. A departmental note dated 11/29/2015 documented the pressure ulcer on Resident #6's right hip had a foul odor and the bandage appeared to be saturated with purulent (sign of infection) drainage. WAR dated 12/1/2015 - Stage III (3.00 cm x 2.50 cm x 0.10 cm) unchanged with moderate serous (clear-straw colored) drainage. An Office Visit progress note dated 12/3/15 indicated Resident #6 was seen by his physician for high blood pressure, diabetes and right arm pain. The note indicated the resident reported discomfort to his right arm and the staff did not report any new or acute problems. A physician telephone order dated 12/7/15 indicated an order for [REDACTED].#6 ' s right hip. WAR dated 12/8/2015 - Stage III (3.00cm x 3.10 cm x 0.20 cm) deteriorated with moderate purulent drainage. WAR dated 12/15/2015 - unstageable with 70% slough (3.80 cm x 3.30 cm x 0.30 cm) unchanged with moderate purulent drainage. A physician telephone order dated 12/15/15 indicated Resident #6 was to receive [MEDICATION NAME] 750 mg daily for 10 days for a wound infection. A physician telephone order dated 12/16/15 indicated an order for [REDACTED]. A care plan signed by the physical therapist dated 12/16/15 indicated Resident #6 had a goal of reduction in perimeters of wound. An approach listed was electromagnetic treatment for [REDACTED]. WAR dated 12/22/2015 - unstageable with 100% slough (3.50 cm x 3.30 cm x 0.50 cm) deteriorated with large amount of purulent drainage. Tunneling 7.00-11 Physical therapy progress notes dated 12/17/15, 12/21/15, 12/22/15, 12/23/15, 12/30/15, 1/1/16, 1/5/16, 1/8/16, and 1/11/16 indicated Resident #6 received diathermy to the right hip. A physical therapy progress note assessment of progress dated 12/23/15 indicated Resident #6 demonstrated progress with the use of diathermy in healing of lumbosacral wound. WAR dated 12/30/2015 - Stage IV with 20% slough (2.90cm x 3.20cm x 2.50cm) improved with a large amount of serosanguineous. Tunneling 5.00-11 WAR dated 01/5/2016 - Stage IV with 10% slough (2.90cm x 3.20cm x 2.50cm) improved with moderate amount of serosanguineous. Tunneling 5.00-1.2-1.2 with signs of infection A physical therapy progress note assessment of progress dated 1/11/16 indicated general assessment of the wound was reported to be improving with tissue granulation and general appearance with the use of diathermy. A physician telephone order dated 1/11/16 contained an order to culture the wounds on Resident #6's right and left hip. WAR dated 01/13/2016 - Stage IV with 5% slough (2.90cm x 3.20cm x 2.50cm) deteriorated with a large amount of purulent drainage. Tunneling 5.00-12-12 with signs of infection A physician telephone order dated 1/14/16 indicated Resident #6 was to receive [MEDICATION NAME] 500 mg daily for 14 days or until wound cultures return and the resident had an or for a CT scan for the hip and pelvis without contrast. A departmental note dated 01/19/2016 indicated an order was received for Resident #6 to receive a computerized tomography (CT) scan and to receive Cefeprime (treats bacterial infections) 2 grams intravenously every 12 hours for 10 days A physician telephone order dated 1/19/16 indicated Resident #6 was to receive Cefeprime 2 grams intravenously every 12 hours for 10 days due to a [DIAGNOSES REDACTED]. The computerized tomography report dated 01/18/16 indicated Resident # 6 had soft tissue swelling with air in the right greater trochanter (hip) of the right femur. Erosions of the trochanter of the right femur also present with osteo[DIAGNOSES REDACTED] and the left greater trochanter had swelling with no evidence of osteo[DIAGNOSES REDACTED]. Gangrene surrounded the greater trochanter right femur with osteo[DIAGNOSES REDACTED] in the outer aspect of the right greater trochanter and [MEDICAL CONDITION] over the greater trochanter (infection in and around the right hip). A physician telephone order dated 1/18/16 indicated Resident #6 ' s [MEDICATION NAME] was discontinued and Bactrim DS two times a day for 14 days was added. During an interview on 03/30/2016 at 12:00 p.m., the treatment nurse said all of her documentation on the Wound Assessment Reports for Resident #6 was not accurate. She said the documentation dated 11/10/15 for the right hip pressure ulcer #1 was actually the right upper buttocks. She said the right hip pressure ulcer #2 was the right hip and there were not two pressure ulcers located on the right hip. The treatment nurse said the right hip pressure ulcer deteriorated on 11/10/15 and it did not improve. The treatment nurse said the wound assessment report had the same measurements and skin assessments documented on 11/3/2015 and 11/10/2015 for the right hip pressure ulcer. The treatment nurse said she did not know why she documented the pressure ulcer deteriorated on 11/10/2015. The treatment nurse said her documentation of the measurements for the pressure ulcer indicated the ulcer decreased and the pressure ulcer improved on 11/17/2015. She said her documentation on the Wound Assessment Report indicated a new order was received on 11/17/15 for the pressure ulcer. The treatment nurse said there was probably a change to the pressure ulcer on 11/10/2015 for there to be a new order on 11/17/2015. The treatment nurse said she did not document the change she saw on the Wound Assessment report on 11/10/2015. The treatment nurse said on 11/24//15 she believed the outside of the resident ' s pressure ulcer got worse and that was why the measurements increased in size. The treatment nurse said she updated the physician assistant every week about the pressure ulcer. She said she notified the physician assistant in November 2015 about her concerns about the pressure ulcer being infected and he would not order a wound culture until December 2015. The treatment nurse said they received an order for [REDACTED]. The treatment nurse said she documented on 12/8/2015 that the pressure ulcer deteriorated and had a moderate amount of purulent drainage with a foul odor. The treatment nurse said the results of the wound culture were received on 12/11/2015 and faxed to the physician assistant on 12/11/15. The treatment nurse said the pressure ulcer was infected and the resident was started on [MEDICATION NAME] 750 mg for 10 days on 12/15/15. The treatment nurse said the wound culture results were faxed on a Friday afternoon and the physician assistant was contacted on 12/15/15. The treatment nurse said the resident ' s pressure ulcer continued to have signs of infection and an order was received to re-culture the pressure ulcer. The treatment nurse said the resident was re-started on [MEDICATION NAME] 500 mg for 10 days on 1/14/16 because the wound remained infected. The treatment nurse said the laboratory report for the wound culture was received on 1/16/16 and indicated the resident was resistant to the [MEDICATION NAME] ([MEDICATION NAME]). The treatment nurse said the on-call physician was notified that the resident was resistant to the [MEDICATION NAME] ([MEDICATION NAME]). The treatment nurse said the on-call physician insisted the resident remain on [MEDICATION NAME] until the wound was re-cultured. The treatment nurse said on 01/18/2016 the physician assistant discontinued the [MEDICATION NAME] and started the resident on Bactrim DS for 14 days since the wound was resistant to [MEDICATION NAME]. Left Hip Pressure Ulcer A care plan with a problem onset date of 10/20/2015 indicated Resident #6 had a Stage II pressure ulcer to left hip and coccyx. Interventions included were to observe and document any signs and symptoms of infection, notify physician, and responsible party of changes, the resident ' s pressure ulcer was to be re-evaluate at least every 2 weeks for appropriateness of treatment orders if no signs of healing, turn and reposition at least every two hours to alleviate pressure to area(s), use padding to prevent skin to skin contact and use a low air mattress on the bed. The Wound Assessment Reports and Departmental Notes for Resident #6 indicated the following: Left hip: WAR dated 10/20/2015 - Stage II (2.70cm x 3.10cm x 0.05cm) new wound WAR dated 10/27/2015 - Stage II (2.70cm x 3.10cm x 0.05cm) unchanged WAR dated 11/3/2015 - Stage II (2.00cm x 3.00cm x 0.05cm) unchanged WAR dated 11/10/2015 - Stage II (2.00cm x 2.30cm x 0.05cm) improved WAR dated 11/17/2015 - Stage III with 50% slough (2.10cm x 2.50cm x 0.10cm) deteriorated small amount of serous drainage. The wound resolved on 12/02/2015. WAR dated 11/24/2015 - Stage II (0.20cm x 0.20cm x 0.00cm) improved with no drainage. The wound resolved on 12/02/2015. WAR dated 12/28/2015 - unstageable with 70% eschar (2.60cm x 3.40cm x 0.00cm) unchanged with scant amount of sanguineous (bloody) drainage. WAR dated 12/30/2015 - unstageable with 50% slough (shedding or casting off dead tissue) (4.20cm x 5.00cm x 0.10cm) improved with scant amount of serosanguineous drainage. WAR dated 01/5/2016 - unstageable with 20% slough and 50% eschar (dead tissue) (4.20cm x 4.80cm x 0.02cm) improved with small amount of serous drainage. WAR dated 01/13/2016 - unstageable with 30% slough and 60% eschar (4.50cm x 5.50cm x 0.00cm) deteriorated with no drainage. During an interview and record review on 03/30/2016 at 2:30 p.m., the treatment nurse said Resident #6 developed a new pressure ulcer to his left hip on 10/20/2015 that was a Stage II. The treatment nurse indicated the documentation on the Wound Assessment Report dated 11/10/2015 indicated the pressure ulcer was improving and the measurements decreased. The treatment nurse said her documentation indicated on 11/17/2015 the left hip was a Stage III and the measurements increased with 50% slough. The treatment nurse said her documentation on 11/24/2015 indicated the pressure ulcer on the left hip decreased in size and went from a Stage III to a Stage II with no slough. The treatment nurse said she could not remember why the measurements decreased. She said she did not know why the pressure ulcer went from a Stage III back to a Stage II because they could not decrease the stage of a pressure ulcer. The treatment nurse said the resident ' s pressure ulcer on the left hip resolved on 12/02/2015. The treatment nurse said her documentation indicated the resident ' s left hip pressure ulcer re-opened on 12/28/2015 and was unstageable with a thin layer of eschar in the center of the wound. Right Upper Buttock Pressure Ulcer A care plan with a problem onset date of 10/12/15 indicated Resident #6 had a Stage II to his right upper buttock. Interventions included were to observe and document any signs and symptoms of infection, notify physician, and responsible party of changes, the resident ' s pressure ulcer was to be re-evaluate at least every 2 weeks for appropriateness of treatment orders if no signs of healing, turn and reposition at least every two hours to alleviate pressure to area(s), use padding to prevent skin to skin contact and use a low air mattress on the bed. The Wound Assessment Reports for Resident #6 indicated the following: Right Buttock/Upper Buttock: 10/12/2015 - Stage II (0.50cm x 0.50cm x 0.05cm) new wound 10/20/2015 - Stage II (0.70cm x 0.50cm x 0.03cm) deteriorated 10/27/2015 - Stage II (0.80cm x 0.50cm x 0.03) deteriorated 11/3/2015 - Stage II (0.90cm x 1.00cm x 0.03) deteriorated 11/10/2015 - Stage II (0.80cm x 1.00cm x 0.01cm) improved 11/16/2015 - wound resolved Coccyx: 10/20/2015 - Stage II (6.20 cm x 2.10 cm x 0.10 cm) new wound 10/27/2015 - Stage II (6.00 cm x 2.20 cm x 0.10cm) unchanged 11/3/2015 - Stage II (5.70cm x 2.30cm x 0.10cm) unchanged with scant amount of sanguineous. 11/10/2015 - Stage II (4.30cm x 2.20cm x 0.10cm) improved with scant amount of sanguineous. 11/17/2015 - Stage II (3.00cm x 1.50cm x 0.05cm) improved 11/24/2015 - Stage II (2.80cm x 1.40cm x 0.05cm) improved 12/1/2015 - Stage II (2.00cm x 1.20cm x 0.05cm) improved 12/8/2015 - Stage II (1.80cm x 1.20cm x 0.05cm) improved 12/15/2015 - Stage II (1.70cm x 1.20cm x 0.40cm) improved 12/22/2015 - Stage II (1.50cm x 1.20cm x 0.20cm) improved 12/30/2015 - Stage II (1.50cm x 0.90cm x 0.10cm) improved 01/5/2015 - Stage II (1.50cm x 0.90cm x 0.10cm) unchanged 01/13/2016 - Stage II (1.20cm x 0.50cm x 0.05cm) improved Left Outer Ankle Pressure Ulcer A care plan with a problem onset date of 10/26/2015 indicated Resident #6 had a Stage II to his left outer ankle. Interventions included were to observe and document any signs and symptoms of infection, notify physician, and responsible party of changes, the resident ' s pressure ulcer was to be re-evaluate at least every 2 weeks for appropriateness of treatment orders if no signs of healing, turn and reposition at least every two hours to alleviate pressure to area(s), use padding to prevent skin to skin contact and use a low air mattress on the bed. Left Lateral Malleolus (Left lateral Ankle) Wound Reports for Resident #6: 10/26/2015 - Stage II (2.40cm x 0.30cm x 0.01cm) new wound 12/08/2015 - wound was resolved A Departmental Note dated 1/26/16 indicated Resident #6 attended a scheduled appointment with the surgeon on 1/26/16. The surgeon ordered the resident to go to the emergency room to be admitted for surgery and intravenous antibiotics. An emergency department report dated 1/26/16 indicated Resident #6 was admitted to the hospital due [MEDICAL CONDITION] and wound infection to both hips and lower back; the infection was worse to the left hip. During an interview on 03/29/2016 at 2:05 p.m., the treatment nurse said Resident #6 did not have any pressure ulcers when he was admitted on [DATE]. She said he was at high risk for developing pressure ulcers. The treatment nurse said the resident developed pressure ulcers to the coccyx, left hip, right hip, lateral malleolus (left outer ankle), and right upper buttock. The treatment nurse said the resident's pressure ulcer to the left outer ankle healed. The treatment nurse said the resident's pressure ulcer to the right hip deteriorated and had purulent drainage. The treatment nurse said when the pressure ulcer deteriorated in October 2015 she requested that the physician assistant assess the resident's pressure ulcer. The treatment nurse said the physician assistant did not assess the resident's pressure ulcer until December 2015. She indicated the physician assistant was surprised the wounds looked that bad and gave an order to culture the wound. She said Resident #6 was placed on antibiotics and the treatment to the pressure ulcers changed to diathermy (intended to generate deep heat within body tissues for the treatment of [REDACTED]. The treatment nurse said she did not consult the medical director when the physician assistant did not assess the resident's wound after it deteriorated. During an interview on 04/04/2016 at 9:30 a.m., LVN A said she did not recall Resident #6 refusing to be turned or repositioned in bed. During an interview on 04/04/2016 at 9:36 a.m., CNAs B and C said they both worked with Resident #6 and he did not refuse care or repositioning in the bed. During an interview on 04/04/2016 at 1:30 p.m., LVN A said she remembered checking the settings on Resident #6's low air mattress bed. She said she thought the settings were in the resident's chart, but nobody showed her how to make sure the settings where accurate. During an interview on 03/30/2016 at 3:50 p.m., the DON said Resident #6's pressure ulcers were acquired at the facility. During an interview on 03/30/2016 at 4:00 p.m., the DON said they contacted the physician assistant about ordering a wound culture for Resident #6 in November 2015 when the pressure ulcers were getting worse. She said he did not order the wound culture, and the treatment nurse talked to him all the time about the wound. The DON said the medical director was not notified of the concerns regarding the physician assistant. The DON said the treatment nurse's recommendation for the wound culture was not documented. During an interview on 03/30/2016 at 4:02 p.m., the administrator said she knew Resident #6 had pressure ulcers, but did not know the extent of the pressure ulcers. An in-service training report regarding documentation of wound care and physician notification and job expectations dated 01/22/2016 indicated: For Treatment nurse to ensure all admits/readmits have skin inspections by nurse within 24 hours, provide wound care, document all communication with physician assistant, nurse practitioner, medical director or other professionals . 2. Physician orders [REDACTED].#5, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The resident had an order for [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #5 required extensive assistance with bed mobility, transfers, and personal hygiene. The MDS indicated Resident #5 required extensive assistance with toileting and was incontinent of bowel and had a Foley catheter. The resident was severely impaired in the area of mental status with no behavior problems. Resident #5 had a Stage IV pressure ulcer at the time of this assessment. A Braden Risk assessment dated [DATE] indicated Resident #5 was at moderate risk for developing skin pressure ulcers due to resident was confined to bed. A care plan with a problem onset date of 03/08/2016 indicated Resident #5 had a Stage IV pressure ulcer to the sacrum. Interventions included provide resident with a low air mattress to bed. During an observation and interview on 04/04/2016 at 10:15 a.m., LVN D and LVN E could not demonstrate how to set the air mattress bed according to Resident #5 ' s weight. LVN D said she thought there was supposed to be an order on how to set the bed according to the resident's weight. LVN E said she thought there was a book that instructed staff how to set the beds. LVN D and LVN E said they documented in the computer that the settings were checked, but did not know if the settings were accurate. 3. Physician orders [REDACTED].#8, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The resident had an order for [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #8 required extensive assistance with bed mobility, transfers, and personal hygiene. The MDS indicated Resident #8 required extensive assistance with toilet use and was incontinent of bladder and occasionally incontinent of bowel. The resident ' s mental status was intact with no behavior problems. Resident #8 had a Stage III pressure ulcer at the time of this assessment. A care plan with a problem onset date of 02/18/2016 indicated Resident #8 had a Stage III pressure ulcer to the sacrum area. Interventions also said re-evaluate area at least every 2 weeks for appropriateness of treatment orders if no signs of healing noted, and use pressure reduction devices as needed. A Braden Risk assessment dated [DATE] indicated Resident #8 was at moderate risk for developing skin pressure ulcers due to resident was chair-fast and mobility was very limited. During an interview on 04/04/2016 at 9:38 a.m., LVN D said she checked the settings on the low air mattress bed every shift and documented on the medication administration record. During an interview on 04/04/2016 at 10:15 a.m., LVN D said she thought there was supposed to be an order on how to set the bed according to the resident's weight. LVN D said they documented in the computer that the settings were checked, but did not know if the settings were accurate. During an observation and interview on 04/04/2016 at 9:50a.m., Resident #5 had a low air loss mattress. LVN E said she checked the settings on the low air loss mattress every shift. LVN E checked Resident #5 ' s low air mattress. She said she was instructed that the alternating pressure should not be below 3 and the setting on the bed was set at 3. LVN E said it had been a while since she changed the settings on a low mattress. She said there was a book staff used to check the mattress settings by the resident ' s weight. She said she did not know where the book was located. During an interview on 04/04/2016 at 10:03 a.m., the DON said the facility did not have a book to go by to check the low air loss mattress settings. She said the settings on the beds were determined by the resident ' s weight. The DON said there were not any orders for the low air mattress settings. During an interview on 04/04/2016 at 10:35a.m., DON said Resident #8 ' s wound healed and she was not supposed to be on a low air mattress bed. She said they just completed an in-service on how to check the settings on a low air mattress bed a couple of months ago. She also said they were working on orders to discontinue the low air mattress bed for Resident #8 and she would check the settings on Resident #5 bed. The DON said they will include low air mattress bed settings in the plan of removal to make sure the beds were being effective. The Wound Care policy and procedure with a revised date of October 2010 indicated: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Documentation the following information should be recorded in the resident's medical record: . (5) Any changes in the resident ' s condition; (6) All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. Reporting (1) Notify the supervisor if the resident refuses the wound care. (2) Report other information in accordance with facility policy and professional standards of practice . The administrator and DON were notified on 04/04/2016 at 9:15 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility ' s Plan of Removal was accepted on 04/04/2016 at 4:30p.m., and included: 1. Notify Medical Director of Immediate Jeopardy status. 2. Notify Regional Director of Clinical Service & Quality Assurance of Immediate Jeopardy status. 3. Resident (#6) no longer resides in facility. 4. All residents will have head to toe assessments by licensed nursing staff to identify any pressure ulcers. 5. Notify physician for any resident identified with pressure ulcers. 6. Notify attending physician and/or Medical Director with concerns not addressed by Physician's Assistant/Nurse Practitioner. 7. Contact Registered Dietician of residents with pressure ulcers. 8. Residents identified with pressure ulcer will have chart audits for lab orders and follow-up for lab results with physician. 9. Instructions for correct settings on pressure redistribution mattresses will remain attached to foot of bed for reference. 10. Education: A. Licensed Nursing Staff will be provided education on April 4, 2016 1. Pressure Sore Assessment and documentation procedures 2. Notification Procedure to physician related to Pressure Ulcers and Lab Results 3. Braden Scale Assessments 4. Pressure Ulcer prevention & treatment 5. Potential complications of pressure areas 6. Lab test notification procedures 7. Notification of attending physicians and/or Medical Director B. Direct Care Staff will be provided education on April 4, 2016 1. Pressure Sore prevention 2. Notification to licensed staff when skin concerns are noted. 3. Monitoring for correct settings on pressure redistribution mattresses 11. Braden Scale Assessments to be completed: A. Weekly x 4 for new and re-admissions B. Quarterly C. Change of Condition 12. Pressure Sore Prevention and Treatment: A. The attached Southwest LTC Pressure Redistribution Selection Algorithm will be used to determine when a pressure redistribution mattress is appropriate. 13. Compliance to be monitored through: A. Observation and record review of residents with pressure ulcers weekly by nursing management and Standards of Excellence committee with corrective action taken when concerns are identified. B. Review of physician orders [REDACTED]. C. Monthly QAPI meetings. On 04/04/2016 the surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: During an observation and interview on 04/04/2016 at 2:00 p.m., DON demonstrated how to adjust and check the settings on Resident #5 low air mattress bed. She said the instructions would be replaced on all of the low air mattress bed. DON said she checked all of the beds that had a low air mattress and they were accurate. During an interview on 04/04/2016 at 4:00 p.m., CNA B said she was in-serviced on reporting pressure ulcers. She said they instructed her to report any changes to the charge nurse and if the charge nurse did not assess the wound then to report it to the Treatment nurse, ADON, and DON. CNA B also said they went over how to check the settings on the low air mattress bed because it was the nurses and CNAs responsibility to make sure the settings was accurate. She said the beds will have a card that will be placed on the machine that will have the bed settings and instructions. During an interview on 04/04/2016 at 4:06 p.m., CNA C said she was instructed on how to report pressure ulcers and to contact the charge nurse, ADON, DON, and administrator. She said they also told them to make sure they turn the residents every two hours and make sure the low air mattress was correct. CNA C said they will a card that will be place on the machines to let them know what the correct settings were. She said if the settings were not accurate then report it

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 11 residents reviewed for pain. (Resident #s 3 and 9) Resident #3 complained of pain and exhibited signs/symptoms of pain (moaning and whimpering), The facility did not assess the resident's pain or provide pain interventions after he complained of pain. An order to increase the pain medication was not initiated until after surveyor intervention. Resident #9 complained of pain and exhibited signs of pain during wound care. The facility did not assess the residents pain and did not provide pain interventions prior to wound care or during wound care. This failure could place the 53 residents receiving pain management at risk for unrelieved pain, discomfort, and decreased quality of life. Findings included: 1. Physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The orders indicated Resident #3 was to receive [MEDICATION NAME] 5-325 milligrams (mg) routinely twice a day for general pain symptoms, [MEDICATION NAME] 5-325 mg every 4 hours as needed (prn) for pain, and [MEDICATION NAME] 10 mg-20 mg every hour prn for pain. The most recent MDS dated [DATE] indicated Resident #3 could usually make himself understood and understood others, had severe cognitive impairment, and he did not exhibit any behaviors. Resident #3 required extensive assistance from staff for all ADLs and received a scheduled pain medication regimen and non-medication interventions for pain. A care plan dated 06/12/15 indicated Resident #3 received routine or PRN pain medications due to complaints of pain. Interventions listed included assess the resident's pain level, document pain severity and location for PRN pain medications, administer as ordered, and assess the effectiveness. A nursing note dated 08/01/15 indicated Resident #3 was noted to be frowning and grunting during rounds and was medicated with [MEDICATION NAME] 5-325 mg for pain. The nurse notes dated 08/02/15 to 08/07/15 indicated there was no documentation of Resident #3's pain. A telephone order dated 08/10/15 indicated Resident #3's routine [MEDICATION NAME] was increased from two times a day to three times a day. There were no nursing notes documented for 08/08/15 to 08/12/15. The 24 hour report/change of condition report for 08/10/15 to 08/11/15 did not indicate Resident #3 experienced pain or that a new order to increase the resident's pain medication was received. A MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During an interview on 08/11/15 at 12:15 p.m., CNA P said Resident #3 was still lying in bed because he was not feeling well. She said Resident #3 would usually eat and drink 100% of his meals when he got up to eat, but if he was not feeling well, he would not eat as well when in bed. During an observation on 08/11/15 at 12:55 p.m., Resident #3 was lying in bed with his head slightly elevated and was moaning and whimpering. LVN H placed Resident #3's tray on his bedside table and asked the resident if he was ready for lunch. Resident #3 started shaking and told the nurse he was hurting. LVN H asked the resident where he was hurting, and he responded all over . The nurse asked the resident where he was hurting, and then continued to set his bed and lunch tray up. Then she left the room. During an observation and interview on 08/11/15 at 1:30 p.m., Resident #3 was lying in bed with his eyes closed with a grimacing expression on his face. Resident #3 said he could not remember if he received any pain medication. A narcotic administration record for [MEDICATION NAME] 5-325 mg indicated Resident #3 received the medication routinely twice daily on 08/10/15 and 08/11/15. There was no indication Resident #3 received a PRN dosage on 08/11/15 during the day. During an interview on 08/11/15 at 1:40 p.m., MA F said Resident #3 only ate approximately 25% of his lunch meal. She said he usually sat up for his meals in the dining room and ate 100%. MA F said Resident #3 was usually in bed if he was not feeling well or was in pain, otherwise he would be up in his wheelchair. MA F said Resident #3 complained of pain to the nurse and he only received his morning dose of [MEDICATION NAME]. During an interview on 08/11/15 at 2:00 p.m., LVN H said Resident #3 complained of pain all over and she told MA F. She said MA F administered Resident #3 pain medication. During an observation on 08/11/15 at 4:35 p.m., CNA D and E transferred Resident #3 to his wheelchair from the bed with a gait belt. Resident #3 was able to pivot on his feet, but his knees were bent. Resident #3 moaned during the transfer. During an interview on 08/12/15 at 9:00 a.m., LVN G said Resident #3 had an order for [REDACTED]. LVN G said she should have put the new order in the computer, but just forgot. LVN G said the nurse who received a new order would be responsible for transcribing that order in the computer so the MAR indicated [REDACTED] During an interview on 08/12/15 at 12:00 p.m., the administrator said she expected the nursing staff to follow the physician orders [REDACTED]. During an interview on 08/12/15 at 1:30 p.m., the DON said it was the charge nurses' responsibility to ensure new orders received were transcribed into the computer. The DON said when Resident #3 complained of pain, LVN H should have completed a pain assessment, documented in the nursing notes, and provided him with pain medication. The DON said LVN H was an agency nurse, but received training from the facility and had access to the charting system on the computer. During an interview on 08/12/15 at 4:10 p.m., the corporate nurse said the order for Resident #3's increase in pain medication was missed. 2. Physician orders [REDACTED].#9, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Resident #9 was to receive [MEDICATION NAME] 5/325mg one by mouth every 4 hours prn for pain. Resident #9 did not have an order for [REDACTED].>The most recent MDS dated [DATE] indicated Resident #9 required the assistance of one person for bed mobility and transfers. Resident #9 had a [MEDICAL CONDITION], had pain, and was able to understand others and make herself understood. A nursing care plan dated 06/10/15 indicated Resident #9 was to receive prn pain medications due to complaint of pain. The goals noted Resident #9 was to be kept comfortable and the interventions included to assess residents pain level, document pain severity and location for as needed pain medications, administer and assess effectiveness. The care plan also indicated Resident #9 had a stage 3 pressure ulcer on her left calf. During an observation and interview on 08/10/15 at 2:45 p.m., RN R provided wound care for Resident #9's Stage 3 pressure ulcer on her left calf. The narcotic administration record dated 8/9/2015 indicated the last PRN pain medication Resident #9 received. Resident #9 was not adminstered any pain medication prior to dressing change. Upon entering the resident's room, RN R said she knew that her pain med was given. Resident #9 said she was not administered any pain medication. RN R proceeded with the dressing change without checking if the resident received pain medication. As RN R started to clean Resident #9's pressure ulcer, the resident slightly jerked her leg two times and made a soft grunting noise while LVN S was holding her leg. Resident #9 said it was tender to touch. RN R continued providing wound care without assessing the resident's pain. During an interview on 08/13/15 at 8:45 a.m., Resident #9 said she was in pain during the wound care. During an interview on 08/13/15 at 9:25 a.m., RN R said she should have checked to see if Resident #9 was administered pain medication prior to providing the resident with wound care. During an interview on 08/11/15 at 10:10 a.m., LVN S said the nurse should stop treatment if a resident stated they were in pain or exhibiting facial grimacing. The August 2015 MAR indicated [REDACTED]. The 08/2015 narcotic administration record indicated Resident #9 was last administered prn pain medication 08/09/15 at 11:00 p.m. During an observation and interview on 08/10/15 at 3:20 p.m., Resident #9 was given pain medication after the wound care treatment was completed. LVN V administered pain medication to Resident #9. RN R said it depended on the resident if pain medication was administered prior to a wound care treatment and if a doctor's orders specified to give prior to a wound care treatment. The Administering Pain Medications policy dated 2010 indicated The pain management program is based on a facility-wide commitment to resident comfort . Be familiar with the physiologic and behavioral (non-verbal) signs of pain. For example: A. verbal expressions such as groaning, crying, screaming; B. facial expressions such as grimacing, frowning, clenching of the jaw, etc.; C. changes in gait . E. limitations in his or her level of activity due to the presence of pain . G. difficulty eating or loss of appetite . The policy also indicated the staff should . administer pain medications as ordered. The Pain - Clinical Protocol dated 2013 indicated .The nursing staff will identify any situations or interventions where an increase in the resident ' s pain may be anticipated; for example, wound care, ambulation, or repositioning. The staff and physician will also evaluate how pain is affecting mood, activities of daily living, sleep, and the resident ' s quality of life, including complications such as gait disturbances, social isolation, and falls. The CMS 672 dated 08/10/15 indicated 53 residents received pain management.

Based on observation, interview, and record review, the facility failed to ensure supervision was provided to prevent accidents and elopement for 4 of 18 residents reviewed for accidents. (Resident #s 4, 11, 12 and 17) Resident #11 was at high risk for elopement. The resident left the faciity on two occasions and was found near the highway that was 150 feet from the facility with a speed limit of 60 miles per hour. The facility did not implement interventions to ensure the resident did not leave the facility unsupervised. The facility did not implement interventions to ensure Resident # 12 did not leave the facility unsupervised. Resident #12 had a history of [REDACTED]. This failure could place 4 residents who had elopement behavior at risk for accident, injury, abuse and neglect, and death. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non- Immediate Jeopardy The facility did not provide adequate staff to prevent injury during incontinent care for Resident #s 4 and 17. Resident # 17 recieved a fracture. This failure could place 56 residents who required assistance with incontinent care, risk for accident and injury. Findings included: 1. Physician orders [REDACTED].# 11 was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] noted Resident #11 had no cognitive impairment and no wandering behavior. Nursing care plans updated [DATE] indicated Resident # 11 required one person assistance with all ambulation, had potential for falls/injury related to unsteady gait, had shortness of breath on exertion/activity, had poor vision related to cataracts and had trouble concentrating or paying attention. The care plan did not address wandering or exit seeking behavior. An elopement risk assessment dated [DATE] indicated Resident # 11 was disoriented at all times and frequently wandered, had poor decision making skills, was not scared of dangerous situations, frequently reported to staff and family that she wanted to go home to Oklahoma, had left the facility and wandered outside, and constantly wandered with no fear. Incident Reports for Resident #11 noted the following: *[DATE] at 7:30 p.m., Resident # 11 was found out by the highway by a passerby. Resident # 11 said she was going home. *[DATE] at 9:51 a.m., Resident # 11 was found walking on the side of the highway in front of the facility by a visitor. During an observation on [DATE] at 5:48 p.m., the highway was approximately 150 feet from the facility. The speed limit was 60 miles per hour. A witness statement dated [DATE] indicated "...I was coming in the driveway to the nursing home when I saw an older lady (Resident #11) with her walker going to the road. I came in the nursing home and asked was the lady supposed to be going to the road, because cars was coming... " Nursing notes for Resident # 11 indicated the following: *[DATE] at 3:20 a.m., Resident "...was awake and confused to care and place. Refuses to put on shoes. Packed up all clothes, papers, and belongings and confused to care and staff. Requires 1 on 1 monitoring and redirections. Noted mental changes and increase in wandering and behaviors..." *[DATE] 4:12 a.m., Resident "...Confused and has been awake packing, up clothes and belongings most of the shift..." *Addendum for [DATE] 5:09 p.m., "...A lady entered the facility and stated that an elderly woman was out by the road. Resident found in driveway near the road..." *[DATE] 4:20 a.m., "...No attempts to leave or exit facility tonight. Staff to monitor closely. Confused and requires monitoring and redirecting..." *[DATE] 10:58 a.m., "...Resident remains disoriented. Requires frequent/constant staff monitoring secondary to wandering..." *[DATE] 2:14 a.m., "...Resident has been awake and pacing in hallways confused to care and happenings..." *[DATE] 6:50 p.m., "...Resident wandering around facility and exit seeking..." *[DATE] 10:40 a.m., "...Resident continues with wandering behavior requiring monitoring by all staff. Frequently asking about catching a bus to various cities, and where the exit doors are. Requires redirection by staff several time per shift to ensure safety..." *[DATE] 10:19 p.m., "...Resident wandering outside heading towards road. Found by nursing staff and redirected to facility. Resident has shown increased desire to leave facility. Unable to state where she is doing. Resident stated she was looking for front gate..." *[DATE] 9:46 p.m., "Resident wanders throughout facility during this shift. Resident continuously asks for deceased husband. PRN (as needed) vistaril given due to resident attempting to leave facility. " *[DATE] 11:41 a.m. "...Resident very confused and disoriented. Has packed up all her clothes and loaded them onto bedside table rolling it all down the hallway, stating that "I'm putting all of this in the car because I have to leave ...Insisting that she needs to go home to work. Resident requiring frequent to constant monitoring due to poor safety awareness..." *[DATE] 8:49 p.m., "...Resident is exit seeking and packing her belongings stating that she is moving..." *[DATE] 10:04 a.m., "...Resident again gathering her clothes and belongings putting her clothes on top of her walker stating that she is leaving. Attempting to exit via front door..." *[DATE] 1:07 p.m., "...Resident restless, seeking exit from building. Resident is ambulatory with walker made several attempts and redirected by staff. Resident then came down hall pushing plastic 3 drawer container and carrying tall floor lamp stating that she is going to Oklahoma. Redirected with some difficulty to dining room..." *[DATE] 9:30 a.m., "...Resident up at nurses station ambulatory, trying to assist another resident. Resident is talking in a rather confused fashion about looking for her husband and going to Jefferson ....Looking for the way out, going to several different doors..." *[DATE] 9:55 a.m., "...Visitor came to nurses desk to report a resident was at the edge of the road with her walker ....staff went immediately to return resident..." *[DATE] 11:00 p.m., "...Resident has been ambulating thru facility ...confused and looking for her car ....went to back door of Hall 400 and attempted to exit ....will continue to monitor every 30 minutes due to high wander risk..." *[DATE] 3:30 p.m., "...Resident continuously attempting to elope at front door. Resident will sit for at least 10 minutes and begin to ambulate and attempt to elope again out of one of the doors..." *[DATE] 4:00 p.m., "...Resident was not in the lobby sitting, not around the nurses station, not in the dining room. Alert was called per CNA to look for resident. We went in rooms, bathroom, outside around facility, up and down the road to make sure she had not left facility property. Resident found walking down 100 hallway..." *[DATE] 8:14 p.m., "...Exit seeking noted. Visual 30 minute monitoring by staff..." During an observation and interview on [DATE] at 4:35 p.m., Resident #11 ambulated independently with a walker throughout the facility. The Resident had some personal belongings in a pink bucket sitting on her walker's seat. The resident said she was trying to figure out what to do. The resident said she was making her way home. Resident #11 stated "someone is going to have to get those girls". Resident #11 was unable to answer questions appropriately. During an interview on [DATE] at 4:55 p.m., CNA R said Resident # 11 was confused and wandered. He said he did not currently know where Resident # 11 was located. He said Resident # 11 would go outside alone. CNA R checked Resident # 11 ' s room and she was not there. CNA R looked outside for Resident # 11 and she was not outside. CNA R located Resident # 11 on a different hall than the one she lived. CNA R said Resident # 11 was not supposed to go outside alone. He said she did go outside sometimes by herself and staff had to go and get her and bring her back. CNA R said the staff had been told to watch Resident # 11 and a couple of other residents that wandered as well. He said no one was specifically assigned to watch Resident # 11. Everyone in the facility was supposed to watch her to make sure she did not try to leave. During an interview on [DATE] at 5:05 p.m. LVN S said Resident # 11 was "extremely" high risk for elopement. She said Resident # 11 tried to leave out using all the exit doors. She said all staff was aware Resident # 11 tried to leave the facility and have been instructed to watch her closely. She said staff was informed verbally that Resident # 11 was at high risk for elopement. She said no specific staff was assigned to watch Resident # 11. She said all staff are responsible for watching the resident. LVN S said Resident # 11 left the building by herself on previous occasions. During an interview on [DATE] at 5:10 p.m., the DON said she had been employed as the DON for approximately 1 month. The DON said since her employment, Resident #11 was confused and wandered. The DON said Resident # 11 was always trying to go home to Oklahoma. The DON said the plan for keeping Resident #11 safe was for all staff to keep an eye on her. She said all staff knew Resident # 11 was at risk for leaving the facility. The DON said no specific staff was assigned to watch Resident #11. She said there was no time frame for checking on Resident #11 and there was no written form of communicating when and where Resident #11 was visualized. The DON said the front door did not require a code for entering and leaving prior to 10:00 p.m. After that time, the front door lock was activated and required a code for entering and leaving. The DON said all side door locks were always activated. She said the side doors alarmed when the push bar was pressed. The side doors would open after the push bar was held down for ,[DATE] seconds. The DON said the current system for watching Resident # 11 was working. She said over the weekend staff could not find Resident #11 and the staff called the DON. She said everyone searched and they found Resident #11 in another resident's room. The DON said she had not updated the care plan specifying a plan to address Resident # 11's elopement risk. She said she put a note in the CNAs care plan. During an observation on [DATE] at 1:12 p.m., an unidentified resident in a wheelchair exited the front door. No code was required to exit and no alarm sounded. During an observation on [DATE] at 1:13 p.m., a surveyor exited the front door. No code was required to exit and no alarm sounded. During an interview on [DATE] at 10:00 a.m., the DON said she did not feel she needed to report the incident of Resident # 11 leaving the facility to the state agency because staff found Resident # 11 on the property. She said staff knew Resident # 11 was outside. During an interview on [DATE] at 11:00 a.m., LVN F said she was working when Resident #11 left the building on [DATE]. LVN F said she did not know Resident # 11 was outside. She said a visitor came inside and told staff Resident # 11 was out by the road. LVN F said Resident # 11 was on the edge of the road with her walker. She said LVN K ran outside and brought Resident # 11 back inside. LVN F said staff did not know Resident # 11 went outside. She said Resident # 11 was never supposed to be outside unsupervised. During an interview on [DATE] at 11:30 a.m., LVN K said he was pushing his treatment cart down Hall 100 on [DATE] when he looked out the side door and saw Resident #11 on the edge of the highway. He said he ran out the side door and directed the resident back inside. He said Resident # 11 was out of breath and told him she was going to Oklahoma. LVN K said he did not know Resident # 11 was outside the facility. During an interview on [DATE] at 1:30 p.m., RA W said she was working when Resident # 11 was found by the road on [DATE]. She said she was at the nursing station when a woman came in from outside and said an elderly woman was out in the road. RA W said LVN K ran out to get her. RA W said she did not know Resident # 11 was outside. 2. Physician orders [REDACTED].#12 was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #12 had severe impaired cognition and exhibited the behavior of wandering on a daily basis. The most recent care plan updated on [DATE] indicated the resident had confusion due to a [DIAGNOSES REDACTED]. During an interview on [DATE] at 1:30 p.m., the administrator said the facility did not have a wanderguard system. She said she would check to see why care plans mention its use. A physician's progress note dated [DATE] indicated Resident #12 was "...not oriented to person, place, day, date, or time..." An incident and accident report dated [DATE] at 5:46 p.m., indicated Resident #12 was trying to leave the facility. The report indicated the resident left twice and on the first attempt the resident fell and scraped her knee. A nursing note dated [DATE] at 10:52 p.m., indicated Resident #12 attempted to leave the facility twice; she fell to her knee on the first attempt; and on the second attempt at leaving she was caught in the field behind the facility with four hangers of clothing. During observations on [DATE] the following were noted: *at 10:38 a.m., Resident #12 was observed sitting in the dining room attending an activity. A wander guard alarm was not observed on the resident. *at 3:30 p.m., Resident #12 was observed ambulating around the nursing station and front lobby area. The resident was observed /standing in the front lobby near the main entrance door. A wander guard alarm was not observed on the resident. During an interview on [DATE] at 5:30 p.m., the DON said Resident #12 walked around the outside of the facility on a daily basis and was not considered an elopement risk. The DON said she was not working at the facility when Resident #12 was found outside in the "field." During an interview on [DATE] at 10:48 a.m., LVN P said Resident #12 was confused, ambulatory and required minimal assistance with ADLs. She said she knew at one time the resident left the facility twice during one shift. She said she was found outside the back of the facility carrying her clothing. She said she was not able to remember where specifically the resident was found, but did remember the resident was more confused than normal because she had a urinary tract infection. During an interview on [DATE] at 1:45 p.m., the MDS coordinator said the facility did not have a wanderguard. She said she brought standard care plans with her when she transferred to the facility and should have marked through those care plan elements to personalize them. During an interview on [DATE] at 11:05 a.m., the administrator said she was not working at the facility when Resident #12 was found outside the facility. She said she would have expected the staff to fill out an incident and accident form. An Elopement policy dated 2001 indicated the director of nursing services or the charge nurse shall "... staff shall investigate and report all cases of missing residents..." and "...complete and file Report of Incident/Accident... " An Accidents and Incidents policy dated 2001 indicated " ... All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. " The administrator and DON were notified on [DATE] at 5:30 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 8:38 p.m. and included: Immediately reviewed and updated all elopement risk assessments. Resident #1's Elopement risk has been completed and Care Plan interventions updated. Immediately place Resident #1 on one-on one monitoring until such time as all exit doors with key pads were functional. Maintenance director/designee would check exit doors with key pads daily to ensure continue operation Any concerns regarding key pad operations will be reported to the administrator immediately and appropriate action will be taken. All residents would have elopement assessments completed on admission, not less than quarterly, and with a cognitive change of condition All current residents would have Elopement Assessments reviewed and updated Monitor all unalarmed doors (main entrance, dining room exit, and laundry exit) until keypads were functional. In-service staff in regards to proper operation of alarmed doors and notification of administrative staff in case of malfunctions. The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Five CNAs, 1 MA and 2 housekeepers were interviewed and said they were in-serviced regarding how to handle residents at risk for elopement. Four LVNs were interviewed and said they were in-serviced regarding how to handle residents at risk for elopement and completing assessments for residents at risk for elopement. All exit doors were observed and were functioning properly. On [DATE] at 11:35 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non Immediate Jeopardy 3. The consolidated physician orders [REDACTED].#17 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The most current MDS dated [DATE] indicated Resident #17 had clear speech with distinct intelligible words, was usually understood due to difficulty communicating some words or finishing thoughts but was able if prompted or given time. The resident was could understand and comprehend most conversation. Resident #17's cognitive function was moderately impaired. She required extensive assistance with her ADL functions. The resident's bed mobility indicated she required extensive assistance of 2 person physical assist. A care plan updated [DATE] indicated Resident #17 had impaired mobility. Approaches were the resident would be assisted with positioning, transfers, as necessary. The CNA Care Plan sheet dated [DATE] indicated Resident #17 required 1 person assistance with mobility. A Resident Incident Report dated [DATE] at 6:29 a.m. indicated Resident #17 "fell out of bed with 2 CNAs assisting in changing her. No head injury, right shoulder pain. " The incident was noted to have occurred at 5:30 a.m. The report indicated the resident's physician was notified at 5:42 a.m., the DON was notified at 6:29 a.m. and the family was notified at 6:38 a.m. The physician ordered an x-ray. The resident was noted to have a pain level of 7 on a scale of ,[DATE]. A radiology report dated [DATE] indicated Resident #17 had a fractured right shoulder. A nursing note dated [DATE] at 5:54 a.m. indicated Resident #17 fell out of bed while 2 CNAs were assisting her. A radiology report dated [DATE] indicated Resident #17 had a fractured right shoulder. During an interview on [DATE] at 1:31 p.m. LVN F said she worked the ,[DATE] shift and was informed by the ,[DATE] shift nurse, LVN Y on [DATE], at around 5:30 a.m. CNA CC asked Resident #17 to roll over in the bed during care, and the resident rolled out of bed. During an interview on [DATE] at 3:30 p.m., LVN Y said she was the nurse on duty at the time of Resident #17's incident on [DATE]. LVN Y said CNA Z told her when CNA CC was assisting Resident #17 the resident rolled out of the bed onto the floor. LVN Y said CNA Z said CNA CC asked her to assist with putting the resident back in her bed. LVN Y said CNA Z said the resident was in so much pain it scared them and that was when CNA Z came to get me. During an interview on [DATE] at 2:34 p.m., CNA Z said on [DATE] CNA CC called her to Resident #17's room to help her get the resident off the floor. CNA Z said CNA CC was working alone with the resident. CNA Z said Resident #17 was a one person assist with all ADLs. She said the resident always would make a " big roll " when asked to assist with turning. CNA Z said she would always tell the resident to be careful because she was going to roll herself out the bed. During an interview on [DATE] at 4:15 p.m., the MDS coordinator said the last MDS indicated Resident #17 was a 2 person assist with bed mobility; therefore 2 CNAs should have assisted the resident. During an interview on [DATE] at 4:25 p.m., the MDS coordinator said Resident #17's CNA Plan of Care dated [DATE] indicated the resident required 1 person assistance with mobility. The MDS coordinator said the CNA Plan of Care should have been changed to a 2 person assist with bed mobility when the last MDS was completed. During an interview on [DATE] at 3:57 p.m. the DON said it was the responsibility of every nurse to change the CNA Plan of Care sheets for the residents on their hall when changes occurred because that was the means of notifying the CNAs of any changes in care for a resident. 4. Physician orders [REDACTED].#4 was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] noted Resident #4 was totally dependent on the assistance of 2+ persons for bed mobility and had severely impaired cognitive skills for decision making. The resident had limited range of motion of all extremities and had a pressure ulcer. Nursing care plans dated [DATE] indicated Resident #4 was at risk for pressure ulcers and a stage 4 pressure ulcer. An intervention listed was "I need two persons to assist with repositioning to avoid skin friction/shearing." A nursing note dated [DATE] at 2:51 a.m,. completed by LVN A documented during incontinent care Resident # 4 slid off the bed onto the floor. During an interview on [DATE] at 2:40 p.m., the DON said she was unaware of the [DATE] incident when Resident #4 fell from the bed. The DON expected to be notified of incidents and expected incident reports to be completed. During an interview on [DATE] at 3:40 p.m., LVN A said she counseled CNA B, who was working the night shift on [DATE], for providing care alone when Resident #4 required 2 person care. The CMS 802 dated [DATE] indicated 56 residents required incontinent care, and 4 residents with wandering behavior.

Based on observation, interview, and record review, the facility failed to implement their policies and procedures to prohibit neglect for 4 of 18 residents reviewed for neglect (Resident #s 4, 11, 12 and 17). Resident #11 was at high risk for elopement. The resident left the faciity on two occasions and was found near the highway, 150 feet from the facility. The speed limt was 60 miles per hour. The facility did not implement interventions to ensure the resident did not leave the facility unsupervised. The facility did not implement interventions to ensure Resident # 12 did not leave the facility unsupervised. Resident #12 had a history of [REDACTED]. This failure could place 4 residents who had elopement behavior at risk for accident, injury, abuse and neglect, and death. This failure created an Immediate Jeopardy situation identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non-immediate Jeopardy: The facility did not provide adequate staff to prevent injury during incontinent care for Resident #s 4 and 17. Resident # 17 recieved a fracture. This failure could place 56 residents who required assistance with incontinent care at risk for abuse and neglect. Findings included: Immediate Jeopardy: 1. Physician orders [REDACTED].# 11 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] noted Resident #11 had no cognitive impairment and no wandering behavior. Nursing care plans updated [DATE] indicated Resident # 11 required one person assistance with all ambulation, had potential for falls/injury related to unsteady gait, had shortness of breath on exertion/activity, had poor vision related to [MEDICAL CONDITION] and had trouble concentrating or paying attention. The care plan did not address wandering or exit seeking behavior. An elopement risk assessment dated [DATE] indicated Resident # 11 was disoriented at all times and frequently wandered, had poor decision making skills, was not scared of dangerous situations, frequently reported to staff and family that she wanted to go home to Oklahoma, had left the facility and wandered outside, and constantly wandered with no fear. Incident Reports for Resident #11 noted the following: *[DATE] at 7:30 p.m., Resident # 11 was found out by the highway by a passerby. Resident # 11 said she was going home. *[DATE] at 9:51 a.m., Resident # 11 was found walking on the side of the highway in front of the facility by a visitor. During an observation on [DATE] at 5:48 p.m., the highway was approximately 150 feet from the facility. The speed limit was 60 miles per hour. A witness statement dated [DATE] indicated " ...I was coming in the driveway to the nursing home when I saw an older lady (Resident #11) with her walker going to the road. I came in the nursing home and asked was the lady supposed to be going to the road, because cars was coming... " Resident # 11's nursing notes indicated the following: *[DATE] at 3:20 a.m., Resident " ...was awake and confused to care and place. Refuses to put on shoes. Packed up all clothes, papers, and belongings and confused to care and staff. Requires 1 on 1 monitoring and redirections. Noted mental changes and increase in wandering and behaviors ..." *[DATE] 4:12 a.m., Resident " ...Confused and has been awake packing, up clothes and belongings most of the shift ... " *Addendum for [DATE] 5:09 p.m., " ...A lady entered the facility and stated that an elderly woman was out by the road. Resident found in driveway near the road ..." *[DATE] 4:20 a.m., " ...No attempts to leave or exit facility tonight. Staff to monitor closely. Confused and requires monitoring and redirecting ..." *[DATE] 10:58 a.m., " ...Resident remains disoriented. Requires frequent/constant staff monitoring secondary to wandering ..." *[DATE] 2:14 a.m., " ...Resident has been awake and pacing in hallways confused to care and happenings ..." *[DATE] 6:50 p.m., " ...Resident wandering around facility and exit seeking..." *[DATE] 10:40 a.m., " ...Resident continues with wandering behavior requiring monitoring by all staff. Frequently asking about catching a bus to various cities, and where the exit doors are. Requires redirection by staff several time per shift to ensure safety ...." *[DATE] 10:19 p.m., "Resident wandering outside heading towards road. Found by nursing staff and redirected to facility. Resident has shown increased desire to leave facility. Unable to state where she is doing. Resident stated she was looking for front gate ..." *[DATE] 9:46 p.m., " ...Resident wanders throughout facility during this shift. Resident continuously asks for deceased husband. PRN (as needed) [MEDICATION NAME] given due to resident attempting to leave facility..." *[DATE] 11:41 a.m., " ...Resident very confused and disoriented. Has packed up all her clothes and loaded them onto bedside table rolling it all down the hallway, stating that "I'm putting all of this in the car because I have to leave ...Insisting that she needs to go home to work. Resident requiring frequent to constant monitoring due to poor safety awareness..." *[DATE] 8:49 p.m., " ...Resident is exit seeking and packing her belongings stating that she is moving ..." *[DATE] 10:04 a.m., " ...Resident again gathering her clothes and belongings putting her clothes on top of her walker stating that she is leaving. Attempting to exit via front door ..." *[DATE] 1:07 p.m., " ...Resident restless, seeking exit from building. Resident is ambulatory with walker made several attempts and redirected by staff. Resident then came down hall pushing plastic 3 drawer container and carrying tall floor lamp stating that she is going to Oklahoma. Redirected with some difficulty to dining room ... " *[DATE] 9:30 a.m., " ...Resident up at nurses station ambulatory, trying to assist another resident. Resident is talking in a rather confused fashion about looking for her husband and going to Jefferson ....Looking for the way out, going to several different doors ..." *[DATE] 9:55 a.m., " ...Visitor came to nurses desk to report a resident was at the edge of the road with her walker ....staff went immediately to return resident ..." *[DATE] 11:00 p.m., " ...Resident has been ambulating thru facility ...confused and looking for her car ....went to back door of Hall 400 and attempted to exit ....will continue to monitor every 30 minutes due to high wander risk..." *[DATE] 3:30 p.m., " ...Resident continuously attempting to elope at front door. Resident will sit for at least 10 minutes and begin to ambulate and attempt to elope again out of one of the doors ... " *[DATE] 4:00 p.m., " ...Resident was not in the lobby sitting, not around the nurses station, not in the dining room. Alert was called per CNA to look for resident. We went in rooms, bathroom, outside around facility, up and down the road to make sure she had not left facility property. Resident found walking down 100 hallway ..." *[DATE] 8:14 p.m., " ...Exit seeking noted. Visual 30 minute monitoring by staff ..." During an observation and interview on [DATE] at 4:35 p.m., Resident #11 ambulated independently with a walker throughout the facility. The resident had some personal belongings in a pink bucket sitting on her walker ' s seat. Resident #11 said she was trying to figure out what to do. The resident said she was making her way home. Resident #11 stated "someone is going to have to get those girls." Resident #11 was unable to answer questions appropriately. During an interview on [DATE] at 4:55 p.m., CNA R said Resident # 11 was confused and wandered. He said Resident # 11 was not supposed to go outside, alone, but she did and staff had to go and get her and bring her back. He said he did not currently know where Resident # 11 was located. CNA R checked Resident # 11 ' s room and she was not there. CNA R looked outside for Resident # 11 and she was not outside. CNA R located Resident # 11 on a different hall than the one she lived on. CNA R said staff had been told to watch Resident # 11 and a couple of other residents due to wandering behaviors. He said no one was specifically assigned to watch Resident # 11. Everyone in the facility was supposed to watch her to make sure she did not try to leave. During an interview on [DATE] at 5:05 p.m., LVN S said Resident # 11 was "extremely " high risk for elopement. She said Resident # 11 tried to leave out using all the exit doors. LVN S said Resident # 11 left the building by herself on previous occasions. She said all staff was aware of Resident # 11's elopement behaviors and were instructed to watch her closely. She said staff was informed verbally Resident # 11 was at high risk for elopement. She said no specific staff was assigned to watch Resident # 11. She said all staff was responsible for watching the resident. During an interview on [DATE] at 5:10 p.m., the DON said she had been employed as the DON for approximately 1 month. The DON said, Resident #11 was confused and wandered. The DON said Resident # 11 was always trying to go home to Oklahoma. The DON said the plan for keeping Resident #11 safe was for all staff to keep an eye on her. She said all staff knew Resident # 11 was at risk for leaving the facility. The DON said no specific staff was assigned to watch Resident #11. She said there was no time frame for checking on Resident #11 and there was no written form of communicating when and where Resident #11 was visualized. The DON said the front door did not require a code for entering and leaving prior to 10:00 p.m. After that time, the front door lock was activated and required a code for entering and leaving. The DON said all side door locks were always activated. She said the side doors alarmed when the push bar was pressed. The side doors would open after the push bar was held down for ,[DATE] seconds. The DON said the current system for watching Resident # 11 was working. She said last week ([DATE]) staff could not find Resident #11 and the staff called the DON. She said everyone searched and they found Resident #11 in another resident's room. The DON said she had not updated the care plan specifying a plan to address Resident # 11's elopement risk. She said she put a note in the CNA's care plan. During an interview on [DATE] at 11:00 a.m., LVN F said she was working when Resident #11 left the building on [DATE]. LVN F said she did not know Resident # 11 was outside. She said a visitor came inside and reported Resident # 11 was out by the road. LVN F said Resident # 11 was on the edge of the highway with her walker. She said LVN K ran outside and brought Resident # 11 back inside. LVN F said staff did not know Resident # 11 went outside. She said Resident # 11 was never supposed to be outside unsupervised. During an interview on [DATE] at 11:30 a.m., LVN K said he was pushing his treatment cart down Hall 100 on [DATE] when he looked out the side door and saw Resident #11 on the edge of the highway. He said he ran out the side door and directed the resident back inside. He said Resident # 11 was out of breath and told him she was going to Oklahoma. LVN K said he did not know Resident # 11 was outside the facility. During an interview on [DATE] at 1:30 p.m., RA W said she worked on [DATE] and a woman came in from outside and said an elderly woman was out in the road. RA W said she did not know Resident # 11 was outside. 2. Physician orders [REDACTED].#12 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #12 had severe impaired cognition and exhibited the behavior of wandering on a daily basis. The most recent care plan updated on [DATE] indicated the resident had confusion due to a [DIAGNOSES REDACTED]. Staff was to monitor the resident's whereabouts frequently, encourage the resident not to go outside unsupervised and have a wander guard in place. During an interview on [DATE] at 1:30 p.m., the administrator said the facility did not have a wander guard system. She said she would check to see why care plans mentioned its use. A physician's progress note dated [DATE] indicated Resident #12 was "...not oriented to person, place, day, date, or time..." An incident and accident report dated [DATE] at 5:46 p.m. indicated Resident #12 was trying to leave the facility. The report indicated the resident left twice and on the first attempt the resident fell and scraped her knee. A nursing note dated [DATE] at 10:52 p.m., indicated Resident #12 attempted to leave the facility twice; she fell to her knee on the first attempt; and on the second attempt at leaving she was caught in the field behind the facility with four hangers of clothing. During observations on [DATE] the following were noted: *at 10:38 a.m., Resident #12 was observed sitting in the dining room attending an activity. A wander guard alarm was not observed on the resident. *at 3:30 p.m., Resident #12 was observed ambulating around the nursing station and front lobby area. The resident was observed /standing in the front lobby near the main entrance door. A wander guard alarm was not observed on the resident. During an interview on [DATE] at 5:30 p.m., the DON said Resident #12 walked around the outside of the facility on a daily basis. She said the resident was not considered an elopement risk. The DON said she was not working at the facility when Resident #12 was found outside in the "field." During an interview on [DATE] at 10:48 a.m., LVN P said Resident #12 was confused, ambulatory and required minimal assistance with ADLs. She said she knew at one time the resident left the facility twice during one shift. She said Resident #2 was found outside the back of the facility carrying her clothing. During an interview on [DATE] at 1:45 p.m., the MDS coordinator said the facility did not have a wander guard system. She said Resident #12 had standard care plans when she transferred to the facility that included the use of a wander guard system. The MDS coordinator said the care plan should have been revised. During an interview on [DATE] at 11:05 a.m., the administrator said she was not working at the facility when Resident #12 was found outside the facility. She said she would have expected the staff to fill out an incident and accident form. An undated Abuse and Neglect policy indicated " ...The health care center will ensure a safe environment for residents by prohibiting physical and mental abuse including involuntary seclusion, neglect and misappropriation of resident property ... " The abuse and neglect policy defined neglect as " ... includes but it is not limited to the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." An Elopement policy dated 2001 indicated the director of nursing services or the charge nurse shall "... staff shall investigate and report all cases of missing residents..." and "...complete and file Report of Incident/Accident... " An Accidents and Incidents policy dated 2001 indicated " ... All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. " The administrator and DON were notified on [DATE] at 5:30 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 8:38 p.m., and included: Immediately reviewed and updated all elopement risk assessments. Resident #11's Elopement risk has been completed and Care Plan interventions updated. Immediately place Resident #11 on one-on one monitoring until such time as all exit doors with key pads were functional. Maintenance director/designee would check exit doors with key pads daily to ensure continue operation Any concerns regarding key pad operations will be reported to the administrator immediately and appropriate action will be taken. All residents would have elopement assessments completed on admission, not less than quarterly, and with a cognitive change of condition. All current residents would have Elopement Assessments reviewed and updated. Monitor all unalarmed doors (main entrance, dining room exit, and laundry exit) until keypads were functional. In-service staff in regards to proper operation of alarmed doors and notification of administrative staff in case of malfunctions. The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Five CNAs, 1 MA and 2 housekeepers were interviewed and said they were in-serviced regarding how to handle residents at risk for elopement. Four LVNs were interviewed and said they were in-serviced regarding how to handle residents at risk for elopement and completing assessments for residents at risk for elopement. All exit doors were observed and were functioning properly. On [DATE] at 11:35 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non Immediate Jeopardy 3. The consolidated physician orders [REDACTED].#17 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The most current MDS dated [DATE] indicated Resident #17 had clear speech with distinct intelligible words, was usually understood due to difficulty communicating some words or finishing thoughts but was able if prompted or given time. The resident could usually understand and comprehend most conversation. Resident #17's cognitive function was moderately impaired. She required extensive assistance with her ADL functions. The resident ' s bed mobility indicated she required extensive assistance of 2 person physical assist. A care plan updated [DATE] indicated Resident #17 had impaired mobility. Approaches were the resident would be assisted with positioning, transfers, as necessary. The CNA Care Plan sheet dated [DATE] indicated Resident #17 required 1 person assistance with mobility. A Resident Incident Report dated [DATE] at 6:29 a.m., indicated Resident #17 " ...fell out of bed with 2 CNAs assisting in changing her. No head injury, right shoulder pain ... " The incident was noted to have occurred at 5:30 a.m. The report indicated the resident's physician was notified at 5:42 a.m., the DON was notified at 6:29 a.m. and the family was notified at 6:38 a.m. The physician ordered an x-ray. The resident was noted to have a pain level of 7 on a scale of ,[DATE]. A nursing note dated [DATE] at 5:54 a.m., indicated Resident #17 fell out of bed while 2 CNAs were assisting her. A radiology report dated [DATE] indicated Resident #17 had a fractured right shoulder. During an interview on [DATE] at 3:30 p.m., LVN Y said CNA Z told her when CNA CC assisted Resident #17 she rolled out of the bed onto the floor. LVN Y said CNA Z said she assisted CNA CC with putting the resident back in bed. LVN Y said CNA Z said the resident was in so much pain it scared them and that was when CNA Z came to get me. During an interview on [DATE] at 2:34 p.m., CNA Z said on [DATE] CNA CC called her to Resident #17's room to help her get the resident off the floor. CNA Z said CNA CC was working alone with the resident. CNA Z said Resident #17 was a one person assist with all ADLs. She said the resident always would make a " big roll " when asked to assist with turning. CNA Z said she always told the resident to be careful because she was going to roll herself out the bed. During an interview on [DATE] at 4:15 p.m., the MDS coordinator said the last MDS indicated Resident #17 was a 2 person assist with bed mobility; therefore 2 CNAs should have assisted the resident. During an interview on [DATE] at 4:25 p.m., the MDS coordinator said Resident #17's CNA Plan of Care dated [DATE] indicated the resident required 1 person assistance with mobility. The MDS coordinator said the CNA Plan of Care should have been changed to a 2 person assist with bed mobility when the last MDS was completed. During an interview on [DATE] at 3:57 p.m., the DON said it was the responsibility of every nurse to change the CNA Plan of Care sheets for the residents on their hall when changes occurred. She said the CNA Plan of Care sheet was the means of notifying the CNAs of any changes in care for a resident. 4. Physician orders [REDACTED].#4 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] noted Resident #4 was totally dependent on the assistance of 2+ persons for bed mobility and had severely impaired cognitive skills for decision making. The resident had limited ROM of all extremities and had a pressure ulcer. Nursing care plans dated [DATE] indicated Resident #4 was at risk for pressure ulcers and a stage 4 pressure ulcer. An intervention listed was " ...I need two persons to assist with repositioning to avoid skin friction/shearing..." A nursing note dated [DATE] at 2:51 a.m., completed by LVN A documented during incontinent care Resident # 4 slid off the bed onto the floor. During an interview on [DATE] at 2:40 p.m., the DON said she was unaware of the [DATE] incident when Resident #4 fell from the bed. The DON expected to be notified of incidents and expected incident reports to be completed. During an interview on [DATE] at 3:40 p.m., LVN A said she counseled CNA B, who was working the night shift on [DATE], for providing care alone when Resident #4 required 2 person for care. The CMS 672 dated [DATE] indicated 56 residents required incontinent care. A list dated [DATE] indicated 4 residents with wandering behavior.

Based on interview and record review, the facility failed to ensure incidents of neglect and an allegation of physical and verbal abuse were thoroughly investigated and reported to the state agency for 4 of 18 residents reviewed for abuse and neglect (Resident #s 4, 11, 12 and 18) The facility did not report and thoroughly investigate incidents of neglect for Resident #s 4, 11, and 12. An allegation of verbal and physical abuse of Resident #18 was not thoroughly investigated and reported to the state agency. This failure created an Immediate Jeopardy situation identified on 7/8/14. The Immediate Jeopardy was removed on 7/10/14. The facility remained out of compliance at a pattern actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 83 residents at risk for abuse and neglect. Findings included: Immediate Jeopardy 1. Physician orders [REDACTED].# 11 was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] noted Resident #11 had no cognitive impairment and no wandering behavior. The care plans updated 7/3/14 indicated Resident # 11 required one person assistance with all ambulation, had potential for falls/injury related to unsteady gait, had shortness of breath on exertion/activity, had poor vision related to [MEDICAL CONDITION] and had trouble concentrating or paying attention. The care plan did not address wandering or exit seeking behavior. Incident Reports for Resident #11 noted the following: *5/9/14 at 7:30 p.m., Resident # 11 was found out by the highway by a passerby. Resident # 11 said she was going home. No investigation was attached. *6/30/14 at 9:51 a.m., Resident # 11 was found walking on the side of the highway in front of the facility by a visitor. No investigation was attached. A witness statement dated 6/30/14 indicated "... I was coming in the driveway to the nursing home when I saw an older lady (Resident #17) with her walker going to the road. I came in the nursing home and asked was the lady supposed to be going to the road, because cars was coming..." Nursing notes for Resident # 11's indicated the following: *5/9/14 4:12 a.m., Resident "...Confused and has been awake packing, up clothes and belongings most of the shift..." *Addendum for 5/9/14 5:09 p.m., "...A lady entered the facility and stated that an elderly woman was out by the road. Resident found in driveway near the road..." *6/30/14 9:30 a.m., "...Resident up at nurses station ambulatory, trying to assist another resident. Resident is talking in a rather confused fashion about looking for her husband and going to Jefferson ....Looking for the way out, going to several different doors..." *6/30/14 9:55 a.m., "...Visitor came to nurses desk to report a resident was at the edge of the road with her walker ....staff went immediately to return resident..." *6/30/14 11:00 p.m., "...Resident has been ambulating thru facility ...confused and looking for her car ....went to back door of Hall 400 and attempted to exit ....will continue to monitor every 30 minutes due to high wander risk..." *7/2/14 4:00 p.m., "...Resident was not in the lobby sitting, not around the nurses station, not in the dining room. Alert was called per CNA to look for resident. We went in rooms, bathroom, outside around facility, up and down the road to make sure she had not left facility property. Resident found walking down 100 hallway..." An elopement risk assessment dated [DATE] indicated Resident # 11 was disoriented at all times and frequently wandered, had poor decision making skills, was not scared of dangerous situations, frequently reported to staff and family that she wanted to go home to Oklahoma, had left the facility and wandered outside, and constantly wandered with no fear. During an observation and interview on 7/8/14 at 4:35 p.m., Resident #11 ambulated independently with a walker throughout the facility. The Resident had some personal belongings in a pink bucket sitting on her walker ' s seat. The resident said she was trying to figure out what to do. The resident said she was making her way home. Resident #11 stated "someone is going to have to get those girls." Resident #11 was unable to answer questions appropriately. During an interview on 7/8/14 at 4:55 p.m., CNA R said Resident # 11 was confused and wandered. He said he did not currently know where Resident # 11 was located. He said Resident # 11 would go outside alone. CNA R checked Resident # 11's room and she was not there. CNA R looked outside for Resident # 11 and she was not outside. CNA R located Resident # 11 on a different hall than the one she lived. CNA R said Resident # 11 was not supposed to go outside alone. During an interview on 7/8/14 at 5:05 p.m., LVN S said Resident # 11 was "extremely" high risk for elopement. She said Resident # 11 tried to leave out using all the exit doors. LVN S said Resident # 11 left the building by herself on previous occasions. During an interview on 7/10/14 at 10:00 a.m., the DON said she did not feel she needed to report the incidents of Resident # 11 leaving the facility to the state agency, because staff found her on the property. She said staff knew Resident # 11 was outside. During an interview on 7/10/14 at 11:00 a.m., LVN F said Resident #11 left the building on 6/30/14. LVN F said she did not know Resident # 11 was outside. She said a visitor came inside and told staff Resident # 11 was out by the highway. LVN F said Resident # 11 was on the edge of the highway with her walker. She said Resident # 11 was never supposed to be outside unsupervised. 2. Physician orders [REDACTED].#18, admitted on [DATE] was [AGE] years old with [DIAGNOSES REDACTED]. Resident was discharged from the facility on 5/25/14. A Face Sheet dated 6/25/14 indicated Resident #18 was discharged on [DATE]. A MDS assessment dated [DATE] indicated Resident #18 was cognitively intact, required staff assistance of one person with bed mobility, transfers, ambulation, hygiene, bathing and dressing, and was unsteady in walking and turning. A care plan dated 3/18/14 indicated Resident #18 had impaired mobility, and unsteady gait. The resident was noted to have a history of falling, muscle weakness and required assistance with transfers and at times. A grievance/complaint report dated 3/11/14 completed by the previous SW indicated Resident # 18 made the following complaint: Resident said he was attempting to walk with walker from bed to bathroom. He said he began to struggle with his balance. The CNA was across the hall in another resident ' s room watching him walk. She began yelling at him saying " I know you can stand. You are faking your disability. I ' m not gonna help you. " She then came into the room and pushed me on the right shoulder forcing me to sit on the bed. She said, " I am not gonna help you, you can just sit there " . Resident stated, " she is a bully, she intimidates me. " Resident described CNA as " black, tall, not fat but big, around 240 lbs., with tattoos on her arm, one tattoo says " Rickie " . CNA told resident she was moving to Houston to get back with her boyfriend. Resident stated the incident happened on Saturday during morning hours." The grievance/complaint report indicated Resident # 18's roommate was interviewed and said the incident did not occur. The report indicated the CNA was moved to another hall and no further investigation was completed. During an interview on 7/9/14 at 1:15 p.m., the administrator said she was not employed when the incident with Resident # 18 occurred. She said she did not find documentation the incident was investigated or reported to the state agency. She said she would have expected a complete investigation regarding the incident and would have reported the event to the state agency. She said she would have expected staff and residents to be interviewed and asked specifically about abuse and neglect. During an interview on 7/9/14 at 1:20 p.m., the DON said she was not employed by the facility when the incident involving Resident # 18 occurred. She said she would have investigated and reported the incident to the state agency. She said she would have interviewed staff and residents about abuse. 3. Physician orders [REDACTED].#4 was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] noted Resident #4 was totally dependent on the assistance of 2+ persons for bed mobility and had severely impaired cognitive skills for decision making. The resident had limited range of motion of all extremities and had a pressure ulcer. Nursing care plans dated 4/22/14 indicated Resident #4 was at risk for pressure ulcers and a stage 4 pressure ulcer. An intervention listed was "...I need two persons to assist with repositioning to avoid skin friction/shearing..." A nursing note dated 6/28/14 at 2:51 a.m., completed by LVN A documented during incontinent care Resident # 4 slid off the bed onto the floor. During an interview on 7/10/14 at 2:40 p.m., the DON said she was unaware of the 6/28/14 incident when Resident #4 fell from the bed. The DON expected to be notified of incidents and expected incident reports to be completed. During an interview on 7/10/14 at 3:40 p.m., LVN A said she counseled CNA B, who worked the night shift on 6/27/14, for providing care alone when Resident #4 required 2 person for care. A incident reports from January to July 2014 did not document an incident on 7/10/14 at 3:42 p.m. regarding Resident #4 falling from the bed. During an interview on 7/10/14 at 3:58 p.m., the DON said no incident report was completed regarding Resident #4's fall. The administrator said she was not aware of the incident and there was no counseling found in CNA B's personnel file. The DON again said she was not notified of the incident. 4. Physician orders [REDACTED].#12 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #12 had severe impaired cognition and exhibited the behavior of wandering on a daily basis. The most recent care plan updated on 06/18/14 indicated the resident had confusion due to a [DIAGNOSES REDACTED]. A physician's progress note dated 06/21/14 indicated Resident #12 was "...not oriented to person, place, day, date, or time..." An incident and accident report dated 03/10/14 at 5:46 p.m., indicated Resident #12 was trying to leave the facility. The report indicated the resident left twice and on the first attempt the resident fell and scraped her knee. A nursing note dated 03/10/14 at 10:52 p.m., indicated Resident #12 attempted to leave the facility twice; she fell to her knee on the first attempt; and on the second attempt at leaving she was caught in the field behind the facility with four hangers of clothing. During observations on 07/09/14 the following were noted: *at 10:38 a.m., Resident #12 was observed sitting in the dining room attending an activity. A wander guard alarm was not observed on the resident. *at 3:30 p.m., Resident #12 was observed ambulating around the nursing station and front lobby area. The resident was observed /standing in the front lobby near the main entrance door. A wander guard alarm was not observed on the resident. During an interview on 07/08/14 at 5:30 p.m., The DON said Resident #12 walked around the outside of the facility on a daily basis and was not considered an elopement risk. The DON said she was not working at the facility when Resident #12 was found outside in the "field". During an interview on 07/10/14 at 11:05 a.m., the administrator said she was not working at the facility when Resident #12 was found outside the facility. She said she would have expected the staff to fill out an incident and accident form. The administrator said she did not know if the incident was reported to the state agency. An Elopement policy dated 2001 indicated the director of nursing services or the charge nurse shall "... staff shall investigate and report all cases of missing residents..." and "...complete and file Report of Incident/Accident... " An Accidents and Incidents policy dated 2001 indicated "... All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident..." An undated Abuse and Neglect policy indicated "...The health care center will ensure a safe environment for residents by prohibiting physical and mental abuse including involuntary seclusion, neglect and misappropriation of resident property. The health care center establishes and implements mechanisms for reporting, investigating, and protecting residents from actual or potential harm. The health care center will conduct an investigation of all alleged or suspected cases of abuse, neglect or misappropriation of property, and will provide notifications and information to the proper authorities according to state and federal regulations. "The facility's abuse and neglect policy defines neglect as " ... includes but it is not limited to the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. " The facility ' s policy also indicated as a preventative measure the " ... Health care center staff will immediately report and protect the resident if an allegation or observation of abuse has occurred. " The facility's policy also indicated as a part of the investigative process "1.The health care center will thoroughly investigate all allegations and take appropriate actions. 2. Investigations will be prompt, comprehensive and responsive to the situation ". The facility's abuse and neglect policy indicated as a form of protection "1. All residents will be immediately protected from harm. 2. Allegations involving staff who has been identified will result in the immediate suspension pending the investigation. " The facility's policy also indicated "the health care center will report allegations to the state agency in accordance with state law ...the health care center will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law... " An Elopement policy dated 2001 indicated the director of nursing services or the charge nurse shall "... staff shall investigate and report all cases of missing residents..." and "...complete and file Report of Incident/Accident... " An Accidents and Incidents policy dated 2001 indicated " ... All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. " The administrator and DON were notified on 7/8/14 at 5:30 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/8/14 at 8:38 p.m., and included: Immediately reviewed and updated all elopement risk assessments. Resident #11's Elopement risk has been completed and Care Plan interventions updated. Immediately place Resident #11 on one-on one monitoring until such time as all exit doors with key pads were functional. Maintenance director/designee would check exit doors with key pads daily to ensure continue operation Any concerns regarding key pad operations will be reported to the administrator immediately and appropriate action will be taken. All residents would have elopement assessments completed on admission, not less than quarterly, and with a cognitive change of condition. All current residents would have Elopement Assessments reviewed and updated. Monitor all unalarmed doors (main entrance, dining room exit, and laundry exit) until keypads were functional. In-service staff in regards to proper operation of alarmed doors and notification of administrative staff in case of malfunctions. The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Five CNAs, 1 MA and 2 housekeepers were interviewed and said they were in-serviced regarding how to handle residents at risk for elopement. Four LVNs were interviewed and said they were in-serviced regarding how to handle residents at risk for elopement and completing assessments for residents at risk for elopement. All exit doors were observed and were functioning properly. On 7/10/14 at 11:35 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 07/08/14 indicated a census of 83 residents.

Based on interview, record review and observations the facility failed to implement their written policies and procedures to prohibit neglect, mistreatment, and abuse for 4 of 18 residents reviewed for abuse and neglect (Resident #s 4, 11, 12 and 18) The facility did not report and thoroughly investigate incidents of neglect for Resident #s 4, 11, and 12. An allegation of verbal and physical abuse of Resident #18 was not thoroughly investigated and reported to the state agency. This failure created an Immediate Jeopardy situation identified on 7/8/14. The Immediate Jeopardy was removed on 7/10/14. The facility remained out of compliance at a pattern actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 83 residents at risk for abuse and neglect. Findings included: Immediate Jeopardy An undated Abuse and Neglect policy indicated "...The health care center will ensure a safe environment for residents by prohibiting physical and mental abuse including involuntary seclusion, neglect and misappropriation of resident property. The health care center establishes and implements mechanisms for reporting, investigating, and protecting residents from actual or potential harm. The health care center will conduct an investigation of all alleged or suspected cases of abuse, neglect or misappropriation of property, and will provide notifications and information to the proper authorities according to state and federal regulations. "The facility ' s abuse and neglect policy defines neglect as " ... includes but it is not limited to the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. " The facility ' s policy also indicated as a preventative measure the " ... Health care center staff will immediately report and protect the resident if an allegation or observation of abuse has occurred. " The facility ' s policy also indicated as a part of the investigative process " 1.The health care center will thoroughly investigate all allegations and take appropriate actions. 2. Investigations will be prompt, comprehensive and responsive to the situation ". The facility's abuse and neglect policy indicated as a form of protection "1. All residents will be immediately protected from harm. 2. Allegations involving staff who has been identified will result in the immediate suspension pending the investigation. " The facility's policy also indicated "the health care center will report allegations to the state agency in accordance with state law ...the health care center will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law..." An Elopement policy dated 2001 indicated the director of nursing services or the charge nurse " shall investigate and report all cases of missing residents ...complete and file Report of Incident/Accident..." An Accidents and Incidents policy dated 2001 indicated "... All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident..." 1. Physician orders [REDACTED]. A [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] noted Resident #11 had no cognitive impairment and no wandering behavior. Nursing care plans updated 7/3/14 indicated Resident # 11 required one person assistance with all ambulation, had potential for falls/injury related to unsteady gait, had shortness of breath on exertion/activity, had poor vision related to [MEDICAL CONDITION] and had trouble concentrating or paying attention. The care plan did not address wandering or exit seeking behavior. Incident Reports for Resident #11 noted the following: *5/9/14 at 7:30 p.m., Resident # 11 was found out by the highway by a passerby. Resident # 11 said she was going home. *6/30/14 at 9:51 a.m., Resident # 11 was found walking on the side of the highway in front of the facility by a visitor. A witness statement dated 6/30/14 indicated " I was coming in the driveway to the nursing home when I saw an older lady (Resident #17) with her walker going to the road. I came in the nursing home and asked was the lady supposed to be going to the road, because cars was coming. " Review of Resident # 11 ' s nursing notes indicated the following: *5/9/14 4:12 a.m. Resident "Confused and has been awake packing, up clothes and belongings most of the shift ". *Addendum for 5/9/14 5:09 p.m. "A lady entered the facility and stated that an elderly woman was out by the road. Resident found in driveway near the road." *6/30/14 9:30 a.m. "Resident up at nurses station ambulatory, trying to assist another resident. Resident is talking in a rather confused fashion about looking for her husband and going to Jefferson ....Looking for the way out, going to several different doors." *6/30/14 9:55 a.m. "Visitor came to nurses desk to report a resident was at the edge of the road with her walker ....staff went immediately to return resident." *6/30/14 11:00 p.m. "Resident has been ambulating thru facility ...confused and looking for her car ....went to back door of Hall 400 and attempted to exit ....will continue to monitor every 30 minutes due to high wander risk." *7/2/14 4:00 p.m. "Resident was not in the lobby sitting, not around the nurses station, not in the dining room. Alert was called per CNA to look for resident. We went in rooms, bathroom, outside around facility, up and down the road to make sure she had not left facility property. Resident found walking down 100 hallway." An elopement risk assessment dated [DATE] indicated Resident # 11 was disoriented at all times and frequently wandered, had poor decision making skills, was not scared of dangerous situations, frequently reported to staff and family that she wanted to go home to Oklahoma, had left the facility and wandered outside, and constantly wandered with no fear. During an observation and interview on 7/8/14 at 4:35 p.m., Resident #11 ambulated independently with a walker throughout the facility. The Resident had some personal belongings in a pink bucket sitting on her walker ' s seat. The resident said she was trying to figure out what to do. The resident said she was making her way home. Resident #11 stated "someone is going to have to get those girls". Resident #11 was unable to answer questions appropriately. During an interview on 7/8/14 at 4:55 p.m. CNA R said Resident # 11 was confused and wandered. He said he did not currently know where Resident # 11 was located. He said Resident # 11 would go outside alone. CNA R checked Resident # 11 ' s room and she was not there. CNA R looked outside for Resident # 11 and she was not outside. CNA R located Resident # 11 on a different hall than the one she lived. CNA R said Resident # 11 was not supposed to go outside alone. During an interview on 7/8/14 at 5:05 p.m. LVN S said Resident # 11 was " extremely " high risk for elopement. She said Resident # 11 tried to leave out using all the exit doors. LVN S said Resident # 11 left the building by herself on previous occasions. During an interview on 7/10/14 at 10:00 a.m. the DON said she did feel she needed to report the incidents of Resident # 11 leaving the facility to the state agency because Resident # 11 was found on the property and staff found the resident. She said staff knew Resident # 11 was outside. During an interview on 7/10/14 at 11:00 a.m. LVN F said Resident #11 left the building on 6/30/14. LVN F said she did not know Resident # 11 was outside. She said a visitor came inside and told staff Resident # 11 was out by the highway. LVN F said Resident # 11 was on the edge of the highway with her walker. She said Resident # 11 was never supposed to be outside unsupervised. 2. Physician orders [REDACTED].#18, admitted on [DATE] was [AGE] years old with [DIAGNOSES REDACTED]. Resident was discharged from the facility on 5/25/14. A Face Sheet dated 6/25/14 indicated Resident #18 was discharged on [DATE]. A MDS assessment dated [DATE] indicated Resident #18 was cognitively intact, required staff assistance of one person with bed mobility, transfers, ambulation, hygiene, bathing and dressing, and was unsteady in walking and turning. A care plan dated 3/18/14 indicated Resident #18 had impaired mobility, and unsteady gait. The resident was noted to have a history of falling, muscle weakness and required assistance with transfers and at times. A grievance/complaint report dated 3/11/14 completed by the previous SW indicated Resident # 18 made the following complaint: "Resident said he was attempting to walk with walker from bed to bathroom. He said he began to struggle with his balance. The CNA was across the hall in another resident ' s room watching him walk. She began yelling at him saying " I know you can stand. You are faking your disability. I'm not gonna help you. " She then came into the room and pushed me on the right shoulder forcing me to sit on the bed. She said, " I am not gonna help you, you can just sit there ". Resident stated, " She is a bully, she intimidates me. " Resident described CNA as " black, tall, not fat but big, around 240 lbs., with tattoos on her arm, one tattoo says " Rickie " . CNA told resident she was moving to Houston to get back with her boyfriend. Resident stated the incident happened on Saturday during morning hours." The grievance/complaint report indicated Resident # 18's roommate was interviewed and said the incident did not occur. The report indicated the CNA was moved to another hall and no further investigation was completed. During an interview on 7/9/14 at 1:15 p.m., the administrator said she was not employed when the incident with Resident # 18 occurred. She said she did not find documentation the incident was investigated or reported to the state agency. She said she would have expected a complete investigation regarding the incident and would have reported the event to the state agency. She said she would have expected staff and residents to be interviewed and asked specifically about abuse and neglect. During an interview on 7/9/14 at 1:20 p.m., the DON said she was not employed by the facility when the incident involving Resident # 18 occurred. She said she would have investigated and reported the incident to the state agency. She said she would have interviewed staff and residents about abuse. 3. Physician orders [REDACTED].#4 was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] noted Resident #4 was totally dependent on the assistance of 2+ persons for bed mobility and had severely impaired cognitive skills for decision making. The resident had limited range of motion of all extremities and had a pressure ulcer. Nursing care plans dated 4/22/14 indicated Resident #4 was at risk for pressure ulcers and a stage 4 pressure ulcer. An intervention listed was "...I need two persons to assist with repositioning to avoid skin friction/shearing..." A nursing note dated 6/28/14 at 2:51 a.m., completed by LVN A documented during incontinent care Resident # 4 slid off the bed onto the floor. During an interview on 7/10/14 at 2:40 p.m., the DON said she was unaware of the 6/28/14 incident when Resident #4 fell from the bed. The DON expected to be notified of incidents and expected incident reports to be completed. During an interview on 7/10/14 at 3:40 p.m., LVN A said she counseled CNA B, who worked the night shift on 6/27/14, for providing care alone when Resident #4 required 2 person for care. A incident reports from January to July 2014 did not document an incident on 7/10/14 at 3:42 p.m. regarding Resident #4 falling from the bed. During an interview on 7/10/14 at 3:58 p.m., the DON said no incident report was completed regarding Resident #4's fall. The administrator said she was not aware of the incident and there was no counseling found in CNA B's personnel file. The DON again said she was not notified of the incident. 4. Physician date June 2014 indicated Resident #12 was [AGE] years old and was admitted on [DATE] with the [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #12 had severe impaired cognition and exhibited the behavior of wandering on a daily basis. The most recent care plan updated on 06/18/14 indicated the resident had confusion due to a [DIAGNOSES REDACTED]. A physician's progress note dated 06/21/14 indicated Resident #12 was "not oriented to person, place, day, date, or time." An incident and accident report dated 03/10/14 at 5:46 p.m., indicated Resident #12 was trying to leave the facility. The report indicated the resident left twice and on the first attempt the resident fell and scraped her knee. A nursing note dated 03/10/14 at 10:52 p.m. indicated Resident #12 attempted to leave the facility twice; she fell to her knee on the first attempt; and on the second attempt at leaving she was caught in the field behind the facility with four hangers of clothing. During observations on 07/09/14 the following were noted: *at 10:38 a.m., Resident #12 was observed sitting in the dining room attending an activity. A wander guard alarm was not observed on the resident. *at 3:30 p.m., Resident #12 was observed ambulating around the nursing station and front lobby area. The resident was observed /standing in the front lobby near the main entrance door. A wander guard alarm was not observed on the resident. During an interview on 07/08/14 at 5:30 p.m., The DON said Resident #12 walked around the outside of the facility on a daily basis and was not considered an elopement risk. The DON said she was not working at the facility when Resident #12 was found outside in the "field." During an interview on 07/10/14 at 11:05 a.m., the administrator said she was not working at the facility when Resident #12 was found outside the facility. She said she would have expected the staff to fill out an incident and accident form. The administrator said she did not know if the incident was reported to the state agency. The administrator and DON were notified on 7/8/14 at 5:30 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/8/14 at 8:38 p.m., and included: Immediately reviewed and updated all elopement risk assessments. Resident #11's Elopement risk has been completed and Care Plan interventions updated. Immediately place Resident #11 on one-on one monitoring until such time as all exit doors with key pads were functional. Maintenance director/designee would check exit doors with key pads daily to ensure continue operation Any concerns regarding key pad operations will be reported to the administrator immediately and appropriate action will be taken. All residents would have elopement assessments completed on admission, not less than quarterly, and with a cognitive change of condition. All current residents would have Elopement Assessments reviewed and updated. Monitor all unalarmed doors (main entrance, dining room exit, and laundry exit) until keypads were functional. In-service staff in regards to proper operation of alarmed doors and notification of administrative staff in case of malfunctions. The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Five CNAs, 1 MA and 2 housekeepers were interviewed and said they were in-serviced regarding how to handle residents at risk for elopement. Four LVNs were interviewed and said they were in-serviced regarding how to handle residents at risk for elopement and completing assessments for residents at risk for elopement. All exit doors were observed and were functioning properly. On 7/10/14 at 11:35 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 07/08/14 indicated a census of 83 residents.

Based on observation, interview, and record review the facility failed to provide care and services to maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 (Resident #17) of 7 residents reviewed for pain and 2 of 2 residents reviewed with Foley catheters. (Residents #4 and Resident #6) *Resident #17 received a fracture of her right shoulder after rolling out of her bed during incontinent care. The resident was in pain and the facility did not provide pain medication for 2 hours. *Resident #s 4 and 6's Foley catheter tubing was not secured to prevent pulling and tension. This failure contributed to Resident #17 recieving a [MEDICAL CONDITION] shoulder. This failure could place 47 residents who received pain management, at risk for discomfort, delayed pain treatment and decreased quality of care and could place 2 residents with Foley catheters at risk for discomfort, urethral trauma, and UTIs. Findings included: 1. The Consolidated Physician Orders dated June 2014 indicated Resident #17 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had an order for [REDACTED]. The most current MDS dated [DATE] indicated Resident #17 had clear speech with distinct intelligible words, was usually understood due to difficulty communicating some words or finishing thoughts but was able if prompted or given time. The resident was usually understand and comprehended most conversation. Resident #17's cognitive function was moderately impaired. She required extensive assistance with her ADL functions. The resident ' s bed mobility indicated she required extensive assistance of 2 person physical assist. The CNA Care Plan sheet dated 05/09/14 indicated Resident #17 required 1 person assistance with mobility. A care plan updated 04/07/14 indicated Resident #17 received pain medications due to complaints of pain. The goal was for the resident to be kept comfortable. The approaches/interventions indicated the resident would receive pain medication as ordered. A Resident Incident Report dated 06/25/14 at 6:29 a.m. indicated Resident #17 "fell out of bed with 2 CNAs assisting in changing her. No head injury, right shoulder pain. " The incident was noted to have occurred at 5:30 a.m. The report indicated the resident's physician was notified at 5:42 a.m., the DON was notified at 6:29 a.m. and the family was notified at 6:38 a.m. The physician ordered an x-ray. The resident was noted to have a pain level of 7 out of a pain scale of 10. Nursing notes for Resident #17 dated 06/25/14 indicated the following: *5:54 a.m. - Resident fell out of bed while 2 CNAs were assisting her. Witnessed fall no head injury. Doctor notified and an x-ray requested due to pain and non-movement. *10:26 a.m. - medication follow up ([MEDICATION NAME] 5-325 tablet 1 by mouth every 6 hour) medication was effective. *10:27 a.m. - 6:00 a.m. resident assessed, in bed alert speech clear and appropriate, noted bruise and swelling to left outer upper corner of eye, complained of right arm/elbow pain and limited range of movement. *10:31 a.m. - 7:20 a.m. Resident complained of increasing pain to right shoulder medicated with as needed [MEDICATION NAME] 5/325 1 tablet by mouth. *1:41 p.m. - 8:30 a.m. Some relief of pain noted Resident still grimaces and complains with any movements positioned for comfort, arm propped on pillow. *1:48 p.m. - 10:20 a.m. Resident complained of continuing pain to right shoulder medicated with [MEDICATION NAME] 5/325 1 tablet by mouth. Family at bedside questioning why x-ray has not been done yet, call placed to mobile x-ray, estimated time of arrival 90 minutes, family informed, offered alternative of sending resident to the emergency room , family declined. *1:56 p.m. - 11:55 a.m. mobile x-ray present and x-ray of right shoulder done. * 1:57 p.m. - 12:40 p.m. X-ray results received family notified and agreed to transfer to hospital, 911 called. *2:17 p.m. - 1:15 p.m. Ambulance present and transferred the resident to the hospital. Resident #17's clinical record indicated the physician was not notified of any head injuries once a knot was found on the resident's left eyebrow area. The MAR indicated [REDACTED] The June 2014 MAR indicated [REDACTED]. During an interview on 07/10/14 at 9:00 a.m., LVN F said Resident #17 did not receive any pain medication from 5:30 a.m. until she administered the first dose at 7:40 a.m. due to the resident not having the pain medication available and she had to call the pharmacy to receive the code to the emergency narcotic locked box and to re-order the resident's [MEDICATION NAME]. LVN F said the nurses were not given the code to the narcotic emergency locked box when the box was delivered each month. LVN F said they had to call and obtain the code from the pharmacist each time a medication was removed. During an interview on 07/10/14 at 2:34 p.m. CNA Z said on 06/25/14 CNA CC called her to Resident #17's room to help her get the resident off the floor. CNA Z said CNA CC was working alone with the resident. CNA Z said Resident #17 was a one person assist with all ADLs. She said the resident always would make a " big roll " when asked to assist with turning. CNA Z said she would always tell the resident to be careful because she was going to roll herself out the bed. CNA Z said Resident #17 kept saying her right shoulder was broke and that she was " stupid " because she rolled herself out of the bed. LVN Y looked at her arm, I went and got a sheet which and wrapped around her shoulder so no one would touch it and then CNA CC, LVN Y and I assisted the resident back into bed. CNA Z said she returned to check on Resident #17 before leaving 6:20 a.m. and the resident was still crying, kept saying her shoulder was broke and complained of the shoulder hurting. During an interview on 07/09/14 at 1:31 p.m. LVN F said she worked the 6-2 shift and was informed by the 10-6 shift nurse, LVN Y on 6/25/14, at around 5:30 a.m. CNA CC asked Resident #17 to roll over in the bed during care, and the resident rolled out of bed. LVN F said LVN Y said Resident #17 was complaining of right shoulder pain, had a bruise to her left eyebrow area and had no other injuries. LVN F said she checked on Resident #17 at about 6:15 to 6:20 a.m. She said she checked the resident's vital signs, conducted a neurological check and looked at the resident's arm. LVN F said Resident #17 complained of pain and "I tried to position her arm in a more comfortable position." LVN F said whenever anyone tried to re-position the resident's right arm she would, grimace, wince, and moan and there were tears. LVN F said she gave Resident #17 a pain pill shortly after checking on her. LVN F said she was unable to remember around what time she gave the pain medication other than to say the resident ' s family showed up shortly after she gave the [MEDICATION NAME] 5-325 tablet. LVN F said to her knowledge the resident had not been provided any pain medication by LVN Y. LVN F said she offered to send Resident #17 to the emergency room but the family declined not wanting the resident moved too much. LVN F said she gave the resident another [MEDICATION NAME] at about 10:30 to 10:45 a.m. The mobile x-ray arrived " right before noon " and indicated Resident #17's right shoulder was fractured and the resident was sent to the hospital. During an interview on 07/09/14 at 2:00 p.m. Resident #17's family member said they arrived at the facility at about 8:00 a.m. on 06/25/14 after being notified of the resident ' s fall. The family member said when they arrived they asked did the resident need to go to the hospital and the nurse present said no an x-ray was ordered and the resident did not need to go to the emergency room if the arm was not broken. The family member said when they arrived that morning, "I do not believe my mother had been given anything for pain. " The family member said the resident was having a great deal of pain, her face was all bruised up, and they did not even have ice on her arm nor the " goose egg " to her left eye brow area or the " goose egg " to the right cheek area. During an interview on 07/09/14 at 2:16 p.m. the DON said if a resident was complaining of pain she would expect the nurse to complete a pain assessment and give pain medication. The DON said the nurse that did the initial assessment should have initiated neurological checks with this fall after finding that the resident had hit her head. The DON said when she was first notified of the incident LVN Y indicated there was no head injury. An investigation was immediately started and CNA Z and CNA CC indicated they had attempted to put Resident #17 back in the bed prior to a nurse assessing the resident. The DON said no staff should attempt to move a resident prior to a nurse assessing the resident and giving approval for the transfer. The CNAs were in-serviced. During an interview on 07/09/14 at 3:30 p.m. LVN Y said she was the nurse on duty at the time of Resident #17's incident on 6/25/14. LVN Y said CNA Z told her when CNA CC was assisting Resident #17 the resident rolled out of the bed onto the floor. LVN Y said CNA Z said CNA CC asked her to assist with putting the resident back in her bed. LVN Y said CNA Z said the resident was in so much pain it scared them and that was when CNA Z came to get me. LVN Y said it was not a common practice for staff to move a resident that fell before an assessment was done. LVN Y said Resident #17 did not receive any pain medication from the time the incident occurred at 5:30 a.m. until LVN F administered the pain medication because the resident did not have any of her as needed [MEDICATION NAME] in the building and she could not get into the narcotic emergency medication box. LVN Y said LVN F called the pharmacy to obtain the code to the narcotic emergency medication box due to Resident #17 not having any pain medication available. LVN Y said the resident was not in any excruciating pain, she was just saying "why me" and moaning because she was concerned that she did not have a functioning arm since she had left side paralysis and now she could not utilize her right arm. LVN Y said during her first head to toe assessment of Resident #17 around 5:30 a.m. the resident did not have a knot or bruising to her head area. LVN Y said she first learned about the knot to Resident #17's left forehead area from LVN F. LVN Y said an addendum was made to the incident report. LVN Y said the doctor was not notified of the head injury. LVN Y said she did not send the resident out upon finding she had a head injury as she was sure the oncoming nurse, LVN F, was going to send her. During an interview on 07/09/14 at 4:15 p.m. the MDS coordinator said the last MDS indicated Resident #17 was a 2 person assist with bed mobility; therefore 2 CNAs should have assisted the resident. During an interview on 07/09/14 at 4:25 p.m. the MDS coordinator said Resident #17's CNA Plan of Care dated 05/09/14 indicated the resident required 1 person assistance with mobility. The MDS coordinator said the CNA Plan of Care should have been changed to a 2 person assist with bed mobility when the last MDS was completed. During an interview on 07/10/14 at 3:57 p.m. the DON said it was the responsibility of every nurse to change the CNA Plan of Care sheets for the residents on their hall when changes occurred because that was the means of notifying the CNAs of any changes in care for a resident. The DON said any time a resident was in so much pain they were crying and indicating something was broken she would expect that resident to be sent out to the hospital. She said during the initial assessment Resident #17 did not have signs that she had hit her head but if during a second observation a knot was noted to the head area she would expect the physician to be notified. 2. Physician orders dated June 2014 indicated Resident #4, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The physician orders did not mention Resident #4's Foley catheter. The most recent MDS assessment dated [DATE] noted Resident #4 was totally dependent on the assistance of 2+ persons for bed mobility and had severely impaired cognitive skills for decision making. The resident had limited range of motion of all extremities, and one stage 4 pressure ulcer, present on admission. A nursing care plan dated 4/22/14 indicated Resident #4 had an indwelling catheter and listed an intervention " ...secure tubing to my thigh to prevent pulling..." During an observation and interview on 7/8/14 at 10:05 a.m., CNAs E and J were bathing Resident #4. The Foley catheter tubing was not secured to Resident #4's thigh. CNA E said she had never seen a thigh strap to secure catheter tubing at the facility. During an interview on 7/8/14 at 10:15 a.m., LVN F said she had never seen catheter leg straps at the facility. During an interview on 7/8/14 at 10:20 a.m., the DON said she expected leg straps to be used to secure catheter tubing on all residents with a catheter. During an observation on 7/8/14 at 10:20 a.m., LVN F applied a leg strap to secure the catheter of Resident #4. 3. Physician orders dated June 2014 documented Resident #6 admitted on [DATE], was [AGE] years old, and had [DIAGNOSES REDACTED]. Resident #6 had a Foley catheter and catheter care was to be provided each shift. The most recent quarterly MDS assessment dated [DATE] indicated Resident #6 was cognitively intact. Resident #6 had no behaviors of rejection of care. Resident #6 required extensive assistance with personal hygiene and support of two or more people for physical assist. Range of motion was impaired on both sides for both upper and lower extremities. Resident #6 had an indwelling catheter. Nursing care plans dated 4/30/14 indicated Resident # 8 had an indwelling catheter and had potential for UTI. Interventions indicated nursing staff were to provide indwelling catheter care every shift and as needed. The nursing care plan did not address securing Resident #6's catheter tubing. During an observation on 7/8/14 at 7:39 a.m., Resident #6 was provided wound care. His indwelling urinary catheter was not secured. During an observation on 7/8/14 at 9:23 a.m., Resident #6 was provided incontinent care. His indwelling urinary catheter was not secured. During an interview on 7/8/14 at 10:22 a.m., the DON indicated her expectation was for indwelling urinary catheters to be secured to residents' legs to prevent pulling and tension. During an interview on 7/8/14 at 1:50 p.m., LVN L indicated Resident #6's catheter tubing was not secured previously. LVN said the indwelling urinary catheter tubing was currently secured to his leg but had to be repositioned due to discomfort because "he's not used to it being there." During an interview on 7/10/14 at 9:30 a.m., DON indicated Resident #6 was not admitted with a Foley catheter. She said the Foley catheter was placed due to the pressure ulcer on his buttocks. The clinical record for Resident #6 did not indicate he refused the use of a leg strap for securing the indwelling urinary catheter tubing. The facility catheter care policy dated 2012 did not address the need to secure indwelling catheters to prevent pulling and tension. <http://www.drugs.com/cg/foley-catheter-placement-and-care.html accessed 7/21/14> indicated " Secure the catheter tube so you do not pull or move the catheter. This helps to prevent pain and bladder spasms. " <Http://www.nursingtimes.net/why-more-attention-must-be-given-to-catheter-fixation/ 63.article accessed 7/21/14> indicated the following " ...Failing to secure urinary catheters can result in complications, including infection and discomfort for patients. This article explores why catheter fixation is important and some of the devices that can be used to achieve it ... " The CMS 672 dated 7/8/14 indicated 4 residents had indwelling catheters and 47 residents were on a pain management program.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development and worsening of a pressure sore for 1 of 5 residents reviewed for pressure sores. (Resident #4) Resident #4 did not receive treatment to a facility acquired pressure sore that was red with a black center to her left hip. The physician was not notified when the wound opened. The pressure was not assessed. No treatment was provided for 6 days after the pressure sore opened. The resident did not have a pressure relieving mattress. The pressure sore worsened to a Stage III. This failure contributed to the decline of Resident #4's pressure sore and could place 5 residents with pressure sores at risk for developing new pressure sores and decline in existing pressure sores. Findings included: February 2013 consolidated physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #4 required extensive assistance from staff with transfers and ADLs. The resident was incontinent of bowel and bladder. The MDS indicated she was at risk for developing pressures sores but had no existing pressure sore. Resident #4's care plan did not address the pressure sore developed on 1/18/13. Nursing notes for Resident #4 indicated the following: 1/18/13 9:00 a.m. area to left hip was slightly red with a dark spot in the center. The area was reported to be abscess like. The physician was faxed. (There were no measurements) 1/19/13 Left hip area with black scab surrounding skin slightly reddened. The physician was faxed. 1/24/13 Notified DON of need to assess the resident's left hip due to wound. 1/25/13 1:00 a.m. Left hip with redness around the middle of site with warmth and small amount of drainage. 1/25/13 12:00 p.m., the physician was faxed. A physician order [REDACTED].#4's left hip with wound cleanser, pat dry, apply wound gel, cover with foam dressing, change daily and as needed for dislodgement or if soiled. The February 2013 TAR indicated Resident #4 did not receive treatment as ordered on 9 days (February 1, 2, 5, 6, 7, 11, 14, 15, and 21). During an observation on 2/25/13 at 1:38 p.m., Resident #4 was transferred from her wheelchair to the bed. The pressure sore to Resident #4's left hip was a Stage III. The wound bed was filled with white slough and greenish-yellow drainage was noted, the wound edges were pink, measured 3.2 cm x 2.1 cm the depth was 0.9 cm. The resident was on a regular scoop mattress (non-pressure relieving). During an interview on 2/25/13 at 2:41 p.m., LVN B said on 1/25/13, she was working the night shift when she noted the wound on Resident #4's left hip was open. She said she faxed the physician and told the day nurse to follow up. She said when she returned to work on 1/30/13 the resident still did not have a treatment. She said she stayed over the next morning to call the doctor. During an interview on 2/25/13 at 4:50 p.m., LVN A said she did the treatments for the month of January and the first 2 weeks of February 2013. She said the area to Resident #4's hip was a red area with a black center. LVN A said the area was not open when she did the treatments. She said she stopped doing treatment the week of February 18th and charge nurses were responsible for completing treatments. She said the physician should have been notified and treatment started within 24 hours since the wound changed. She said the wounds should be measured weekly. She said she did not do any measurements for Resident #4's wound. LVN A said the resident was on a regular scoop mattress, not a pressure relieving mattress. During an interview on 2/25/13 at 3:50 p.m., the DON said Resident #4's treatment should have been in place before 1/30/13. She said that the resident went 6 days without a treatment to her pressure sore during the month of January 2012. The DON said there should have been weekly assessments and measurements of the resident's pressure sore. The DON said the resident should have been placed on a pressure relieving mattress. The Prevention of Pressure Ulcers policy dated June 2006 documented: -the facility will identify residents that are at risk for breakdown of skin integrity, provide interventions to prevented pressure ulcers and provide treatment that promotes healing of pressure ulcers, -a pressure ulcer risk form would be completed upon admission, quarterly, and with a significant change in condition, a licensed nurse will complete a weekly skin assessment for residents with a high risk for skin breakdown,. -Utilize pressure reducing devices to aide in the prevention of pressure ulcer while in bed or in a wheel chair/Geri-chair, -assess residents nutritional and hydration needs, -evaluate lab values and notify physician of abnormal values including [MEDICATION NAME] level, Protein level, and Hemoglobin/Hematocrit, -the interdisciplinary care plan team will develop a resident specific plan of care for prevention of pressure ulcers. The Pressure Ulcer & Skin Care Management policy dated June 2006 documented: -all residents with pressure ulcers will receive appropriate treatment and services to aide in healing and prevent further breakdown, -a licensed nurse will assess pressure ulcers and contact the physician for appropriate treatment orders. Treatment orders will be transcribed to the TAR, -the licensed nurse will document the assessment of the pressure ulcer, -the licensed nurse will document a complete description of the wound in the clinical record including measurements, drainage, necrotic tissue, appearance of the wound bed and peri-wound area, residents response to treatment. The National Pressure Ulcer Advisory Panel Website www.npuap.org/pr2.htm accessed on 2/28/13 indicated the following: " Common Definition of Pressure Ulcers 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. International NPUAP- EPUAP Pressure Ulcer Classification System Category/Stage III: Full thickness skin loss (fat visible) Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunneling. Suspected Deep Tissue Injury-depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Further description: The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with treatment. " The CMS 672 dated 2/25/13 indicated 6 residents with pressure sores.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent worsening of pressure ulcers for 1 of 6 residents reviewed for pressure ulcers. (Residents #2) The facility did not set Resident #2's air mattress at the appropriate setting, assess the resident's pressure ulcer frequently to determine if the wound was worsening and send the resident to the wound care clinic as ordered. Resident #2's Stage II pressure sore worsened to a Stage III. This failure contributed to the worsening of Resident #2's pressure ulcer. This failure could place 13 residents with pressure ulcers at risk for developing new pressure ulcers and/or decline in existing pressure ulcers. Findings included: Physician orders [REDACTED]. Her [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident #2 was totally dependent on staff for transfers and ADLs. The resident was incontinent of bowel and bladder. The MDS indicated Resident #2 had a Stage III pressure ulcer with yellow or white slough. The care plan last updated 3/19/13 indicated Resident #2 had a pressure sore. Interventions listed required staff to provide treatments per physician orders [REDACTED]. During an observation and interview on 4/2/13 at 9:49 a.m., Resident #2 had a Stage III to her right lower buttock. The wound bed was beefy red. An area of the wound had dark gray slough (dead tissue that has shedded and covers the wound bed) at 11:00, the wound edges were macerated (soft, white, deteriorating skin). The wound had blood and clear, watery fluid drainage. The wound measured 7 cm X 4.3 cm X 1.5 cm depth. The resident was on an air mattress set at 8 of 10. The treatment nurse said Resident #2's wound bed was a Stage 3 with necrotic tissue, and the wound bed was beefy red. A physician faxed order dated 3/11/13 documented Resident #2 was to be referred to the wound care clinic. The clinical record for Resident #2 did not have documentation of services from the wound care clinic. During an interview on 4/2/13 at 1:13 p.m., LVN B said Resident #2 had not been to the wound care clinic. She verified that the resident had an order dated 3/11/13 for referral to the wound care clinic. She said the appointment was made by the as needed nurse that was doing wound care on the weekends. The pressure/vascular wound log for Resident #2 indicated: -3/5/13 Stage III to right buttock 3 cm X 2.5 cm; -3/10-16/13 no measurements; and -3/18/13 Stage III to right buttock 6 cm X 3.5 cm with slough and moderate drainage. The weekly wound tracking worksheet for Resident #2 indicated: -3/24/13 previous week a Stage III to right buttock 6.7 cm X 3.5 cm X 2.8 cm depth with slough, current stage not documented; -3/31/13 previous week a Stage IV to right buttock, currently a Stage IV to right buttock 6 cm X 3.5 cm X 2.5 cm depth with slough and eschar (dead tissue). The April 2013 weight log dated 4/1/13 indicated Resident #2's weight was 118.6 pounds. During an interview on 4/2/13 at 1:13 p.m., LVN B said air mattresses were set up by the company that brought them to the facility. She said they do not change any settings on the bed unless they lose power and the bed had to be reset. During an interview on 4/2/13 at 3:40 p.m., LVN C said air mattresses were set up by the company that delivered them, she said they explained how to set the bed up. LVN C said the treatment nurse would monitor the bed to ensure it was set correctly. During an interview on 4/2/13 at 3:42 p.m., the DON said she was not sure why Resident #2's mattress was set at an 8. She said the mattress should be set around 6. She said it was the responsibility of all nursing staff to ensure the bed remained at the correct setting. She said the mattresses came from a company that brought and sets them up. She said she did not have any manufacturers' information on the bed but would call the company to see what information she could find out. The DON said Resident #2 had not been to the wound care clinic. The DON said when the nurses received the new orders for Resident #2 to go to the wound care clinic, an appointment should have been scheduled. The undated Kair Medical Patriot ALAL quick reference guide indicated an air mattress should be set at 3 for weight of 110-130 pounds. The Pressure Ulcer & Skin Care Management policy dated June 2006 documented: -routine preventive care includes application of pressure relieving or pressure reducing devices, -all residents with pressure ulcers will receive appropriate treatment and services to aide in healing and prevent further breakdown, -the licensed nurse will document the assessment of the pressure ulcer, -the licensed nurse will document a complete description of the wound in the clinical record including measurements, drainage, necrotic tissue, appearance of the wound bed and peri-wound area, residents response to treatment. The National Pressure Ulcer Advisory Panel Website www.npuap.org/pr2.htm accessed on 4/4/13 indicated the following: "Common Definition of Pressure Ulcers 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. International NPUAP- EPUAP Pressure Ulcer Classification System Category/Stage II: Partial thickness skin loss or blister 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. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This category/stage should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. Category/Stage III: Full thickness skin loss (fat visible) Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunneling." The CMS Form 672 dated 4/2/13 documented 13 residents had pressure ulcer.

Based on observation, interview and record review, the facility failed to consult the physician when there was a significant change in condition and need to alter treatment for 1 of 10 residents sampled for physician notification. (Resident #2) Resident #2 developed an unstageable pressure sore on the right hip on 2/25/11. The physician orders [REDACTED]. On 4/12/11, the facility documented the pressure sore had deteriorated, but continued to provide the same treatment. Signs of infection were noted on 5/1/11. The physician was not consulted and provided an opportunity to alter the treatment until surveyor intervention, 41 days after the facility documented a deterioration of the pressure sore. On 5/23/11, the pressure sore had green and yellow bloody drainage and a foul odor. This failure contributed to the worsening of pressure sores for Resident #2 and could place 3 other residents with pressure sores at risk for deterioration of the pressure sores and [MEDICAL CONDITION]. Findings included: 1.) Consolidated physician orders [REDACTED]. These consolidated orders included an order, initiated 2/25/11, for staff to apply wound gel to an unstageable facility-acquired pressure sore to Resident #2's right hip, and cover with [MEDICATION NAME] dressing and change every three days and as needed. The orders included an order, initiated 6/28/10, for Resident #2 to be placed on hospice due to [DIAGNOSES REDACTED]. A hospice interdisciplinary visit note dated 2/25/11 identified a new unstageable pressure sore with blackened eschar to the right hip with a treatment for [REDACTED]. The National Pressure Ulcer Advisory Panel Website www.npuap.org/pr2.htm accessed on 5/31/11 indicated the following: 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 and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated." Stage IV "Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling." Unstageable "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." Resident #2's pressure ulcer risk assessment dated [DATE] following readmission indicated she was at high risk for pressure sores with a total score of 12. Resident #2's assessment total score declined to an 11 on 5/6/11, 5/13/11 and 5/20/11 indicating a high risk for developing pressure sores. Resident #2's care plans dated 3/24/11 indicated she had an alteration in skin integrity with an unstageable pressure sore to the right hip with slough present and a Stage IV pressure sore to the coccyx. The care plan indicated the physician was to be notified of changes in the wound. An MDS dated [DATE] indicated Resident #2 could make her needs known with prompting, was dependent upon staff for ADLs, was bedfast, incontinent of bowel, had two pressure sores, and experienced frequent pain. A weekly skin sheet dated 4/12/11 indicated the right hip pressure sore deteriorated to a 2.4 cm x 2.5 cm x 4 cm unstageable pressure sore with green necrotic tissue to the wound bed. Nursing notes dated 4/12/11 through 5/23/11 indicated the physician was not notified of the changes or deterioration of Resident #2's right hip pressure sore or consulted for a change in the treatment. A weekly skin sheet dated 5/1/11 documented the unstageable pressure sore to Resident #2's right hip was 3.4 cm x 4.5 cm x 2.2 cm with continued deterioration and 2.8 cm of undermining. The wound had a moderate amount of greenish, yellow slough with a foul odor. A hospice interdisciplinary visit note dated 5/19/11 documented the unstageable pressure sore to Resident #2's right hip continued to deteriorate and measured 4 cm x 4 cm x 2.5 cm with 3.5 cm and 1.8 cm undermining. Resident #2's most recent pressure ulcer risk assessment dated [DATE] documented she was at high risk for developing pressure sores. During an observation and interview on 5/23/11 at 9:19 a.m., Resident #2 had Stage IV pressure sores on her coccyx and right hip with wet to dry dressings in place. Resident #2 had an open area to her right heel that LVN A said was new. During an interview on 5/23/11 at 2:28 p.m., the hospice nurse said she did the dressing changes for Resident #2 on 5/19/11. The hospice nurse said the right hip pressure sore had an odor. The hospice nurse said she thought there was eschar present that needed to be debrided that was causing the odor. The hospice nurse said she probably should have obtained a culture to see if the pressure sore was infected. She said the current treatment of [REDACTED]. During an observation and interview on 5/23/11 at 3:02 p.m., LVN A removed the dressing from the pressure sore to Resident #2's right hip. He said the foul odor in the room was Resident #2's pressure sore. LVN A said the wound had drainage and a foul odor for as long as he could remember and he had not notified the physician. Resident #2 had her nose covered with her hospital gown. LVN A measured the pressure sore and noted the following: 3.7 cm x 4.3 cm x 2.5 cm with 0.8 cm of undermining with noted slough to the wound bed - copious amounts of malodorous green, yellow, bloody drainage saturated the dressing and the blue pad beneath the resident. During an interview on 5/24/11 at 9:22 a.m., the ADON said Resident #2's pressure sore treatment order for a wet to dry dressing every three days was not an appropriate order. The ADON said she did not notify the physician regarding the changes in Resident #2's right hip pressure sore until 5/23/11 because she thought hospice was managing the wound. During an interview on 5/24/11 at 10:03 a.m., Resident #2 said her wounds smelled bad and that was why she covered her nose with her gown during wound care on 5/23/11 at 3:02 p.m. During a telephone interview on 5/24/11 at 11:13 a.m., the attending physician said on her last visit with Resident #2 on 4/28/11, she did not recall if she had seen the resident's pressure sore but had not been notified of any changes in the sore. The physician said the treatment for [REDACTED]. The physician said if a pressure sore showed signs and symptoms of infection the resident should be placed on antibiotics. The physician said she had not been notified of any changes or deterioration in Resident #2's right hip pressure sore prior to 5/23/11. During a telephone interview on 5/24/11 at 11:20 a.m., the PA said when he saw Resident #2 on 5/10/11, he did not see her pressure sores because they were covered and no one had reported any changes or deterioration of the right hip pressure sore. The PA said a pressure sore should not have a foul odor or bloody, green drainage. He said he would have ordered a culture and changed the treatment from a wet to dry dressing to something more aggressive if he had been told about the changes in the pressure sore. During an interview on 5/24/11 at 5:34 p.m., LVN B said she assessed and measured Resident #2's pressure sores on 4/12/11, 5/1/11, and 5/19/11. She said on 5/19/11 the right hip dressing was saturated with greenish drainage and had yellow slough with a foul odor. LVN B said she continued to perform wet to dry dressing changes every three days and as needed. LVN B said she did not notify the physician of any changes or deterioration in Resident #2's pressure sore because she thought the hospice nurse was managing the pressure sore. During an interview on 5/25/11 at 9:08 a.m., LVN I said Resident #2's pressure sore to the right hip had "stringy stuff" in it. She said it had an odor with a moderate amount of drainage and she had not notified the physician because she thought hospice was managing the wound. During an interview on 5/25/11 at 9:10 a.m., the hospice CNA said Resident #2's pressure sore on the right hip had a lot of dark drainage with a strong odor over the weekend. The hospice CNA said the blue pad beneath the resident was saturated with drainage but she did not notify anyone of the changes of Resident # 2's pressure sore because the hospice nurse was aware of the pressure sore. During an interview on 5/25/11 at 9:13 a.m., CNA H said Resident #2's pressure sore to the right hip had brownish, greenish drainage with a bad odor. CNA H said she knew the smell and odor were not normal and she had notified her charge nurse, ADON, and the DON twice in the past two weeks. During an interview on 5/25/11 at 3:10 p.m., the DON said she did not notify the physician of the changes or deterioration of Resident #2's right hip pressure sore until 5/23/11, following surveyor intervention, because she wasn't aware of the decline in the pressure sore. After surveyor intervention on 5/23/11: A physician telephone order dated 5/23/11 at 6:46 p.m. indicated Resident #2 was started on Bactrim DS one tablet by mouth twice daily for ten days for a possible wound infection. A physician telephone order dated 5/24/11 at 10:50 a.m. indicated the treatment to the right hip was changed to apply calcium alginate to the wound bed, pad with 4 x 4 gauze, cover with an ABD pad, and secure with tape daily and as needed. An untimed physician telephone order dated 5/24/11 noted to send Resident #2 to the emergency room for evaluation of a possible wound infection and to rule [MEDICAL CONDITION]. The undated Change in a Resident's Condition or Status Policy page A-6 indicated the facility should promptly notify the attending physician of changes in the resident's medical/mental condition and/or status. The Wound Care Protocol Orders dated 9/08 indicated the treatment for [REDACTED]. E: Notify MD and they will consider surgical consult if indicated. According to <http://www.hopkinsmedicine.org/bin/a/n/Section8.pdf> accessed 6/3/11 COMPLICATIONS FROM PRESSURE ULCERS "The development of pressure ulcers can lead to several complications. Probably the most serious complication [MEDICAL CONDITION]. ...Additional complications of pressure ulcers include localized infection, [MEDICAL CONDITION], and osteo[DIAGNOSES REDACTED]. ...Mortality can also be associated with pressure-ulcer development. ...Thus, careful assessment of a pressure ulcer is essential. Finally, other complications of pressure ulcers include pain and depression. Both pain and depression have been associated with decreased wound healing." The CMS 672 dated 5/23/11 indicated 5 residents had pressure sores.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to prevent the worsening of existing pressure sores and development of new pressure sores for 2 of 8 residents sampled for pressure sores. (Resident #s2 and 12) On 2/25/11, Resident #2 was identified with a new facility acquired unstageable pressure sore with blackened eschar to the right hip. The treatment ordered was a wet to dry dressing every three days. The pressure sore deteriorated on 4/12/11 and the facility continued the same treatment. Signs of infection were noted on 5/1/11. The facility continued with the wet to dry dressing which was not an appropriate treatment and the pressure sore was not cultured or treated for [REDACTED]. On 5/23/11, the pressure sore had green, yellow, bloody drainage and foul odor. The physician was not consulted regarding the pressure sore deterioration until surveyor intervention on 5/23/11, 41 days after the facility documented a deterioration of the pressure sore. Resident #12 did not receive timely skin assessments and had pressure sores develop that the facility was not aware of. These failures contributed to the deterioration of pressure sores for Resident #2, the development of a new pressure sore for Resident #12, and could place 2 other residents who had pressure sores at risk for development of new pressure sores, deterioration of existing pressure sores, and [MEDICAL CONDITION]. Findings included: 1.) Consolidated physician orders [REDACTED]. These consolidated orders included an order, initiated 2/25/11, for staff to apply wound gel to an unstageable facility-acquired pressure sore to Resident #2's right hip, and cover with [MEDICATION NAME] dressing and change every three days and as needed. The orders included an order, initiated 6/28/10, for Resident #2 to be placed on hospice due to [DIAGNOSES REDACTED]. A hospice interdisciplinary visit note dated 2/25/11 identified Resident #2 had a new unstageable pressure sore with blackened eschar to the right hip with a treatment for [REDACTED]. The National Pressure Ulcer Advisory Panel Website www.npuap.org/pr2.htm accessed on 5/31/11 indicated the following: 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 and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated." Stage IV "Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling." Unstageable "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." A hospital operative report dated 6/15/10 indicated Resident #2 had undergone surgical debridement of a large sacral pressure sore. Resident #2's care plans dated 3/24/11 indicated she had an unstageable pressure sore to the right hip with slough present and a Stage IV pressure sore to the coccyx. The care plan indicated the physician was to be notified of changes in the wound. An MDS dated [DATE] indicated Resident #2 could make her needs known with prompting, was dependent upon staff for ADLs, was bedfast, incontinent of bowel, had two pressure sores, and experienced frequent pain. A weekly skin sheet dated 4/12/11 indicated the right hip pressure sore deteriorated to a 2.4 cm x 2.5 cm x 4 cm unstageable pressure sore with green necrotic tissue to the wound bed. Nursing notes dated 4/12/11 through 5/23/11 indicated the physician was not notified of the changes or deterioration of Resident #2's right hip pressure sore or consulted for a change in the treatment. A weekly skin sheet dated 5/1/11 documented the unstageable pressure sore to Resident #2's right hip was 3.4 cm x 4.5 cm x 2.2 cm with continued deterioration and 2.8 cm of undermining. The wound had a moderate amount of greenish, yellow slough with a foul odor. A hospice interdisciplinary visit note dated 5/19/11 documented the unstageable pressure sore to Resident #2's right hip continued to deteriorate to 4 cm x 4 cm x 2.5 cm with 3.5 cm and 1.8 cm undermining. Resident #2's pressure ulcer risk assessment dated [DATE] following readmission indicated she was at high risk for pressure sores with a total score of 12. Resident #2's assessment total score declined to an 11 on 5/6/11, 5/13/11 and 5/20/11 indicating a high risk for developing pressure sores. During an observation and interview on 5/23/11 at 9:19 a.m., Resident #2 had Stage IV pressure sores on her coccyx and right hip with wet to dry dressings in place. Resident #2 had an open area to her right heel that LVN A said was new. During an interview on 5/23/11 at 2:28 p.m., the hospice nurse said she did the dressing changes for Resident #2 on 5/19/11 with LVN B. The hospice nurse said the right hip pressure sore had an odor that she thought was being caused by eschar that needed to be debrided. The hospice nurse said she probably should have obtained a culture to see if the pressure sore was infected. She said the current treatment of [REDACTED]. During an observation and interview on 5/23/11 at 3:02 p.m., LVN A removed the dressing from the pressure sore on Resident #2's right hip. He said the foul odor in the room was Resident #2's pressure sore. LVN A said the wound had drainage and a foul odor for as long as he could remember and he had not notified the physician. Resident #2 had her nose covered with her hospital gown. LVN A measured the pressure sore and noted the following: 3.7 cm x 4.3 cm x 2.5 cm with 0.8 cm of undermining with noted slough to the wound bed - copious amounts of malodorous green, yellow, bloody drainage that saturated the dressing and the blue pad beneath the resident. During an interview on 5/24/11 at 9:22 a.m., the ADON said Resident #2's pressure sore treatment order for a wet to dry dressing every three days was not an appropriate order. The ADON said she did not notify the physician regarding the changes in Resident #2's right hip pressure sore until 5/23/11. During an interview on 5/24/11 at 10:03 a.m., Resident #2 said her wounds smelled bad and that was why she covered her nose with her gown during wound care on 5/23/11 at 3:02 p.m. During a telephone interview on 5/24/11 at 11:13 a.m., the attending physician said on her last visit with Resident #2 on 4/28/11, she did not recall if she had seen the resident's pressure sore, but had not been notified of any changes in the sore. The physician said the treatment for [REDACTED]. The physician said if a pressure sore showed signs and symptoms of infection the resident should be placed on antibiotics. The physician said she had not been notified of any changes or deterioration in Resident #2's right hip pressure sore prior to 5/23/11. During a telephone interview on 5/24/11 at 11:20 a.m., the PA said when he saw Resident #2 on 5/10/11, he did not see her pressure sores because they were covered and no one had reported any changes or deterioration of the right hip pressure sore. The PA said a pressure sore should not have a foul odor or bloody, green drainage. He said he would have ordered a culture and changed the treatment from a wet to dry dressing to something more aggressive if he had been told about the changes in the pressure sore. During an interview on 5/24/11 at 5:34 p.m., LVN B said she assessed and measured Resident #2's pressure sores on 4/12/11, 5/1/11, and 5/19/11. LVN B said on 5/19/11 the hospice nurse did the dressing change. LVN B said the right hip dressing was saturated with moderate amount of greenish, yellow slough with a foul odor. LVN B said she continued to perform wet to dry dressing changes every three days and as needed. LVN B said she did not notify the physician of any changes or deterioration in Resident #2's pressure sore because she thought the hospice nurse was managing the pressure sore. During an interview on 5/25/11at 9:08 a.m., LVN I said Resident #2's pressure sore to the right hip had "stringy stuff" in it. She said it had an odor with a moderate amount of drainage and she had not notified the physician. During an interview on 5/25/11 at 9:10 a.m., the hospice CNA said Resident #2's pressure sore on the right hip had a lot of dark drainage with a strong odor over the weekend. The hospice CNA said the blue pad beneath the resident was saturated with drainage. She had not notified anyone of the changes of Resident #2's pressure sore. During an interview on 5/25/11 at 9:13 a.m., CNA H said Resident #2's pressure sore to the right hip had brownish, greenish drainage with a bad odor. CNA H said she knew the smell and odor were not normal and she had notified her charge nurse, ADON, and the DON twice in the past two weeks. During an interview on 5/25/11 at 3:10 p.m., the DON said she did not notify the physician of the changes or deterioration of Resident #2's right hip pressure sore until 5/23/11 following surveyor intervention. After surveyor intervention, a physician telephone order dated 5/23/11 at 6:46 p.m. indicated Resident # 2 was started on Bactrim DS one tablet by mouth twice daily for ten days for a possible wound infection. A physician telephone order dated 5/24/11 at 10:50 a.m. indicated the treatment to the right hip was changed to apply calcium alginate to the wound bed, pad with a 4 x 4 gauze, cover with an ABD pad, and secure with tape daily and as needed. An untimed physician telephone order dated 5/24/11 indicated a new order to send Resident #2 to the emergency room for a possible wound infection and to rule [MEDICAL CONDITION]. 2.) Physician orders [REDACTED]. The orders indicated Resident # 12's heels were to be offloaded with waffle boots. An MDS dated [DATE] indicated Resident #12 was cognitively impaired, dependent upon staff for ADLs, bedfast, incontinent of bowel, was at risk for skin breakdown, and experienced frequent pain. Resident #12's care plans dated 1/14/11 indicated she was at risk for skin breakdown related to incontinence of bowel and bladder. She was to have weekly skin assessments. Resident #12's most recent pressure ulcer risk assessment dated [DATE] documented she was at high risk for developing pressure sores. Resident #12's last weekly skin assessment dated [DATE] indicated no pressure sores. During an observation on 5/24/11 at 4:32 p.m., Resident #12 was lying in bed facing the door with waffle boots partially on both of her lower extremities. During an observation and interview on 5/24/11 at 5:04 p.m., LVN F removed Resident #12's waffle boots and socks and identified a new dark purple DTI to the left heel that measured 2.6 cm x 3.9 cm. LVN F assisted Resident #12 onto her side and identified a new Stage II pressure sore to the coccyx that was pink and measured 0.6 cm x 0.8 cm x less than 0.25 cm. LVN F said she was unaware of either of the pressure sores. The National Pressure Ulcer Advisory Panel Website www.npuap.org/pr2.htm accessed on 5/31/11 indicated the following: Pressure Ulcer Stages Suspected Deep Tissue Injury "Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue." Stage II "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 blister." During an interview on 5/24/11 at 5:25 p.m., the ADON said she was unaware Resident #12 had pressure sores to the coccyx and right heel. During an observation on 5/24/11 at 6:19 p.m., Resident #12 was lying in bed on a standard mattress without her heels offloaded. During an interview on 5/25/11 at 9:29 a.m., CNA P said she worked the 11-7 shift on 5/23/11 and reported to her charge nurse that Resident #12 had an area to her coccyx that looked like it was going to turn into a pressure area. CNA P said the charge nurse said it was "nothing to worry about." During an interview on 5/25/11 at 4:15 p.m., CNA M said she provided incontinent care for Resident #12 on 5/23/11 on the 3-11 shift and noted a red mark on her coccyx. CNA M said she told CNA N to report it to LVN O. During an interview on 5/25/11 at 4:20 p.m., LVN O said she was unaware Resident #12 had any pressure sores. LVN O said CNA N may have reported a skin issue to her on 5/23/11 and she may not have heard it. During an interview on 5/25/11 at 4:35 p.m., CNA N said CNA M asked her to report to LVN O that Resident #12 had a pressure sore to her coccyx. CNA N said she reported it and LVN O said she would look at it and see what needed to be done. The Wound Care Protocol Orders dated 9/08 indicated the treatment for [REDACTED]. A: Culture wound if signs and symptoms of infection. B: Institute physical therapy consultation. C: Wound care center to manage care or evaluate and recommend care. D: Wound care center to be consulted if any wound is not progressing positively. E: Notify MD and they will consider surgical consult if indicated. The Ulcer Dressing Reference Guide dated 11/16/07 indicated the treatment for [REDACTED]. *Alginates *Hydro fibers *Foams *ORC/Collagen *Sodium chloride dressings *Absorptive dressing *Negative pressure wound therapy Infected wound treatment would be: *Debridement *Cadexomer iodine *Silver dressings *Negative pressure wound therapy *Systemic antibiotics The undated Change in a Resident's Condition or Status Policy page A-6 indicated the facility should promptly notify the attending physician of changes in the resident's medical/mental condition and/or status. The CMS 672 dated 5/23/11 indicated 5 residents with pressure sores.