Every finding on record at Hibbard Skilled Nursing & Rehabilitation Center

Based on review of the facility's abuse policy and procedure, review of the Adult Protective Services-APS reported incident, and interviews, the facility failed to notify the State agency (Division of Licensing and Certification-DLC) of an allegation of staff to resident abuse (Resident #1 [R1]) for 1 of 1 reviewed incident on 6/12/26.Finding: A review of the facility abuse policy and procedure indicated under the 'Reporting Allegations to the Administrator and Authorities' #1 If resident abuse, neglect, exploitation, misappropriation of property or injury of unknown source is suspected, the suspicion must be reported immediately to the and Administrator and to other officials according to State law. #2 the Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The State Licensing/Certification agency responsible for survey/licensing the facility. On 6/12/26, a complaint was filed with Adult Protective Services-APS by a Hospice Social Worker who was visiting R1. The report indicated that R1 communicated/implied to the Social Worker that C.N.A.1 and a Hospice Nurse had abused her by touching her in a sexual manner. On 6/12/26, the Social Worker told the facility Charge Nurse what R1 communicated to her. On 7/7/26 at 11:28 a.m., in an interview with the Charge Nurse, she stated the Social Worker did reported to her about a staff to resident abuse incident. The Charge Nurse stated she reassigned C.N.A.1 to another unit, checked on R1, and called her Supervisor about the allegation. She stated she did not report the incident to DLC. On 7/7/26 at 11:35 a.m., in an interview with the Supervisor, she stated after the Charge Nurse informed her of the incident. She notified the Administrator and Director of Nursing of the incident. She stated she did a thorough investigation to ensure the resident was safe and unharmed. The Supervisor stated she did not notify DLC of the allegation due to her finding lack of evidence that the abuse occurred.

Based on record review and interviews, the facility failed to ensure that a clinical record was complete and contained accurate information for 2 of 9 days for a treatment to check a pacemaker monitor and 1 of 1 treatment for a urinalysis dip for 1 of 1 resident reviewed (Resident #1 [R1]). Findings:On 2/10/26, R1's clinical record was reviewed and included the following documentation on February's Treatment Administration Record (TAR):1. The treatment on TAR for Please check to ensure that the pacemaker monitor is plugged in once per evening shift was documented on 2/1/26 and 2/8/26 with staff initials and coded with 2 to indicate that the drug not available. On 2/10/26 at 12:35 p.m., during an interview with a surveyor, Registered Nurse #1 (RN1) stated that she documented both times incorrectly and does not know why she chose drug not available for the pacemaker monitor check. The surveyor confirmed the inaccurate documentation during this interview. 2. The treatment on TAR for Surveillance Urinalysis (UA) dip, if positive, follow up with culture to make sure Urinary Tract Infection is resolved was documented with a staff initials only on 2/1/26. The clinical record or Provider Request - Physician Order (dated 1/31/26) lacked evidence of the result of the UA dip. On 2/17/26, during an interview with a surveyor, the Skilled Unit Manager stated that she spoke with RN2, who stated that he did the treatment, but he didn't chart it because nothing popped up for him to chart after he signed the treatment off or did he print out the results from the machine and place it on the doctor's order. The surveyor confirmed the lack of documentation regarding the UA dip during this interview.

Based on record reviews and interviews, the facility failed to provide care in accordance with the resident's comprehensive care plan for 1 of 3 residents reviewed for falls during a complaint investigation (Resident #2).Finding:Resident #2 has diagnoses to include dementia, visual loss, and falls.Review of Resident #2's care plan, dates12/21/25 states, The resident has had an actual fall with minor injury r/t [related to] seizure, poor balance, unsteady gait and poor safety awareness d/t [due to] Blindness and Dementia.Continue interventions on the at-risk plan. and The resident is a high risk for falls r/t Dementia, gait/balance problems, Unaware of safety needs, and vision/hearing problems.The resident uses floor mats and hip protectors as ordered.A review of Resident #2's active physician orders revealed an order with a start date of 10/1/24 for Check to ensure that HIP Protectors are on resident at all times unless being laundered.On 12/30/25 at 10:44 a.m., during an interview, Certified Nursing Assistant #2 (CNA2) stated Resident #2 has fall mats and a low bed in place and that she is not aware of anything else being done for falls. When the surveyor asked about hip protectors, CNA2 lifted Resident #2's blanket, and the surveyor and CNA2 observed that hip protectors were not in place. On 12/30/25 at 10:48 a.m., during an interview, RN1 stated that Resident #2 had a recent fall and that fall mats and the low bed have been in place because Resident #2 tends to crawl off his/her bed. When the surveyor asked about Resident #2's hip protectors, RN1 stated that he/she had hip protectors and is supposed to be wearing them but has not had them since transferring to this unit several months ago.On 12/30/25 at 11:06 a.m. the above finding was discussed with the Long Term Care (LTC) Manager. At this time, the LTC manager stated that Resident #2 is supposed to have hip protectors in place and is not sure why he/she does not have them and that she will order a new set today.On 12/30/25 at 2:06 p.m. during an interview, the above finding was discussed with the Director of Nursing (DON).

Based on observation, record review, interviews, and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection by failing to follow their own Enhanced Barrier Precautions (EBP) policy for 1 of 1 resident reviewed for wounds (Resident #1).Finding:Facility policy Enhanced Barrier Precautions, revised 3/2025 states, .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents.EBPs are indicated.for residents with wounds.Wounds generally include chronic wounds (i.e. pressure ulcers, diabetic foot ulcers, venous stasis ulcers .).EBPs remain in place for the duration of the resident's stay or until resolution of the wound.Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the residents room indicating the type of precautions and PPE required.Resident #1 has diagnoses to include peripheral vascular disease, chronic venous insufficiency, and chronic right leg ulcers.On 12/30/25 at 10:37 a.m. during an observation of Resident #1's room, there was no EBP sign posted on the door or on the wall outside the room. The surveyor observed Resident #1 lying in bed with his/her right lower leg exposed with a visible wound that appeared to have betadine applied. At this time, during an interview, Certified Nursing Assistant #1 (CNA1) stated Resident #1 is not on EBP or any type of precautions.A review of Resident #1's care plan indicated The resident has a hx [history] of a venous wound on [his/her] right lower leg .follow EBP.A review of R1's active physician orders revealed the following: An order with a start date of 12/17/25 for Cleanse R [right] dorsal foot wound with NS [normal saline], apply santyl and calcium alginate and cover with dry dressing, every day shift for wound care. An order with a start date of 12/4/25 for Cleanse RLE [right lower extremity] wound, apply betadine and leave open to air, every day shift. An order with a start date of 12/19/25 for Santyl External Ointment 250 UNIT/GM.Apply to R dorsal foot wound topically every day shift for wound careA review of Resident #1's December 2025 Treatment Administration Records (TAR) indicated Registered Nurse #2 (RN2) provided Resident #1's wound care on 12/18/25, 12/19/25, 12/22/25, 12/23/25, 12/24/25, 12/26/25, 12/29/25, and 12/30/25 (date of survey).On 12/30/25 at 1:49 p.m. during an interview, RN2 stated that she thinks Resident #1 was on EBP at some point, but that his/her wounds had also improved at one point, so he/she was taken off EBP.On 12/30/25 at 2:30 p.m. during an interview, the above concerns were discussed with the Infection Preventionist (IP). The IP stated that every Friday at the Risk meeting, the facility discusses all residents with open wounds and devices and stated that RN2 is usually the one who discontinues a resident's precautions because she does the wound treatments. The IP then stated that if a wound is not draining the resident would not need to be on EBP. On 12/30/25 at approximately 2:45 p.m. the above findings were discussed with the Director of Nursing.

Based on record review and interview, the facility failed to ensure that a clinical record contained accurate and complete information regarding the location of a venous ulcer for Resident #1 (R1) for 7 of 7 months reviewed (May 2025 - December 2025). Finding:On 12/10/25, the facility provided a document to the surveyor that indicated that R1 currently has a chronic ulcer that was being treated on the right lower extremity. Review of R1's physician progress notes for a visit on 10/5/25 indicated that the patient has been treated for recurring right lower leg wounds. In April 2025, R1 was seen multiple times for a right lower leg wound On 12/10/25 9:55 a.m. a surveyor and Registered Nurse #1 (RN1) reviewed R1's clinical record. During this review, the following were observed:On 10/3/25 at 8:02 a.m., a progress note was written by RN1 that indicated that she went to perform a treatment on R1's left lower leg (venous ulcer) and observed a new abrasion on the leg the treatment was being done to. The current care plan included a FOCUS of The resident has a history of a venous wound on his/her left lower leg. 11/1/24 - Leg area has resolved, continue to monitor and treat to prevent reopening and 4/2025 - treatment to right lower extremity (RLE) cellulitis. This FOCUS was initiated on 10/2/24 and revised on 5/8/25. The GOALS under this FOCUS was Wound will be free of signs or symptoms of infection in venous area on left lower leg which was initiated on 5/8/25 and revised on 10/14/25 and The resident's RLE cellulitis will resolve which was initiated on 2/10/25 and revised on 8/26/25. Review of the physician orders and progress notes indicated that the treatment was to the right lower leg, not the left. The care plan FOCUS to which leg the venous ulcer was present has been inaccurate since the FOCUS was updated on 5/8/25 even though a new intervention was added on 7/23/25 and the GOALS were revised on 8/26/25 and 10/14/25. During this review, RN1 stated that R1 had never had an issue with a venous wound on the left leg and that would have been entered in the Care Plan incorrectly as well as she had documented the wrong extremity in the 10/3/25 progress note. The surveyor confirmed that the documentation and care plan did not reflect the correct leg for the venous wound.

Based on facility policy review, record reviews, and interview, the facility failed to ensure that the resident and/or resident representative received assistance/follow up assistance to complete the written information provided concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, for 5 of 7 residents reviewed for advanced directives. (Resident #21 [R21], R24, R42 R72, R75). Findings: Review of facility policy Advanced Directives dated 3/25, Page 3 of 5, Section: If the Resident Does not have an Advanced Directive states if the resident or representative indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advanced directives. Nursing staff will document in the medical records the offer to assist and the residents decision to accept or decline assistance. 1. On 6/3/25, a review of R21's electronic medical record indicated that on 7/20/2023, R21 documented that they did not have an advanced directive and a family member would look into one. The medical record lacked evidence that the facility followed up with the resident and/or resident representative concerning the right to accept or refuse medical or surgical treatment and to ensure the completion of the resident's advanced directive wishes. 2. On 6/2/25, a review of R24's electronic medical record indicated that on 3/6/2019, documentation indicated that R24 did not have an advanced directive and declined to have one. Documentation in the clinical record indicated that R24 is diagnosed with Alzheimer's disease and is cognitively impaired and has a family member listed in the clinical record as the resident representative. The medical record lacked evidence that the facility followed up with the resident representative concerning the right to accept or refuse medical or surgical treatment and to ensure the completion of the resident's advanced directive wishes. 3. On 6/3/25, a review of R42's electronic medical record indicated that on 1/2/2024, documentation indicated that R42 did not have an advanced directive and would look into it. The medical record lacked evidence that the facility followed up with the resident/resident representative concerning the right to accept or refuse medical or surgical treatment and to ensure the completion of the resident's advanced directive wishes. On 6/3/25 at 11:25 a.m., in an interview with the surveyor, the Licensed Social Worker, confirmed that she was unable to find a documented note regarding the resident's/representative's advanced directive wishes and outcomes. 4. On 6/3/25, a review of Resident #71's Acknowledgement of Important Infomation and Policies, dated 12/3/24, indicates Resident #71 has an Advance Directive and states, will provide to us. On 6/3/25 at 11:35 a.m., during an interview, the Social Services Director stated Resident #71's spouse was looking for documents. At this time, the Social Services Director confirmed the clinical record lacks evidence that the facility followed up with Resident #71's representative concerning the right to formulate an Advance Directive. 5. On 6/3/25, a review of Resident #75's Acknowledgement of Important Infomation and Policies, dated 5/8/25, indicates Resident #75 does not have an Advance Directive and states, working on one. On 6/3/25 at 11:42 a.m., during an interview in the presence of 4 surveyors, the Social Services Director stated Resident #75 does not have an Advance Directive but that it was discussed in the Interdisciplinary Team (IDT) meeting dated 5/13/25, and Resident #75's family are working on one. A Review of the IDT meeting notes, dated 5/13/25, lacks evidence that Advance Directives were discussed.

Based on record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was newly diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required, or incorporate the recommendations from a PASRR level II determination into a resident's assessment and care planning for 2 of 5 sampled residents reviewed for PASRR [Resident #30 (R30), R52]. Findings: 1. On 6/3/25, R30's clinical record was reviewed. R30's PASRR level II, completed on 4/22/20, indicated the following: Specialized Services: [R30] will need to be provided the following specialized services: -Individual therapy by licensed behavioral health professional (may include mobile therapy): You we're receptive to having a counselor to come meet with you at [another facility]. You were able to have a few visits prior to the COVID-19 Pandemic. You may benefit from having this service start again once the quarantine protocols are lifted. -Neuropsychiatric evaluation by neurological and behavioral health professional: Recommending a psychiatric and/or neurological evaluation to determine if symptoms are related to mental health for Parkinson's disease and to assess possible treatment options. Possibly looking into some holistic options that therapist could work on: breathing exercises and ways to communicate needs without being aggressive with care team. Rehabilitative services: [R30] will need to be provided the following services and/or supports: -Occupational Therapy Evaluation -Physical Therapy Evaluation -Speech/language therapy -Neurological Examination -Family Involvement in the Individual's Care -Supportive Counseling from [Nursing Facility (NF)] Staff -Obtain Archive Psychiatric Records to Clarify History The clinical record lacked evidence that these services were offered, provided, and/or refused, addressed in resident assessments or during care planning. On 6/4/25 at 1:06 p.m., during an interview with a surveyor, the Scheduler stated there are no appointments or referrals for R30 for specialized services. On 6/4/25 at 1:09 p.m., during an interview with the Long Term Care Manager and a surveyor, R30's clinical record was reviewed. At this time the surveyor confirmed that there was no evidence specialized services were offered, provided, and/or refused, or addressed in the care plan. 2. On 6/2/25 at 3:24 p.m., during an interview with a surveyor, R52 stated they wanted their call bell back, that the facility took it away after a suicide attempt. R52 stated he/she wanted therapy for Post Traumatic Stress Disorder (PTSD). On 6/3/25, review of R52's clinical record indicated the following: -Review of R52's PASRR, completed on 4/1/24, indicated R52's history of suicidal talk and behaviors occurred greater than 5 years ago. The PASRR level I result indicated: A PASRR Level II evaluation is not required at this time for the following reason: No status change has occurred and the current PASRR evaluation remains valid. If a status change occurs, then an updated level I must be submitted by the NF to report that change. -Review of the current PASRR evaluation indicated The following services must be provided to [R52]. 1. Initial psychiatric evaluation to determine diagnosis and develop plan of care, to manage psychotropic medicines, and assess need for changes if needed. 2. Individual therapy by a licensed behavioral health professional (may include mobile therapy) to address self-injurious behaviors and PTSD. -Review of the medical diagnosis list indicated that on 4/29/25, R52 had a new diagnosis of Schizophrenia (See F842). -The provider's note, signed 12/2/24 at 7:23 p.m., stated During [R52's] hospital stay, [R52] made statements about wanting to kill [himself/herself] and [R52] was seen by behavioral health team with medication adjustment. This note indicates R52 had suicidal talk / behaviors within the past 5 years prior to admission to the facility. -Review of nursing notes indicated that R52 had several incidents involving suicide talk/behaviors since their date of admission. The clinical record lacked evidence that R52 was referred to the State mental health authority for a new PASRR level II determination after new incidents of suicidal talk / behaviors, or after a new qualifying diagnosis. On 6/4/25 at 9:18 a.m., during an interview with the Licensed Social Worker and a Surveyor, R52's clinical record was reviewed. At this time, the surveyor confirmed the PASRR assessment was not accurate to the R52's condition on admission and was not resubmitted for a new level II determination after new incidents of suicidal talk / behaviors, or after a new qualifying diagnosis.

Based on observation, record reviews, and interview, the facility failed to obtain physician orders for the treatment of a surgical wound and pressure ulcer for 1 of 1 Resident sampled for wound care (Resident #333). Finding: Resident #333 was recently admitted with diagnoses to include status post recent lower extremity bypass surgery and stenting, with surgical incisions of the right arm, left groin, and left leg; Left great toe arterial wound; and Stage 2 pressure ulcers of the sacrum and left heel. A review of Resident #333's clinical record lacked treatment orders for the right arm surgical incision and the left heel pressure ulcer. On 6/4/25 between 9:59 a.m. and 11:15 a.m., during an observation of Resident #333's dressing changes, Registered Nurse (RN) #1 removed the existing bordered gauze dressing from Resident #333's right arm surgical wound, cleansed the wound with normal saline solution (NSS), and applied a new bordered gauze dressing. RN #1 then removed the existing silicone dressing from Resident #333's left heel, cleansed the wound with NSS, and applied a new silicone dressing. Following the wound treatments, a surveyor reviewed Resident #333's current Treatment Administration Record (TAR) with RN #1 and discussed the above concerns. At this time, RN #1 confirmed the clinical record lacked evidence of orders for the right arm surgical wound care and left heel arterial wound care and stated she thought she had a general order for dry dressings daily but that it could have been for another resident because she does not see that in the active orders. On 6/4/25 at 2:02 p.m., the above concerns were discussed with the Director of Nursing.

2. On 6/3/25, review of R52's clinical notes indicated the following: On 12/2/24 at 7:23 p.m., a provider note stated During [R52's] hospital stay, [R52] made statements about wanting to kill [himself/herself] and [R52] was seen by behavioral health team with medication adjustment. There is no evidence that a referral was made for follow-up services at that time. On 12/4/24 at 3:22 a.m., a provider note indicated [complaint of (c/o)] hallucinations. [He/She] is seeing 'corpses in the room with [him/her] . Actively having visual hallucinations. [Differential diagnosis (Ddx)] includes hepatic encephalopathy, infection, medication. There was no evidence that R52's active diagnosis of PTSD was addressed. On 12/4/24 at 6:37 a.m., a nurse note stated [R52] stated There is a dead body's on the wall and decomposing body's with maggots coming out of their mouths. A provider was notified and gave an order for Hydroxyzine 25mg x1 with positive effect. Additional orders for urine culture, and bloodwork were submitted at that time. There is no documentation to indicate PTSD was addressed at that time. On 12/4/24 at 11:52 a.m., The provider's admission note identified an active diagnosis of Suicidal ideation . Multiple episodes and will check to see if [he/she] is to continue following with Acadia, and Continue to follow up with Acadia. There is no evidence that Acadia was contacted for follow-up care at that time. On 12/11/24 at 6:50 a.m., a nurse note indicated R52 expressed suicidal ideation by throwing self on floor to break his/her skull, wanting a gun to shoot self, and use of johnny pants to strangle self. At 2:37 p.m., a social service note indicated, [Crisis Worker] reports that he believes that R52's suicidality can be managed in the facility. His reported listed the following recommendations for R52 to try when escalated: . 6. Participate in mental health counseling [Social Service Director (SSD)] will submit a referral for Counseling and will continue to check in with nursing as needed. There is no evidence that a referral was submitted for counseling at that time. On 12/16/24 at 10:23 a.m., a provider note indicated R52 had suicidal ideation with severe PTSD and anxiety. R52 was referred to Mayo Hospital Emergency Department (ED) for suicidal ideation and self-harm behavior. [R52] needs a psychiatric provider. [He/she] does go to the [Veteran Affairs (VA)] and maybe able to refer [him/her] to VA for telemedicine. Will check to see what maybe available for when [he/she] comes back from the hospital. There is no evidence that a referral was made to the VA. On 6/3/25, review of the current Pre-admission Screening and Resident Review (PASRR) evaluation indicated Individual therapy by a licensed behavioral health professional must be provided to R52 to address self-injurious behaviors and PTSD (See F644). There is no evidence that a referral was made by the facility for behavioral health services prior to 4/11/25. On 6/3/25 at 12:45 p.m., During an interview with a surveyor, the Scheduler stated R52 is on a waiting list for Acadia, they say it would be a year out before an in-person appointment. Nursing called Acadia on 4/11/25, but they were unable to connect due to an issue with the equipment (computer), follow-up calls were made on 4/28/25 and 5/1/25. R52 had their telepsych visit on 5/2/25. R52 tried telepsych, but said it wasn't working for him/her, R52 had an in-person appointment with Acadia on 5/28/25 and is now on their waiting list. On 6/3/25 at 3:38 p.m., during an interview with a surveyor, the Licensed Social Worker (LSW) stated she had not completed an initial trauma assessment on R52. On 6/4/25 at 9:18 a.m., during an interview with a surveyor, the LSW stated the referral for counseling services referenced in her note on 12/11/24, was the call made to Acadia on 4/11/25. At this time the surveyor confirmed that referrals were not made by the facility for counseling services, to Acadia, or to the VA for R52's active diagnosis of PTSD and / or incidents of suicidal speech / behaviors, to eliminate or mitigate re-traumatization, from admission through 4/11/25. The surveyor also confirmed at the time of the interview that no referrals had been made to the VA for services. Based on record reviews and interviews, the facility failed to address the needs of residents diagnosed with Post Traumatic Stress Disorder (PTSD) in order to eliminate or mitigate triggers that may cause re-traumatization for 2 of 4 residents reviewed with PTSD [Resident #52 (R52) and R57]. Findings: 1. A review of the facility's policy, Trauma Informed Care and Culturally Competent Care, revised 3/2025, states, Purpose .To address the needs of trauma survivors by minimizing triggers and/or re-traumatization .Resident Assessment .Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers .Resident Care Planning .Identify and decrease exposure to triggers that may re-traumatize the resident . Resident #57 was admitted in November 2022 and has diagnoses to include PTSD. Review of Resident #57's Quarterly Minimum Data Set (MDS), dated [DATE], Section I, 16100. Post Traumatic Stress Disorder, indicated Resident #57 has an active diagnosis of PTSD. Review of Resident #57's care plan, updated 5/31/25, includes, Focus: The resident has potential for psychosocial well-being problem r/t [related to] PTSD . but lacked evidence that a trauma informed care plan was established to include Resident #57's trigger(s) for PTSD. Review of Resident #57's clinical record revealed, Trauma Informed Care Assessment-PTSD 5, dated 4/29/25 and states, Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic Have you ever experienced this kind of event? The assessment response indicates, No. On 6/3/25 at 11:54 a.m., during an interview in the presence of 4 surveyors, the Social Services Director stated it is her understanding that she should be completing the above screening based only on changes in the past 90 days and confirmed she did not complete the assessment based on Resident #57's current PTSD diagnosis. At this time, the Social Services Director confirmed Resident #57's care plan does not address his/her trigger(s) for PTSD. On 6/3/25 at 3:59 p.m., during a follow-up Interview, the Social Services Director stated she does not have an initial trauma screen for Resident #57 and stated she does not know if an initial trauma screen was ever done for Resident #57.

Based on record review, interview and facility policy the facility failed to ensure temperatures were monitored in the walk-in refrigerator and freezer in order to prevent food borne illness for 2 of 3 months reviewed (January and February 2025). Findings: Review of facility Food Storage policy undated states .Refrigerated Food Storage: Foods must be maintained at or below 41 degrees.Thermometers should be checked twice per day and recorded on a temperature log . Frozen Food Storage: Frozen foods must be maintained at a temperature to keep the food frozen solid. At best that should be 0 degrees F or below. The freezer thermometers shall be checked twice per day and recorded on a temperature log Review of Jan [January] Year: 2025 Walk in Refrigerator Temperatures lacked evidence that temperatures were taken on 1/1/25 and 1/2/25 at 6 a.m., or 6 p.m. Review of Feb [February] Year 2025 lacked evidence temperatures were taken on 2/23/25 at 6 a.m. or 6 p.m., and 2/4/25, 2/18/25, and 2/29/35 at 6 p.m. Review of Jan [January] Year: 2025 Walk in Freezer Temperatures lacked evidence that temperatures were taken on 1/1/25 and 1/2/25 at 6 a.m., or 6 p.m. Review of Feb [February] Year 2025 lacked evidence temperatures were taken on 2/23/25 at 6 a.m., or 6 p.m., and 2/18/25 and 2/29/25 at 6 p.m. During a review of temperature logs with the Dietary Manager (DM) on 6/2/25 at 10:55 a.m., DM stated temperatures are supposed to be obtained and logged 3 times a day, and she had a hard time getting the cook at that time to ensure temperatures were being logged. At this time the DM confirmed the above findings. During an interview on 6/3/25 at 10:03 a.m. the above was discussed with the Administrator.

Based on observations, interviews and record review, the facility's interdisciplinary team (IDT) failed to determine if it was clinically appropriate for a resident to keep medications at bedside and self-administer medications for 2 of 29 Residents reviewed during a medication pass (Residents #1 [R1] and R9). Findings: Review of facility policy, Self-Administration of Medications, revised 3/2025 states, .the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident .If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan .For self-administering residents, the nursing staff determine who is responsible (the resident or the nursing staff) for documenting that medications are taken . Self-administered medications are stored in a safe and secure place, which is not accessible by other residents .Nursing staff reviews the self-administered record for each nursing shift, and transfers pertinent information to the medication administration record (MAR) .noting that the doses were self-administered. During a medication pass observation for Resident (R)9 on 6/3/25 at 7:28 a.m., Certified Nursing Assistant/ Medication Technician (CNA/MT) was observed to retrieve 1 tablet of Medication [NAME] back and body oral 500-32.5 [milligram (mg)] and placed it in a medication cup. At this time CNA/MT stated, Just to let you know [he/she] has an order for self-administration of the [NAME], but I don't think its care planned, but there is an order to self-administer. CNA/MT was then observed walking into R9's room and placed medication cup on R9's over the bed table and left the room. Review of R9 clinical record revealed an order with start date 5/7/25 that states [NAME] Back & Body Oral Tablet 500-32.5 mg (Aspirin-Caffeine) Give 1 tablet by mouth one time a day related to other chronic pain. Administration time per resident request . Further review of R9s medication orders lacked evidence of an order to self-administer this medication. Review of R9's electronic and paper chart lacked evidence that a Self-Administration Assessment was completed. Review of R9's care plan updated 5/13/25 lacked evidence of self-administration goals and interventions. During a review of R9's clinical record with Long Term Care Unit Manager (LTCUM) on 6/3/25 at approximately 9:08 a.m., LTCUM stated residents should have an order to self-administrator medications, they should have an assessment completed as well as an established care plan. At this time LTCUM confirmed the above findings. 2.On 6/2/25 at 11:21 a.m. and 6/3/25 at 9:00 a.m., during observations of Resident #1's room, a box containing a 15 milliliter (mL) bottle of Muro 128 eye drops was observed in a basket on Resident #1's over-the-bed table. A review of Resident #1's clinical record revealed an active order with start date of 5/6/25 for Muro 128 Ophthalmic Solution 5% (Sodium Chloride Hypertonic) . Instill 2 drops in both eyes every 4 hours as needed for corneal edema. Review of Resident #1's May 2025 and June 2025 Medication Administration Record (MAR) lacked evidence of administration of the eye drops. Further review of Resident #1's clinical record lacked evidence of an IDT assessment for self-administering medications, a physician order to self-administer the eye drops, or documentation on the care plan. On 6/3/25 at 11:21 a.m., during an interview, Resident #1 stated he/she is supposed to administer the eye drops to himself/herself, 3 to 4 hours after the nurses administer his/her other eye drops. On 6/3/25 at 10:03 a.m. during an interview, Licensed Practical Nurse (LPN) #1 stated for a resident to self-administer medications, there needs to be a physician order to self-administer medications, an order to store the medication at bedside, and a self-administration assessment. At this time, LPN #1 reviewed Resident #1's entire electronic record and paper chart and confirmed it lacked evidence of an order to self-administer medications and lacked evidence of a self-administration assessment. On 6/3/25 at 10:15 a.m., the above finding was discussed with the Operations Consultant.

Based on interviews, record review and facility policy, the facility failed to thoroughly investigate an allegation injury of unknown origin for 2 of 3 facility incident reports reviewed [Resident #4 (R4) and R61]. Findings: Review of facility Abuse & Neglect - Clinical Protocol dated 10/22 states :Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse, and mental abuse The nurse will assess the individual and document related findings: Assessment data will include: injury assessment (bleeding, bruising deformity, swelling etc); pain assessment; current behavior; patients age and sex.; all current medications, especially anticoagulants, NSAIDS, salicylate; other plate inhibitors; vital signs; behavior over last 24 hours (bruise could be related to movement disorder or aggressive behavior); history of any tendency toward bruising, any related labs The staff, with the physician's input (as needed) will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes . Review of facility policy titled Resident Rights, and dignity dated 10/2022 states . The staff, with the physician's input (as needed), will investigate all alleged occurrences of abuse and neglect to clarify what happened and identify possible causes . 1. On 5/27/25, the Department of Licensing received a Facility Reported Incident indicating that on 5/24/25, Resident #4 sustained an injury of unknown origin after he/she returned from an acute care hospital on 5/23/25, a nurse noted Resident #4's left knee to be swollen and warm to the touch. X-ray results revealed Resident #4 had sustained a femoral fracture. Review of H&P dated 5/28/25 states During transfer, patient had a seizure and was consequently transferred to eastern Maine medical center and subsequently admitted . After returning from the hospital on May 22, 2025, patient complained of left knee pain and x-ray discovered a left femoral supracondylar fracture. [He/she] was then sent to the emergency department . where [he/she] received a CT of [his/her] knee which showed a fracture of the distal epiphysis of the femur. Patient then complained of left wrist pain and an x-ray was obtained 2 days later which showed an acute angulated right distal radial fracture. [He/she] was then transferred to the emergency room and was given a splint for [his/her] wrist. Review of Facility 5-day Investigation Follow-up dated 5/27/25 states [RN] spoke with residents [family member] who reported to her that [Resident #4] complained of L [left] knee pain while hospitalized last week further review of the 5-day investigation named 3 staff members, Resident #4 and a family member were interviewed, but facility was unable to show any written documentation these interviews took place. Further review of Resident #4's clinical record lacked evidence that this injury was noted in the emergency department. During an interview on 6/2/25 at 10:03 a.m., Long Term Care Unit Manager (LTCUM) stated that the facility was not sure if the injuries happened at the facility or while in the hospital. 2. On 5/19/25 the Department of Licensing received a facility reported incident stating that on 5/18/25 Resident #61 sustained an Injury of Unknown Origin. Report states No known history of a fall . What interventions were in place at the time of the incident? Please describe in full below: Resident has rails next to toilet to assist with independent toileting, to prevent falls . Were there any adverse effects to the resident/patient (physical or mental)? Yes: Resident has a large hematoma near L [left] eye. Review of facility 5-day follow up dated 5/20/25 states Description of incident: bruise of unknown origin. Resident did have an unwitnessed fall on 5/18/25 prior to noticing bruise over left eye. Bruise was not noticed at time of assessment following fall. Resident has also had increasing confusion and unsteady gate . Further review of facility follow-up lacked evidence that this injury of unknown origin was thoroughly investigated. During a review of above 5-day follow ups on 6/2/25 at 12:31 p.m., Long Term Care Unit Manger (LTCUM) stated that all injuries of unknown injury should be investigated as possible abuse, she is now responsible for the investigations in Long Term Care and is new to this role and was unsure of how to complete the follow up investigations. At this time LTCUM confirmed thorough investigations of the above incidents were not conducted, and in the future, she will ensure she has all the necessary information in the investigation.

Based on obervation, record review, and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 5 residents reviewed for baseline care plans (Resident #333). Finding: 1. Review of Facility policy, Care Plans-Baseline, revised 3/2025, states, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight [48] hours of admission .and must include the minimum healthcare information necessary to properly care for the resident, including, but not limited to the following: Initial goals, based on admission orders and discussion with the resident/representative .physician orders .Dietary orders .Therapy services .Social services .PASSAR recommendation, if applicable . Resident #333 was recently admitted with diagnoses to include Coronary artery disease; Chest pain with exertion; Chronic Obstructive Pulmonary Disease (COPD); Type 2 Diabetes Mellitus (DM); Neuropathy (nerve pain); acute and chronic pain; peripheral artery disease, status post recent lower extremity bypass surgery and stenting, with surgical incisions of the right arm, left groin, and left leg; Left great toe arterial wound; and Stage 2 pressure ulcers of the sacrum and left heel. On 6/2/25 at 11:18 a.m., during an observation, Resident #333 had a gauze dressing on his/her left lower extremity, extending over his/her foot, and blood was observed coming through the dressing on the bottom of the foot. At this time, Resident #333 stated the nurse just changed his/her left leg dressing and had to come back in to change his/her wrist dressing because of bleeding and then stated he/she has been on 2 anticoagulants (blood thinner) since his/her surgery. A review of Resident #333's clinical record revealed the following active physician orders: -An order for Pregabalin Oral Capsule 75 MG .Give 75 mg by mouth three times a day for Pain -An order for ProAir HFA Inhalation Aerosol Solution .2 puff inhale every 4 hours as needed for COPD -An order for Nitrostat Sublingual Tablet .as needed for Chest pain .Notify MD [medical doctor] immediately -An order for Apixaban Oral Tablet 5 MG .Give 5 mg by mouth two times a day for DVT [Deep Vein Thrombosis] -An order for Clopidogrel Bisulfate Oral Tablet 75 MG .Give 75 mg by mouth one time a day for DVT -An order for Acetaminophen Oral Tablet 500 MG .Give 2 tablet by mouth every 6 hours as needed for chronic foot pain . -An order for Blood Glucose Monitoring before meals and HS [hour of sleep] four times a day for DM -An order for Apply dry dressing to the groin incision daily .for wound care -An order for Apply Mepilex to sacrum every 3 days or as needed .for wound care Review of Resident #333's baseline care plan lacked evidence that goals and interventions were put into place for the cardiac diagnoses, chest pain, anticoagulant use, COPD, Diabetes, acute and chronic pain, care of the surgical and pressure wounds, nutrition, or therapy services. On 6/4/25 at 2:02 p.m., the above concerns were discussed with the Director of Nursing.

Based on Smoking Policy review, record review and interviews, the facility failed to complete a Safe Smoking Evaluation for 1 of 1 sampled resident that actively smokes cigarettes (Resident #383 [R383]). Finding: On 6/5/25, a review of the facility's Smoking Policy indicated under Number 6-Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: 6d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). On 6/5/25, a review of R383's clinical record was completed. In a Provider assessment note dated 5/21/25, the resident declines smoking cessation given his/her diagnosis of Amyotrophic Lateral Sclerosis (ALS) and being on Hospice for palliative care. There was no evidence that a Safe Smoker Evaluation had been completed. On 6/5/25 at 10:30 a.m., in an interview with the surveyor, the resident stated they are currently smoking when able. On 6/5/25 at 11:25 a.m., in an interview with the surveyor, the Skilled Nursing Manager confirmed that a Safe Smoker Evaluation was not completed.

Based on record reviews and interview, the facility failed to notify the physician of a suspected Urinary Tract Infection (UTI) for 1 of 4 Residents (Resident #71) reviewed for indwelling urinary catheters. Resident #71 was admitted in December 2024 with diagnoses to include Benign Prostatic Hyperplasia (enlarged prostate), retention of urine, obstructive uropathy (a blockage in the urinary tract that causes difficulty urinating), and indwelling urinary catheter (Foley catheter). Review of Resident #71's clinical record revealed a nursing progress note dated 6/1/25 states, Flushed resident's foley with acetic acid solution, replaced bag and tubing as it was full of sediment and smelled badly. Resident may have a UTI, recommend a UA [urinalysis] to r/o [rule out]. Further review of Resident #71's clinical record lacked evidence that the physician was notified of the above urinary concerns and that a urinalysis was done. On 6/2/25 at 12:13 p.m., during an interview, Resident #71's representative stated over the weekend, the staff told him/her they were going to check for a UTI because of a change in Resident #71's mental status, but he/she hasn't heard back. On 6/5/25 at 9:40 a.m., the above finding was discussed with the Administrator.

Based on record reviews and interviews, the facility failed to implement, monitor and/or revise as necessary interventions to prevent or manage a resident's pain for 2 of 4 residents reviewed for pain (Resident #52 (R52) and R333) Findings: 1. On 6/3/25, review of R52's clinical record revealed the following: -R52's Care Plan identifies Potential for Acute Pain / Chronic Pain, [R52] is on pain/OPIOD medication therapy [related to (r/t)] chronic pain, and [R52] has chronic pain r/t end stage liver failure with ascites. - On 4/7/25 at 10:45 a.m., the provider note indicated R52 had an existing order for 5 milligrams (mg) oxycodone for pain, and a new order for buprenorphine 5 micrograms (MCG) / hour (HR) transdermal (application of medicine through the skin) patch to be applied weekly. At 1:35 p.m., Order notes indicated, The order you have entered Buprenorphine Transdermal Patch Weekly 5 MCG/HR (Buprenorphine) *Controlled Drug* Apply 1 patch transdermally one time a day every [Tuesday (Tue)] for pain and remove per schedule Has triggered the following drug protocol alerts/ warning(s): Drug to Drug Interaction The system has identified a possible drug interaction with the following orders: oxycodone [Hydrochloride (Hcl)] Oral Tablet 5 mg . Severity: Severe Interaction: Buprenorphine, . may diminish the analgesic effect of opioid agonists and precipitate withdrawal symptoms in patients chronically maintained on full agonist opioids ([example (eg)], oxycodone Hcl Oral Tablet 5 MG). The opiate receptor antagonist effects of buprenorphine are expected at higher doses. The record lacks evidence that the severe interaction warning was discussed with the provider. - On 4/10/25 at 9:01 a.m., a nursing note indicated R52 stated he had exhibited suicidal behaviors because I am in pain. At 2:11 p.m., a nurse note indicated R52's family member expressed concern that [R52] is in constant pain .every time that I talk with [R52] [he/she] [complains of (c/o)] pain. -On 4/11/25 at 12:30 p.m., a provider note indicated R52 was seen by the provider. R52 stated he/she had stopped taking their medications because they were in pain. The provider ordered as needed medications would be scheduled as R52's cognition may prevent the resident from asking for pain medicine. At 4:04 p.m., an order note indicated a new order for oxycodone 5mg Give 1 tablet by mouth [immediately (STAT)] for pain stat dose for increased pain, triggered a severe drug to drug interaction warning. At 4:06 p.m., an order note indicated a severe drug to drug interaction between scheduled oxycodone 5 mg to be given by mouth twice a day and buprenorphine transdermal 5MCG/HR patch weekly. At 4:21 p.m., an order note indicated a severe drug to drug interaction between scheduled oxycodone 5 mg to be given by mouth twice a day and buprenorphine transdermal 5MCG/HR patch weekly. There is no evidence that the severe drug interaction warning was reviewed with the provider. On 6/3/25 at 11:22 a.m., during an interview with the surveyor and the Long Term Care Unit Manager (LTCUM) R52's medical record was reviewed. LTCUM stated there is no evidence that the drug interaction was addressed or reviewed with the provider. At this time the surveyor confirmed the resident had increased reports of pain after the introduction of the pain patch and the facility did not monitor and revise as necessary to treat R52's pain. On 6/4/25 at 10:23 a.m., during an interview with a surveyor, the Physician Assistant (PA) stated nursing did not make her aware of the medication conflict, and stated if she had known she would have used an alternative option. 2. Resident #333 was recently admitted with diagnoses to include Acute and chronic pain; status post recent lower extremity bypass surgery and stenting, with surgical incisions of the right arm, left groin, and left leg; Left great toe arterial wound; and Stage 2 pressure ulcers of the sacrum and left heel. A review of Resident #333's clinical record revealed the following physician orders: - An active order for Pain Monitoring - Assess for pain every shift for pain - An active order for oxycodone HCl Oral Tablet 5 MG .Give 2 tablet by mouth three times a day for pain for 30 Days -An active order for oxycodone HCl Oral Capsule 5 MG .Give 1 tablet by mouth every 4 hours as needed [PRN] for pain control for 29 Days On 6/3/25 at 12:45 p.m., a surveyor attempted to observe Resident #333's dressing changes with Licensed Practical Nurse (LPN) #2 and asked Resident #333 permission to observe the dressing change. Resident #333 became tearful, stating his/her pain medications are messed up and that he/she had spoken to the doctor and thought he/she would be receiving a PRN dose of oxycodone so he/she could have medication prior to the dressing change. Resident #333 then stated that he/she cannot tolerate a dressing change now because it will be too painful. Resident #333 proceeded to state he/she went 12 hours last night (6/2/25) without pain medication because the facility did not have the medication in stock. At this time, LPN #2 stated there is a call out to the physician to clarify the pain medication orders. On 6/4/25 at 8:40 a.m., during a follow-up interview, Resident #333, stated the nurse came in before supper last night and said he/she had orders for scheduled and PRN oxycodone but when he/she asked for a PRN dose at 1:30 a.m., he/she was told there was no oxycodone available, so he/she went 10 hours without pain medication. Review of Resident #333's June 2025 Treatment Administration Record (TAR) revealed Resident #333 received a PRN dose of Oxycodone at 12:45 p.m. on 6/2/25 and did not receive any additional doses of oxycodone until the 2:00 p.m. scheduled dose on 6/3/25. The TAR indicated Resident #333's pain level was 5/10 on the night shift on 6/3/25. Further review of the TAR revealed that on 6/3/25, Resident #333 received a scheduled dose of oxycodone at 10:00 p.m. and did not receive any additional doses of oxycodone until the 6:00 a.m. scheduled dose on 6/4/25. The TAR indicated Resident #333's pain level was 8/10 on the morning of 6/4/25. On 6/4/25 at 9:15 a.m., during an interview, LPN #1 stated new orders are entered in the electronic medical record (EMR) and go directly to the pharmacy, and the Cubex [medication storage cabinet] in the medication room has house stock available while awaiting the delivery from the pharmacy. In the presence of a surveyor, LPN #1 checked the medication cart and stated Resident #333 has 172 tablets of oxycodone 5mg on hand and that 6 have been given so far. At 9:17 a.m., in the presence of a surveyor, LPN #1 signed into the Cubex and confirmed there was no oxycodone 5mg in stock and stated she knows she used the last 6 tablets on the night of 6/2/25 and is not sure if it has been refilled since then. On 6/4/25 at 2:02 p.m., during an interview, the above finding was discussed with the Director of Nursing (DON). At this time, the DON stated that Resident #333 probably did get his/her pain medication and is telling everyone he/she is not getting it.

Based on observations and interviews, the facility failed to ensure expired medications were removed from the available for use supply, for 1of 3 Medication storage Carts reviewed (Treatment Cart). Finding: On 6/3/25 at 7:33 a.m., during review of the treatment cart a surveyor observed and confirmed the following were on the cart and available for use with the Licensed Practice Nurse (LPN2): -1 used bottle (less than half full of fluid) 100 milliliters (ml) Normal Saline irrigation fluid, open, unlabeled, and undated. -1 Tube of Hydrophilic Wound Dressing (Triad) open, unlabeled, with an expiration date of 3/31/25. -1 sealed multi-use vial containing 10ml of Insulin glargine 100units (u)/10ml, labeled with a yellow sticker stating refrigerate. LPN2 stated it should be in the refrigerator until it is opened. LPN2 was unable to determine how long the vial had been out of the refrigerator. -1 sealed multi-use vial containing 10ml of Insulin Lispro 100u /10ml, labeled with a yellow sticker stating refrigerate. LPN2 stated it should be in the refrigerator until it is opened. LPN2 was unable to determine how long the vial had been out of the refrigerator. -1 3-ounce tube of GoodSense Arthritis Relief with an expiration date of 1/2025. -1 tube of Triamcinolone Acetonide 0.1%, the pharmacy label indicated Discard After 11/28/24 -1 opened package of Lidocaine Hydrochloride Jelly USP 2% (package is a sterile kit when sealed, used to numb genitalia prior to foley catheter insertion), resting in an unsealed zip lock bag dated 4/4/25.

Based on record reviews, interviews, and policy review, the facility failed to ensure that clinical records were complete and contained accurate information for 5 of 26 sampled residents reviewed. (Resident #46 [R46], R7, R52, R71, R333). Findings: Review of facility Abuse & Neglect - Clinical Protocol dated 10/22 states :Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse, and mental abuse The nurse will assess the individual and document related findings> Assessment data will include: injury assessment (bleeding, bruising deformity, swelling etc.); pain assessment; current behavior; patients age and sex.; all current medications, especially anticoagulants, NSAIDS, salicylate; other plate inhibitors; vital signs; behavior over last 24 hours 9 bruise could be related to movement disorder or aggressive behavior); history of any tendency toward bruising, any related labs The staff, with the physician's input (as needed) will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes . On 4/19/25 the Department of Licensing received a facility reported incident indicating on 4/19/25 R#7 stated Resident #46 had threatened to shoot [him/her] earlier today. RN heard them arguing and heard Resident #46 say Ow. RN assessed R#46 and noted redness and slight swelling on R#46's left side of face. The residents were separated, and in-house provider will assess R#46. 1. R#46 was admitted [DATE] and has diagnoses to include vascular dementia with psychotic disturbance, and major depressive disorder. Review of Nursing note dated 4/19/25 at 16:21 states [R#46] was in [his/her] wheelchair in the hallway. [R#7] was going the same way and went beside [R#46]. [He/she] stated [R#46] had threatened to shoot [him/her] earlier today. This RN heard them arguing and heard [R#46] say OW I heard them as I was at the computer at the nurse's station, I did not see [him/her] hit [him/her]. Redness noted on left side of [R#46's] face with slight swelling. Residents were separated. Provider is in the building and was notified, she will assess [R#46]. Ice pack applied to [R#46's] face. Family to be notified. DON was notified. Review of R7's clinical record lacked evidence that the provider assessed this resident. Review of provider note dated 4/19/25 states [R#46] is a long-term resident I am asked to see on account of increasing episode of behaviors with agitation and outburst towards other residents. Today, there was an incident where [he/she] was telling another resident that [he/she] would kill them. ultimately, this resulted in the resident striking [R#46] in the face. There is no significant injury from this, however staff note that the episodes seem to be increasing in frequency greatly lately.[His/Her] BIMS score was 3 of 3, indicating severe cognitive impairment .has a history of vascular dementia with psychotic features, type 2 diabetes mellitus, and right above-knee amputation. bupropion was increased from 150 mg back to 300 mg daily. Review of progress note dated 5/1/25 at 15:05 states Behavior note: Argumentative with peer in front of the nurses station. Asked resident to please not engage with other resident as the other party will not end confrontation very easily. Separated residents and both seemed to be calmer and more agreeable. A short time later, this resident continued the verbal confrontation, Redirected. Progress note dated 5/1/25 at 16:09 states Behavior note: confrontation with peer again. Removed residents from situation. SS aware Music therapy initiated with positive effect. Review of Resident (R)46 care plan most recently updated 5/21/25 lacked evidence that it was updated to reflect goals/interventions for verbal and physical behaviors. Observation of Resident #46 on 6/2/25 at 11:39 a.m., resident in hall in wheelchair, self-propelling, dressed for time and season. stating: 'stinking pig, stinking pig . During an interview on 6/2/25 at 11:42 a.m., Licensed Practical Nurse (LPN)1 stated R#46 does have verbal and physical behaviors and can get vocal and has been in verbal altercation with previous roommate. 2. R7 has a diagnosis to include anxiety. Review of R#7's progress note dated 5/19/25 at 16:21 states [R#46] was in [his/her] wheelchair in the hallway. [R#7] was going the same way and went beside [R#46]. [He/she] stated [R#36] had threatened to shoot [him/her] earlier today. This RN heard them arguing and heard [R#46] say OW I heard them as I was at the computer at the nurse's station, I did not see [him/her] hit [him/her]. Redness noted on left side of [Resident #46's] face with slight swelling. Residents were separated. Provider is in the building and was notified, she will assess [R#46]. Ice pack applied to [R#46's] face. Family to be notified. DON was notified. Review of R7's clinical record lacked evidence that the provider assessed this resident. Review of R#7 care plan updated 5/30/25 lacked evidence that goals and interventions were put into place for R#7's physical behaviors. During an interview on 6/4/25 at 3:10 p.m. R#7 stated he/she was angry because R#46 comes into his/her room all the time, every day, and tells me to get of my own room. He/she yells all the time. Yes, I hit [him/her], and I don't feel bad about it either. During a review of R#7's clinical record with Long Term Care Unit Manager (LTUM) on 6/4/25 at 2:30 p.m., LTCUM confirmed R#7's progress note was a copy and paste directly from R#46's progress note, and there is no evidence that R#7 was assessed by the in house provider. During an interview LTCUM and Skilled Nursing Manager (SNM) on 6/4/25 at 3:15 p.m., SNM stated care plans are updated during the weekdays they are done in real time and if it happens over the weekend they are updated on Monday. At this time SNM reviewed R7's care plan and confirmed it was not updated for physical behaviors, and R#46 did not have a care plan for verbal and physical behaviors. During an interview on 6/4/25 at 4:02 p.m. the above was discussed with the Administrator. 3. On 6/3/25, review of R52's clinical record indicated the following: On 12/4/24 at 11:52 a.m., the provider note indicated the R52 was prescribed Risperidal 0.5 milligrams (mg) to be taken by mouth twice a day for anxiety. There was no mention of a diagnosis of Schizophrenia at that time. On 12/10/24 at 4:28 p.m., a new order for Risperidal 1mg to be taken by mouth twice a day for schizophrenia was entered by nursing staff. The clinical record lacks evidence that the resident was evaluated to confirm a new diagnosis of schizophrenia. On 12/16/24 at 10:23 a.m., the provider note did not address a new diagnosis of schizophrenia. The medications listed at the end of the provider note indicated Risperidal 1mg to be taken by mouth twice a day for schizophrenia. On 4/29/25, schizophrenia was added to R52's list of active diagnosis. The clinical record lacks evidence that the resident was evaluated to confirm a new diagnosis of schizophrenia. On 6/4/25 at 10:23 a.m., during an interview with a surveyor and the Physician Assistant (PA), R52's record was reviewed. The PA stated she knows R52 has psychosis but cannot state where the diagnosis of schizophrenia came from. The PA stated there is no order to change the diagnosis on the risperidone. The PA also confirmed the diagnosis heading found above nurse and provider notes, as well as the medications listed at the bottom of a provider note automatically flow over from Point Click Care (the electronic record) and are not documented by the provider. At this time the surveyor confirmed R52's record contained inaccurate / incomplete documentation regarding the new diagnosis of schizophrenia. 4. On 6/4/25 at 9:18 a.m., during an interview with a surveyor and the Licensed Social Worker (LSW) , R52's Social Services Quarterly Note and Pre-admission Screening and Resident Review (PASRR) were reviewed. The LSW confirmed R52 is on a psychotropic medication, but the Social Services Quarterly Note indicated R52 is not receiving psychotropic medications. At this time the surveyor confirmed the Social Services Quarterly Note had inaccurate documentation regarding the use of psychotropic medications, and the PASRR contained inaccurate information regarding R52's medical condition (See F644). 5. Resident #71 was admitted with diagnoses to include Benign Prostatic Hyperplasia (enlarged prostate), retention of urine, obstructive uropathy (a blockage in the urinary tract that causes difficulty urinating), and indwelling urinary catheter (Foley catheter). Review of Resident #71's clinical record revealed the following active physician orders: -An order for Measure I & O [intake and output] every shift for foley -An order for Weigh weekly in the morning every Wed [Wednesday] for weight monitoring Review of Resident #71's May and June 2025 Treatment Administration Records (TAR) lacked evidence that I &O was recorded for the following shifts on the following dates: -Day shift: -5/8/25 -Evening shift: -5/20/25 -6/2/25 -6/3/25 -Night shift: -5/2/25 -5/4/25 -5/16/25 -5/19/25 -5/28/25 -5/30/25 -5/31/25 -6/2/25 Further review of the May TAR lacked documentation of the weekly weight on 5/14/25 and 5/21/25. On 6/5/25 at 9:18 a.m., during an interview, Registered Nurse (RN) #2 stated I & O is documented by nurses and certified nursing assistants (CNAs), but nurses review the CNA documentation at the end of the shift and total the I & O recorded by the CNA and the nurse, and document that amount on the TAR because the physician reviews the TAR. 6. Resident #333 was recently admitted with diagnoses to include left great toe arterial wound and Stage 2 pressure ulcer of the sacrum. A review of Resident #333's clinical record revealed the following physician orders: -An active order for Apply mepilex [a type of foam dressing] to sacrum every 3 days or as needed for soiled dressing . -An order for Iodosorb External Gel 0.9% .Apply to L [left] great toe topically every day shift for wound -An active order for Blood Glucose Monitoring before meals and HS [bedtime] -An order for Insulin Lispro Injection Solution 100 UNIT/ML .Inject as per sliding scale .before meals for dm2 [Type 2 Diabetes Mellitus] Review of Resident #333's June 2025 TAR lacked evidence that the above Mepilex dressing and Iodosorb treatment was applied on 6/3/25, or that the resident refused treatment(s). Further review of the TAR revealed the Insulin Lispro was scheduled for 6:00 a.m., 11:00 a.m., and 4:00 p.m. daily and lacked evidence that the Insulin Lispro was administered, held, or refused for the 6:00 a.m. doses on 6/1/25, 6/2/25, and 6/3/25. On 6/5/25 at 9:40 a.m., the above findings were discussed with the Administrator.

Based on observations and interviews, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to a dressing change and the processing of linens for 1 of 2 observations during the survey. Findings: 1. On 6/4/25 at 9:59 a.m., a surveyor entered Resident #333's room with Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 to observe Resident #333's wound dressing change. Upon entering the room, a surveyor observed an unbagged, soiled gown and an open, clear plastic trash bag containing soiled linen lying on the floor under the sink. RN #1 walked from Resident #333's bed to the sink and stepped on the soiled gown as she washed her hands. RN #1 then returned to Resident #333's bedside and began the dressing change. Resident #333 requested help supporting his/her left leg during the dressing change, and RN #1 proceeded to remove a pillow from the top of the bed and placed it under Resident #333's left knee. A surveyor observed dried blood on the pillowcase and asked Resident #333 if he/she uses this pillow, and he/she stated he/she uses it to sleep. RN #1 then began removing the existing left leg dressing. At this time (10:25 a.m.) a surveyor intervened and voiced concern regarding performing a wound dressing change on a soiled pillowcase. LPN #1 then changed the pillowcase and obtained a clean, disposable under pad to place over the pillow before completing the dressing change. RN #1 then stated Resident #333 was previously able to hold his/her leg up for the dressing change, so RN #1 did not come prepared with supplies. After the dressing change observation, a surveyor discussed the above concern regarding the soiled linens under the sink with RN #1, and that multiple staff entered and exited the room throughout the observation and failed to remove the soiled linens. On 6/4/25 at 1:20 p.m., during an interview, the above findings were discussed with the Infection Preventionist (IP).

Based on facility policy review, record reviews, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to offer the updated Pneumococcal Conjugate Vaccination (PCV) 20 to 2 of 5 residents (Resident #47 [R47] and R72). Findings: 1. The facility's policy, Pneumococcal Vaccine, revised 06/2022, indicated prior to or upon admission, residents will be assessed for eligibility to receive the Pneumococcal Vaccine series and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. Assessments of Pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. Administration of the Pneumococcal vaccines are made in accordance with current CDC recommendations at the time of the vaccination. 1. The documentation in R72's clinical record indicated that R72 received the PCV13 in 2016, and Pneumococcal Polysaccharide Vaccine (PPSV) 23 in 2018. The CDC recommendation was based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. The clinical record lacked evidence that the PCV20 was offered, provided, or refused by R72. 2. The documentation in R47's clinical record indicated that R47 received the PCV13 in 2018 but refused the PPSV23 in 2022. The CDC recommendation was to give one dose of PCV20 or PCV21 at least 1 year after PCV13. The clinical record lacks evidence that the PCV20 was offered, provided, or refused by R47. On 6/5/25 at 10:30 a.m., during an interview with a surveyor, the Administrative Coordinator stated she did not offer PCV20 to R47 or R72 because she believed they were up to date on the vaccine, that if a resident had the PCV13 they would not need the PCV20. The Administrative Coordinator and surveyor reviewed the policy. At this time the surveyor confirmed the PCV20 was not offered to R47 or R72 as recommended by CDC guidelines, or as directed by the facility's policy.

Based on record reviews, interviews, and facility policy, the facility failed to ensure a resident was free from physical and psychosocial harm which caused the resident to be afraid, angered, and embarrassed (Resident #1). In addition, the facility failed to ensure that a resident was free from physical and verbal abuse which caused the resident to have undue anxiety (Resident #2) for 2 of 2 facility incident reports reviewed. Findings: Review of facility policy titled Resident Abuse Prevention Policy and Procedure dated February 2022 states It is the policy of this facility to prevent abuse, neglect, and exploitation of residents living at this facility . Review of facility policy titled Resident Rights and Dignity dated February 2022 states Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . The staff and physician will monitor individuals who have been abused at least until their medical condition, mood, and function have stabilized, and periodically thereafter .The medical director will advise facility management and staff about systems to ensure that basic medical, functional, and psychosocial needs are being met and the potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately . 1. On 1/12/23 at 4:02 p.m., the Division of Licensing and Certification received a facility reported incident indicating that Resident #1 informed a member of the management team that on 1/9/23, Certified Nursing Assistant (CNA)1 force fed [him/her] lunch and ended up vomiting. During a medical record review, Resident #1 that was admitted to the facility on [DATE] with diagnosis to include narcolepsy [sleep disorder that causes an urge to fall asleep suddenly during the daytime] and dysphasia [difficulty swallowing] and is on aspiration [when food or fluid gets in the airway] precautions. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 has a Brief Interview for Mental Status (BIMS) 15 of 15 indicating resident is cognitively intact. Review of Resident #1's care plan, initiated 5/4/18 updated 1/17/23 states .I eat with supervision with set up . I have the potential to aspirate, because I have a history of dysphagia, on aspiration precautions . I may fall asleep during meals-wake me up please. I am a slow eater-allow plenty of time, I need my aides to set up my meal so I can eat . remind me and encourage me as needed look at me and speak to me during meals, let me take as much time to eat as I need, I eat slowly . Review of Social Service note, dated 1/12/23 at 3:40 p.m., states . [Resident #1] asked to speak with me. [Resident #1] stated that on 1/9/23 [he/she] was eating lunch and CNA1[Certified Nursing Assistant] told [him/her] she was going to feed [him/her]. [Resident #1] stated that [he/she] did not need to be fed and [he/she] could feed [himself/herself], [he/she] also told CNA1 Leave me alone.[He/she] stated that she stated, I want to get you out of here quicker and kept feeding [him/her] . I asked why [he/she] accepted the food CNA1 was giving [him/her [Resident #1] stated that [he/she] was afraid to choke and didn't wanna rock the boat or make anyone upset .a while later [Social Service] reported hearing CNA1 confront Resident #1 after the incident (in his/her room). Licensed Social Worker (LSW) heard Resident #1 state loudly get out multiple times and CNA1 was leaving Resident #1's room stating, if that's the way you want it. Resident stated to LSW [he/she] was ok was red faced and heavy breathing. Review of Resident #1's clinical record revealed Nursing note dated 1/9/23 at 1:44 p.m., stating Vomiting large amounts of food. States food intake was too quick for [Resident #1] at lunchtime. During an interview on 3/22/23 at 2:39 p.m., Long Term Care Unit Manger (LTC) indicated [Resident #1] is a choking risk and needs intermittent supervision because [he/she] also has narcolepsy and will fall asleep with food in his/her mouth and needs to be woken up. States [Resident #1] takes 1-3 hours per resident's preference because he/she is afraid will choke. LTC Manager further indicated that when an abuse allegation is brought to her attention, she will pull CNA right away and talk to resident and if any abuse they are sent home immediately. LTC indicated on 1/9/23 CNA1 and CNA3 ran to her and were upset and told her [Resident #1] told them that CNA1 force fed [him/her] and threw up. LTC Manager stated she spoke with CNA1 who said [Resident #1] was asleep with food coming out of [his/her] mouth, I offered to help [him/her], and [he she] said no, I feed myself. CNA1 then went and helped another resident eat and went back to [Resident #1] took [his/her] spoon and put a little broccoli on it said why don't you take a bite and [he/she] allowed her to feed [him/her] and afterwards thought about it and that [he/she] could think [he/she] was forced fed. LTC Manager stated that Resident #1 indicated that the first time [he/she] told her to stop and she went back to feed someone else and came back started feeding [him/her] without asking. LTC Manager indicated that because [Resident #1] said that [he/she] allowed it the second time, and it's not force feeding if you allow it, and [he/she] didn't say no. LTC then indicated that she changed CNA1's assignment to another unit which was away from Resident #1 for the remainder of the shift. During a telephone interview on 2/23/23, at 12:25 p.m. CNA2 indicated that she had observed CNA1 feeding Resident #1 lunch and asked another staff member [Medical Technician] why she was feeding [him/her] as [he/she] is an independent eater, eats really slow and hates to be fed. CNA2 further indicated that a little while later she was asked to help Resident #1 get cleaned up as [he/she] had vomited thier lunch. While CNA2 was cleaning Resident #1 up in [his/her] room, [he/she] was crying and informed CNA2 that CNA1 force fed [him/her] lunch and that's why [he/she] threw up. CNA2 indicated that CNA3 had come in the room to help, and Resident #1 told her what had happened while they were cleaning [him/her] up. At that time CNA1 (who had been listening outside the door) came into the Resident #1's room and said, I'm messy, you want to be messy, I can make things messy. CNA2 indicated Resident #1 was visibly scared, and she and CNA3 would not leave [him/her] alone in [his/her] room until CNA1 left the area. When CNA1 left the area, CNA2 and CNA3 immediately reported the incident to the Unit Manager. CNA2 further indicated that LTC Manager spoke with CNA1 in the office and then spoke with Resident #1 in [his/her] room and that afterward, LTC Manager told her that when she spoke with Resident #1, [he/she] said that [he/she] wasn't force fed. CNA2 further indicated that she (CNA2) went back into Resident #1's room to check on [him/her and asked [him/her] why [he/she] said [he/she] wasn't force fed, but it was what [he/she] told her [CNA2]. CNA2 then indicated that Resident #1 got very upset and told her [he/she] never said [he/she] wasn't force fed. At this time CNA2 stated, I know it really, really bothered [Resident #1] because [he/she] kept talking about it over and over for weeks. During a phone interview on 3/24/23 at 1:23 p.m., [Family member] indicated he/she was upset it happened because [Resident #1] has choked in the past and had needed the Heimlich maneuver. [Family member] further indicated [Resident #1] needs to eat very slowly and eats independently but staff need to wake [him/her] up because [he/she] has narcolepsy and will fall asleep with food in [his/her] mouth. [Family member] indicated that they visited a few days after the incident and [Resident #1] was distraught over the whole thing and told [family member] that CNA1 told [him/her] she was going to help [him/her] hurry up and eat and [he/she] ended up vomiting after which was very upsetting to us. [Family member] further indicated that [Resident #1 is very easy going and would not want to say anything that would get anyone into trouble, and it was obviously upsetting enough for [him/her] to say something to someone about it and [he/she] kept bringing it up for weeks after. During a telephone interview on 3/24/23 at 11:45 a.m., Licensed Social Worker (LSW) indicated that [Resident #1] is very articulate and came to her on 1/12/23 and was very upset and told her that CNA1 told [him/her] she was going to feed [him/her] and [Resident #1] said, no, I feed myself, but CNA1 fed [him/her] anyway. LSW asked [Resident #1] if [he/she] asked her to stop while she was feeding [him/her] and [Resident #1] said no, because [he/she] was afraid to because that the pace she was feeding [him/her], [he/she] was afraid [he/she] was going to choke, and [he's/she's] really afraid of choking. [Resident #1] then informed her that [he/she] ended up vomiting soon after the incident. LSW indicated that she feels that it was a traumatizing event for Resident #1 because [he/she] kept talking about it for quite some time afterward and even brought it up in the Interdisciplinary Team Meeting (IDT) in February (2023). LSW indicated that she spoke with CNA1 who said, It's not a big deal, I don't know what your problem it, that's how we do things. LSW stated she informed [CNA1] that it is a big deal, and resident have rights and they need to be respected and CNA1 walked away. Review of Resident #1's clinical record lacked evidence of monitoring by staff and/or medical provider. Review of CNA1's timecard revealed she worked the following shifts: 1/9/23 from 7:06 a.m., to 22:51. On 1/20/23 from 14:02 to 22:51, and on 1/12/23 from 14:11 to 22:52. During an interview on 2/22/23 at 3:07 p.m., Administrator confirmed a medical provider was initially informed of the incident but there has been no follow up, and that the facility had concluded that the allegation that Resident #1 made was true and CNA1's travel contract was canceled. 2. On 8/24/22 at 7:02 a.m., the Department of Licensing & Certification received a facility reported incident indicating that on 8/22/23 at 10:00 a.m., the LSW overheard CNA4 being verbally abuse, and when LSW went to Resident #2's room to check on the citation, she witnessed CNA4 being physically abusive toward Resident #2. Resident #2 was admitted to the facility on [DATE] with diagnoses to include dementia. Review of Quarterly MDS dated [DATE] indicated Resident #2 had a BIMS of 12 of 15 indicting moderate cognitive impairment. Further review revealed [he/she] needs extensive assist with Activities of Daily Living (ADL's). During an interview on 3/22/23 at 9:15 a.m., CNA5 indicated that a while ago Resident #2 had complained about a staff member with short dark hair, and [he/she] didn't like her attitude and [he/she] didn't like her as a person. CNA5 further indicated that no one could figure out who [he/she] was talking about but it had to have bothered [him/her] a lot because [he/she] mentioned her multiple times. During a telephone interview on 3/24/23 at 11:40 a.m., Licensed Social Worker (LSW) indicated that 8/22/22 at 10:00 a.m., she was walking up A wing and overheard CNA4 yelling at Resident#2 saying you're fine: CNA4 continued to yell at [him/her] but LSW could not understand what she was saying so she turned around and walked back to the room where she witnessed Resident #2 in a chair and CNA4 was stepping back as she pulled on Resident #2's right arm above the elbow with both of her hands gripped around [his/her] arm as she pulled up, and stepped back. [Resident #2] suddenly pulled up on [his/her] arm and screamed God Damn I it, get away from me that hurt. At this time [LSW] said what are you doing, and CNA4 stated well [he/she] is just ugly so I will come back later and she was walking down the hallway without stopping. Review of CNA4's timecard dated 8/22/23 revealed CNA4 punched in at 6:30 a.m., and out at 10:30 a.m. During an interview on 2/22/23 at 3:09 p.m., the Administrator confirmed the above concerns and indicated that she felt it was verbal and physical abuse and that it was CNA4's first and last shift at the facility.

Based on record review, review of the facility's Pain Assessment Management Policy and Procedure, and interviews it was determined that the facility failed to put pain relieving interventions in place for 1 of 1 resident reviewed for pain management (Resident #1). Due to this facility's failure, the resident experienced consistent, unrelieved pain for four consecutive days in August 2022 and in September 2022. Finding: On 9/20/22, a review of Resident #1's clinical record was done. The resident was diagnosed with Dementia, stroke with residual deficits, legally blind, Stage II pressure ulcer on the coccyx, eschar to left heel, [CONDITION(S)]-Stage 4, and other co-morbidities. Documentation on the admission nurse note dated 6/30/22, indicated that at that time Resident #1 was alert and oriented. The Physician MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, [MEDICATION(S)] 200 mg by mouth, two times a day was given for neuropathic pain. Resident #1's July, August,and September 2022 Medication Administration Records (MAR) and Treatment Administration Records (TAR) were reviewed. On the TAR's, pain screening was documented on every day, evening and night shift. The pain was evaluated by using a pain scale from 0-10 (0=no pain up to 10=extreme pain). Documentation on the July TAR was coded to indicate that the resident experienced mild pain at a pain scale of 3 for 2 days out of 31 days. All other days documented as zero-no pain. Documentation on the August TAR was coded to indicate that on 8/25/22, Resident #1 experienced pain level of (4). On 8/26/22, Resident #1 experienced a pain level of (4). On 8/27/22, Resident #1 experienced a pain level of (5). On 8/28/22, Resident #1 experienced a pain level of (3). All other days were zero-no pain. Documentation on the September TAR (9/1/22 thru 9/6/22, was coded zero-no pain. Nurse's Notes and 'Daily Wound Monitoring' notes for July, August and September 2022 were reviewed for pain management interventions for the four days in August that Resident #1 experienced pain for four consecutive nights. There was no evidence in Resident #1's clinical record that indicated a pain assessment had been completed and no evidence that pain relieving interventions (pharmaceutical and/or non-pharmaceutical) were instituted. Documentation on the September 'Daily Wound Monitoring' note (coccyx and left heel), dated 9/3/22 at 11:00 a.m., indicated the resident's pain level was a (7). At 3:30 p.m., the same day, the pain level was a (5). On 9/4/22 at 10:31 a.m., Resident #1's left heel pain level was a (5), at 10:33 a.m., Resident #1's coccyx pain level was a (7) and at 4:59 p.m. the coccyx pain level was a (6). On 9/5/22 at 4:17 p.m., the coccyx pain level was a (7). On 9/6/22 at 6:09 p.m., the coccyx pain level was a (4). 9/7/22, the resident was hospitalized per family request. A review of the facility's 'Pain Assessment Management Policy and Procedure', last revised 2/2022, directs staff to: recognize pain, identify cause, define goals and appropriate interventions, implement pain management strategies, monitor and modify approaches. A review of the care plan problem for pain was done. The care plan approaches were to ask the resident if they hurt, offer pain medication, be patient with them, change their position, be extra gentle with resident, keep it quiet around resident, make bed comfortable, give extra pillows if resident wants them, tell nurse resident hurts. There was no documentation of what the resident pain scale tolerance level was. On 9/27/22 at 10:55 a.m., in an interview with Licensed Practical Nurse #1 (LPN#1), she stated to the surveyor, that Resident #1 was having some pain towards the end of her stay. LPN#1 thought the pain was coming from the resident's coccyx and her shoulder. LPN #1 stated she gave Resident #1 his/her scheduled Tylenol and [MEDICATION(S)]. LPN#1 confirmed there was no as needed (prn) pain medication to give Resident #1. LPN#1 stated she thought there should have been a prn pain medication other than Tylenol. There was no documented evidence in Resident #1's clinical record that indicated that pain relieving interventions were put in place and implemented when Resident #1 suffered from pain on 8/25/22 thru 8/27/22 and on 9/3/22 thru 9/6/22. On 9/29/22 at 1:32 p.m., in an interview with the Administrator, she stated the facility inquired about an additional pain medication order, but the doctor did not provide one. The Administrator confirmed that there was no evidence that pain relieving interventions (pharmaceutical and non-pharmaceutical) were put in place for Resident #1.

Based on a review of the Nursing Facility Reportable Incident Form submitted to the Division of Licensing and Certification on 1/12/2021, the facility's internal investigation, dated 1/14/ , facility policy, and interviews, the facility failed to ensure a resident's safety in the area of transfers by not using appropriate lifting technique while transferring a resident with a hoyer lift, resulting in the resident sustaining avoidable injuries requiring hospitalization for 1 of 13 residents who requiring mechanical lift transfers (#1). Findings: A review of the Nursing Facility Reportable Incident form submitted to the Division of Licensing and Certification on 1/12/2021 revealed that on the morning of 1/11/2021 Certified Nursing Assistants (CNA's) #1 & #2 were transferring Resident (#1) from bed to wheelchair via hoyer lift. Strap apparently let go from hoyer resulting in resident falling to the floor. Resident sent to ER for eval. Further review showed that Resident #1 sustained a subdural hematoma and was subsequently admitted to an acute care hospital. A review of the facility's internal investigation dated 1/14/ revealed the following: The accident was reenacted with the 2 CNA's and a manikin using the same lift pad. While observing the procedure it was determined that before tension was on the strap it had risen up to the top of the lift hood and was unnoticed. During the transfer when the resident reached up changing the pressure on the lift strap allowed to slide off the lift hook. A review of the facility's Lifting machine- using a portable policy effective 6/2016 states, In order to protect the safety and wellbeing of staff and residents, use appropriate techniques and devices to lift and move residents. Attach the sling to the life. Be sure the hooks are placed so that they are facing away from the resident. A review of manufactures instructions states, 1. place the straps of the sling over the hoods of the swivel bar. 2. Match the corresponding colors on each side of the sling for an even lift of the patient. 3. Use the lift. On 1/20/2021 at 9:35 a.m., Director of Nursing Services (DNS) stated,Staff are supposed to ensure that the straps are secured beforehand. When the resident is on the pad, as it gets lifted their weight can shift the straps, they're supposed to double check before they are lifted. On 1/20/2021 at 12:25 p.m., Certified Nurse Aide (CNA) #1 stated, I honestly still have no idea how it could have happened. We put the Hoyer pad underneath him/her, we rolled him/her on to it. All of a sudden, we saw his/her head going back and the strap wasn't on and he/she fell back and hit his head on the leg of the Hoyer lift. CNA#1 was then asked if the straps are supposed to be double checked prior to lifting the resident. CNA#1 stated We're supposed to check them again when their weight starts to shift the pad, but we obviously didn't, or it wouldn't have happened. On 1/20/2021 at 3:00 p.m., a surveyor discussed with the Administrator that although the facility did remove the hoyer lift from the floor and put appropriate measures into place immediately after the incident, the facility failed to ensure Resident #1's safety during a transfer.

Based on record reviews, observations and interview, the facility failed to: assess and monitor pressure ulcers; failed to update a care plan to address the development of pressure ulcers, as well as interventions to prevent and treat pressure ulcers; failed to notify a physician of the development of pressure ulcers; failed to obtain orders for the treatment of [REDACTED].#1, #6, #7). These failures resulted in Resident #1 developing 8 pressure ulcers between his/her admission on 1/22/15, and before his/her discharge on 2/17/15 and resulted in Resident #6 developing two unstagable ankle pressure ulcers and having a stage 1 heel ulcer decline to an unstagable pressure ulcer. In addition, the facility failed to ensure measures were in place to protect a heel pressure ulcer during ambulation for 1 of 8 sampled residents (#6). Findings: 1. Resident #1's Minimum Data Set, Version 3.0 (MDS) assessment, dated 1/29/15, was coded, (under Section M), to indicate the resident had no pressure ulcer during the assessment period. The MDS assessment was also coded to indicate the resident had [MEDICAL CONDITION], and was coded to indicate that the resident required the assistance of at least one staff for transfers and positioning. The resident's care plan, dated 1/23/15, did not indicate that it was updated after the completion of the MDS assessment and indicated the resident had a potential for development of pressure ulcers. Resident #1's electronic treatment record, dated 1/31/15, indicated a "New Skin Issue Observation" was conducted and the resident's left heel was observed purple in color with the skin intact. The electronic treatment record, dated 2/3/15, under "New Skin Issue Observation" indicated that the resident had a Stage 2 area on the back of the left lower leg, a Stage 2 area on the left heel and a Stage 2 area on the right posterior lower leg. Resident #1's electronic daily wound treatment form, dated 2/11/15, indicated the resident had excoriated areas on both the right and left buttocks. The electronic daily wound treatment form, dated 2/12/15, indicated the resident had developed an unstagable pressure ulcer on the coccyx area in the buttock crease. The resident's current care plan, updated on 1/23/15, was not updated to include the development of 7 pressure ulcers and did not address interventions to prevent the development of additional pressure ulcers or interventions to promote healing of these areas. In addition, the resident's care plan was not updated to include the physician's orders [REDACTED]. 2. Resident #1's electronic "daily wound monitoring" form, dated 2/12/15, indicated that the resident had developed an unstagable pressure ulcer located in the buttock crevice of the coccyx area. The electronic treatment records indicated a treatment was started to this area. The resident's electronic medical record lacked evidence that the physician was notified of the development of this pressure ulcer and of the treatment that was started by the facility. 3. Resident #1's "Physician communication Form," dated 2/4/15, indicated the resident had three stage II pressure ulcers. One on the left heel; one on the posterior left lower extremity and one on the posterior right lower extremity. The electronic daily wound monitoring notes, dated 2/11/15, indicated that the resident had developed two excoriated areas: one on the right buttock and one on the left buttock. The physician was notified of the two new excoriated areas. The electronic daily wound monitoring notes, dated 2/15/15, indicated that the left buttock had two Stage II areas; a second excoriated area on the left buttock; a Stage III area on the coccyx area; an area on the left lower leg; an area on the right lower leg and an area on the left heel. The resident's medical record lacked evidence that the physician was made aware that the resident had seven pressure ulcers, two of which developed after the physician's visit of 2/11/15. A treatment note, dated 2/17/15, indicated the physician was out of the office "yesterday" and that the facility was unable to obtain treatment orders. A fax "Physician's Communication Form," dated 2/16/15, identified that the resident's wounds were not improving and informed the physician that the left posterior leg was now unstagable; the coccyx wound had eschar; the right posterior leg was larger and the left heel contain slough. The fax form did not identify the other three pressure ulcers that had developed on 2/16/15. 4. Resident #1's electronic "daily wound monitoring" documentation, dated 2/12/15, indicated that the resident had developed an unstagable pressure ulcer on his/her coccyx. The electronic treatment record indicated that the staff were applying [MEDICATION NAME] to the unstagable pressure ulcer from 2/12/15 through 2/17/15. The [MEDICATION NAME] was ordered by the physician on 2/10/15, for the treatment of [REDACTED]. The resident's electronic record lacked evidence of orders for the treatment of [REDACTED]. 5. Resident #1's electronic treatment record, dated 1/31/15, indicated a "New Skin Issue Observation" was conducted and the resident's left heel was observed purple in color with the skin intact. There were no documented measurements of this area at the time of the note. The electronic treatment record, dated 2/3/15, under "New Skin Issue Observation" indicated that the resident had a Stage 2 area on the back of the lower leg, a Stage 2 area on the left heel and a Stage 2 area on the right posterior lower leg. The treatment record contained measurements and descriptions of these areas. The electronic treatment record, dated 2/7/15, contained a note indicating the right lower leg dressing was placed an the wound area was pink/beefy red. There was no documentation of the Stage 2 area on the left heel or on the back of the left leg. There was no daily documentation of the pressure area available on 2/10/15. Resident #1's electronic daily wound treatment form, dated 2/11/15, indicated the resident had excoriated areas on both the right and left buttocks. No measurements were available. The electronic daily wound treatment form, dated 2/12/15, indicated the resident continued to have excoriated areas on the right and left buttocks with no measurements, and had developed an unstagable pressure ulcer on the coccyx area in the buttock crease. No measurements were available when this wound was identified. On 2/13/15, the "daily wound monitoring' sheet, identified two ulcers on right lower leg instead of the one previously identified on the 'weekly wound charting sheet, done on February 10, 2015. 6. Resident #1's "physician progress notes [REDACTED]. A fax "physician communication form" signed by the physician on 2/17/15, indicated that the resident's left lower posterior leg Stage 2 is "now unstagable with black eschar and slough; the unstagable area on the resident's coccyx has eschar and is "becoming larger"; the resident's lower right posterior leg is "becoming larger" and the resident's left heel Stage 3 has a small amount of slough. The resident's discharge note, dated 2/17/15, indicated the resident was transferred to another facility. A physician's progress note, dated 2/18/15, from the receiving facility, indicated the resident was transferred to this facility for long term care services. The progress note indicated under the "A/P" section "pressure sores. This is a bigger issue and I am a bit shocked at the number and staffing of these pressure sores." This note indicated the resident will need a higher level of care for the debridment of the pressure ulcers, will need to be on an airflow bed and would be transferred to a hospital immediately. This progress note indicated the resident had [MEDICAL CONDITION] of the lower extremities and the skin exam showed the following: The resident's left halux has an oblong 3 cm sore that is just a stage I with some granulation tissue on it. The right lateral tibia area has two sores: one is 2 cm in diameter and the other one is 1.5 cm and both of these are felt to be Stage 2. The left lateral leg has a large irregular area of eschar that measures 10 by 5 cm with no ability to staff this area due to eschar. The area appears to look like a traumatic injury or sustained from pressure or compression, (the electronic progress notes from the facility indicated the resident used multipodus boots and ace wraps on his/her legs prior to the development of the pressure ulcers). The left heel has a 2 cm ulceration that is felt to be a Stage 2. On the sacrum there are two sores: one is superficial Stage 1 about 1 cm but the larger one is 4 cm and I believe is a Stage 3, it has a centimeter (cm) of depth but it has slough and eschar. On 2/18/15, the resident was transferred to the hospital for treatment of [REDACTED]. The hospital "History and Physical" form, dated 2/18/15, indicated the resident was admitted due to multiple decubitus (pressure) ulcers on the bilateral lower extremities and in the sacral area. The "History and Physical" form, documents that the resident had stated he/she was receiving physical therapy but stated he/she was being moved every "now and then". The note indicated that the resident indicated the frequency of the positioning was not as much as he/she thinks it should have been. On 2/24/15 at approximately 2:30 p.m., a surveyor discussed these findings with the Administrator. 7. Resident #6's "Face Sheet," dated 2/4/15, indicated the resident was admitted to the facility on [DATE], for rehabilitation services after surgical repair of a fractured right hip. The resident's "Admission Day #1-Nursing Documentation-Page #1" form, dated 1/16/15, indicated that a skin check had been completed on 1/6/15 and the resident had a persistent area of skin redness that does not disappear when pressure relieved (Stage 1) on the right heel. The note indicated the resident did not have a history of pressure ulcers in the past 90-days. This form also indicated the resident had a red area on the coccyx. The electronic daily wound monitoring documentation does not address the daily monitoring of the resident's coccyx until 1/10/15, (4 days after the resident was admitted ). The wound monitoring forms, dated 1/10/15 at 9:52 p.m., indicated the coccyx area remained blanchable with redness. On 1/11/15 at 8:08 p.m., and on 1/12/15 at 9:08 p.m., the wound monitoring notes indicated the area on the resident's coccyx remained blanchable but was a "pink/beefy red" color. There was no further documentation on the coccyx pressure area after 1/12/15. On 3/9/15 at 12:45 p.m., in an interview with a surveyor, a Licensed Practical Nurse stated that she was not aware of any pressure ulcers or redness on the resident's coccyx or buttocks and that staff turn the resident at least every hour because the resident's skin is so fragile. On 3/9/15 at approximately 1:40 p.m., in an interview with a surveyor, the Registered Nurse (RN), Director of Nursing stated that the red area on the resident's coccyx was healed. On 3/9/15 at 3:00 p.m., in an interview with a surveyor, the Administrator stated that the coccyx area was healed. A surveyor discussed that the daily monitoring and assessments were not available for this coccyx red area and that the resident's records (electronic and paper) did not identify that the area had resolved. 8. Resident #6's "Face Sheet," dated 2/4/15, indicated the resident was admitted to the facility on [DATE], for rehabilitation services after surgical repair of a fractured right hip. The resident's "Admission Day #1-Nursing Documentation-Page #1" form, dated 1/16/15, indicated that a skin check had been completed on 1/6/15 and the resident had a persistent area of skin redness that does not disappear when pressure relieved (Stage 1) on the right heel. The note indicated the resident did not have a history of pressure ulcers in the past 90-days. The resident's medical record lacked evidence of monitoring and assessment of the resident's heel after admission. An electonic note, dated 1/22/15 at 8:41 a.m., indicated the resident had a right heel pressure ulcer with black brown eschar that was aquied in the hopsital measuring 3 by 4 cms with no tunneling. This note indicated the resident was to wear "black medidex heel protector boots at all times." On 1/24/15 a electronic note indicated that the resident right heel Stage 1 pressure area had declined and was now a "right foot heel unstagable pressure area with black/brown eschar in the wound bed, redness at the periwound area and no visual exudates. The note did not contain measurements of the heal pressure area. On 1/28/15 at 1:10 p.m., an electronic note indicate the resident indicated that this was a late entry note for 1/15/15, that indicated the resident had a right heel unstagable pressure ulcer that was present upon admission from a boarding home, there are no measurements of the heel ulcer, (this note contradicted the admission note on the admission from dated 1/6/15). The 1/28/15 note also indicated a "boot" was being applied to reduce pressure on the area. The daily wound documentation notes, dated 1/28/15, identified that the resident now has two (2) right heel ulcers. These notes indicate one if the pressure ulcers is located on the right heel and the second pressure ulcer is located on the right lateral heel. There are no measurements of the pressure ulcers. On 2/3/15 at 1:19 p.m. (7 days after the pressure ulcers on the heel were identified), an electronic assessment of the resident's right heel was completed indicating that the right heel is an unstagable pressure ulcer with a wound bed covered in slough and/or eschar, that this pressure ulcer was identified "after admission," and measures 2.6 centimeters (cm) long, by 5.5 cm wide with no depth. A "clarification note" indicated that the lateral heel and posterior heel pressure ulcers have now merged into one area. This note also indicated that the resident would have his/her feet elevated off the bed with pillows to offload pressure. On 3/9/15 at 1:50 p.m., a surveyor observed the resident's right heel. The resident was observed seated in a recliner with both bare feet propped on a wedge cushion and pillow so his/heels were elevated off the footrest. The resident was observed with a dollar sized circular area extending from the outside of the heel to the back of the heel. The wound bed had black and dried slough with no drainage and no odor. The resident's heels were left open to air. On 3/9/15 at 12:45 p.m., in an interview with a surveyor, a Licensed Practical Nurse (LPN) stated that she did not know how the heel pressure area was acquired but stated that the area was about the size of a half dollar with black/brown eschar. The LPN stated that a dressing was not applied and the pressure ulcer was left open to air. The LPN stated that the resident requires total assistance with positioning, transferring and mobility. On 3/9/15 at 1:40 p.m., in an interview with a surveyor, the Registered Nurse (RN), Director of Nursing stated that the resident was admitted with the pressure ulcer on his/her heel and that the pressure ulcers are left open to air. On 3/9/15 at 3:00 p.m., in an interview with a surveyor, the Administrator stated that the resident had a Stage 2 pressure ulcer on the right heel at the time of admission. The resident was wearing a "boot" that he/she wore at home at the time of admission. The Administrator stated that the heel area declined to an unstagable pressure area and the facility changed over to a pressure relieving boot. The Administrator stated that the facility stopped using the boot when the resident developed two pressure ulcers on the right lateral ankle after the application of the boot. The resident now has the areas open to air with his/her feet elevated and the area is smaller in size but still has eschar. At the time of the interview, a surveyor discussed the failure to assess the pressure ulcer, failure to monitor the pressure ulcer on admission and the decline of the pressure ulcer with the Administrator. 9. Resident #6's "Face Sheet," dated 2/4/15, indicated the resident was admitted to the facility on [DATE], for rehabilitation services after surgical repair of a fractured right hip. The resident's "Admission Day #1-Nursing Documentation-Page #1" form, dated 1/16/15, indicated that a skin check had been completed on 1/6/15 and did not indicate that the resident had any open areas on the right ankle. An electonic note, dated 1/22/15 at 8:41 a.m., indicated the resident had a right heel pressure ulcer with black brown eschar that was aquied in the hopsital measuring 3 by 4 cms with no tunneling. This note indicated the resident was to wear "black medidex heel protector boots at all times." Daily wound/pressure ulcer monitoring notes and electronic pressure ulcer notes from admission through 1/28/15, do not identify any pressure ulcers on the resident's right ankle. On 1/28/15 at 2:41 p.m. and on 1/29/15 at 10:48 a.m., electronic noted indicated that the resident has an "unstagable" pressure ulcer on the right lateral ankle with black/brown eschar. No measurements of this pressure ulcer were available in these notes. The resident's medical record lacked evidence of daily monitoring of the ankle pressure area until 2/2/15, when an electronic daily monitoring note indicates that the right ankle has black/brown eschar in the wound bed that is thick and "lifting". The note indicates no dressing has been applied. An electronic wound assessment note, dated 2/10/15 at 2:39 p.m., indicates the resident has a right ankle new unstagable pressure ulcer, with the wound bed covered by slough and/or eschar. The note indicates the area is being treated by elevating the resident's legs and leaving the area open to air. The note indicated the area was 1.2 cm long by 0.7 wide with no depth and no drainage. This note also indicates the resident has a second right ankle pressure ulcer, "above the ankle bone" that has black/brown eschar in the wound bed measuring 2.1 cm in length, by 0.3 cm in width with no depth. On 2/19/15 at 6:24 p.m., (9 days later) the resident's two ankle pressure ulcers were reassessed. The note indicated that there was no change in the measurements of the open area on the resident's right ankle bone and that the pressure ulcer above the resident's ankle bone had decreased in length (from 2.1 cm to 1.3 cm) but had increased in size (from 0.3 cm to 0.5 cm). Both the areas were documented as unstagable and with black/brown eschar in the wound bed. On 3/9/15 at 1:50 p.m., a surveyor observed Resident #6's ankle pressure areas. The resident was observed with two pressure areas on the right ankle area. The area above the resident's right ankle was observed to be a backward half moon shaped area approximately 3 cm in length by <0.5 cm in width, the area had a "scab" like covering. The second pressure ulcer was observed directly over the resident's outer ankle bone and was an irregular circular dime sized area with no drainage and the wound bed was covered with a scab like covering. Both areas were observed open to air and the resident's feet and ankles were observed suspended above the footrest with pillows and a wedge shaped cushion. On 3/9/15 at 3:00 p.m., in an interview with a surveyor, the Administrator stated that the resident developed the two pressure ulcers after admission to the facility. The Administrator stated that they believe the ankle pressure ulcers were a result of the pressure boot that the facility applied. At the time of the interview, a surveyor discussed the failure to prevent the development of pressure ulcers, and the failure to assess pressure ulcers with the Administrator. 10. Resident #6's electronic wound pressure ulcer assessment forms and daily monitoring forms, indicated the resident has an unstagable pressure ulcer on the right heel. An electronic note, dated 2/19/15 at 6:32 p.m., indicates that staff are "unable to rate pain" and that the resident "grimaced" briefly when applying pressure to the wound to assess for blanching. On 3/9/15 at 1:30 p.m., a surveyor observed Resident #6 ambulating from his/her room, down the hallway past the beauty parlor and then half way down the hallway that leads to the main entrance, with the assistance of a Physicial Therapist and a Certified Nursing Assistant (CNA). The resident was observed wearing only non-skid slipper socks on both feet, no cushioning or padding was observed between the resident's sock and heel pressure ulcer to protect the heel pressure ulcer during ambulation. The resident was observed ambulating using a rolling walker and taking small, short steps. The resident was observed placing his/her weight on the ball of the right foot and attempting to maintain his/her right heel off the floor. The resident was observed taking approximately 6 steps when his/her right heel touched the floor. The resident was observed visibly wincing, sucking in a breath while simultaneously lifting his/her right heel off the floor. The resident was observed pausing for a few seconds directly after this then continuing to ambulate. The resident was observed stopping approximately every 25 feet to lift his/her right heel off the floor. On 3/9/15 at approximately 1:40 p.m., in an interview with a surveyor, the Registered Nurse (RN), Director of Nursing stated that the resident was not walking when he/she was admitted but has been doing much better. On 3/9/15 at approximately 2:00 p.m., in an interview with a surveyor, the Physical Therapist stated that the resident does walk on the ball of his/her foot and that the resident will moan or act like he/she has pain when the resident sets his/her heal down. The Therapist stated that they did not want to put on shoes or socks to prevent friction or rubbing but the therapist stated that they had not considered padding or cushioning the heel area when the resident walks. On 3/9/15 at 3:00 p.m., a surveyor discussed this finding with the Administrator. 11. Resident #7's electronic daily wound monitoring forms, indicated the resident has an unstagable pressure ulcer on the right hip, and the physician order, dated 3/4/15, directed staff to," clean wound with sea-cleans, cover with ABD pad and secure with [MEDICATION NAME] ytape daily, only until [MEDICATION NAME] comes in. Documentation by the Registered Nurse on both 3/7/15 and 3/8/15 indicated, "dressing replaced other; washed with sea-cleans, applied calcium alginate, covered with [MEDICATION NAME] foam". When questioned on 3/9/15 at 1:50 PM, the nurse stated, I should have gotten a clarification of the order, I just used what had been ordered before." The previous order, cleanse with sea-cleans, apply calcium alginate and cover [MEDICATION NAME] and secure with [MEDICATION NAME] tape, by the physician had been discontinued on 2/23/15, when a new order from the wound clinic was given directing use of [MEDICATION NAME]. On 3/9/15 at 1:50 PM, the surveyor discussed this finding with the Registered Nurse who had completed the treatment.

Based on observation, record review and interview, the facility failed to ensure that measures to protect a heel pressure ulcer and prevent pain during ambulation were in place for 1 of 8 sampled residents (#6). This failure resulted in Resident #6 experiencing pain when he/she put pressure on his/her heel ulcer. Also, physician's orders [REDACTED].#7). Finding: 1. Resident #6's electronic wound pressure ulcer assessment forms and daily monitoring forms, indicated the resident has an unstagable pressure ulcer on the right heel. An electronic note, dated 2/19/15 at 6:32 p.m., indicates that staff are "unable to rate pain" and that the resident "grimaced" briefly when applying pressure to the wound to assess for blanching. On 3/9/15 at 1:30 p.m., a surveyor observed Resident #6 ambulating from his/her room, down the hallway past the beauty parlor and then half way down the hallway that leads to the main entrance, with the assistance of a Physical Therapist and a Certified Nursing Assistant (CNA). The resident was observed wearing only non-skid slipper socks on both feet, no dressing or padding was observed between the resident's sock and heel pressure ulcer. The resident was observed ambulating using a rolling walker and taking small, short steps. The resident was observed placing his/her weight on the ball of the right foot and attempting to maintain his/her right heel off the floor. The resident was observed taking approximately 6 steps when his/her right heel touched the floor. The resident was observed visibly wincing, sucking in a breath while simultaneously lifting his/her right heel off the floor. The resident was observed pausing for a few seconds directly after this then continuing to ambulate. The resident was observed stopping approximately every 25 feet to lift his/her right heel off the floor. On 3/9/15 at approximately 1:40 p.m., in an interview with a surveyor, the Registered Nurse (RN), Director of Nursing stated that the resident was not walking when he/she was admitted but has been doing much better. The RN, Director of Nursing stated that the resident is on a scheduled pain medication regime and does not have a dressing on his/her heel. On 3/9/15 at approximately 2:00 p.m., in an interview with a surveyor, the Physical Therapist stated that they usually try to ambulate the resident after the resident has had his/her scheduled pain medication but today the resident was running late due to morning appointments. The Therapist stated that the resident does walk on the ball of his/her foot and that the resident will moan or act like he/she has pain when the resident sets his/her heal down. The Therapist stated that they did not want to put on shoes or socks to prevent friction or rubbing but the therapist stated that they had not considered padding or cushioning the heel area when the resident walks. On 3/9/15 at 3:00 p.m., a surveyor discussed this finding with the Administrator. 2. Resident #7's electronic daily wound monitoring forms, indicated the resident has an unstagable pressure ulcer on the right hip, and the physician order, dated 3/4/15, directed staff to ", clean wound with sea-cleans, cover with ABD pad and secure with [MEDICATION NAME] tape daily, only until [MEDICATION NAME] comes in. Documentation by the Registered Nurse on both 3/7/15 and 3/8/15, indicated, "dressing replaced other; washed with sea-cleans, applied calcium alginate, covered with [MEDICATION NAME] foam". When questioned on 3/9/15 at 1:50 PM, the nurse stated, I should have gotten a clarification of the order, I just use what had been ordered before." The previous order, cleanse with sea-cleans, apply calcium alginate and cover [MEDICATION NAME] and secure with [MEDICATION NAME] tape, by the physician had been discontinued on 2/23/15, when a new order from the wound clinic was given directing use of [MEDICATION NAME]. On 3/9/15 at 1:50 PM, the surveyor discussed that the facility failed to follow a physician's orders [REDACTED].

Based on record review and interview, the facility failed to ensure an attending physician supervised the care of pressure ulcers for 1 of 4 sampled residents (#1). This failure resulted in Resident #1 developing 8 pressure ulcers between his/her admission (1/22/15) and discharge (2/17/15). Finding: Resident #1's Minimum Data Set, Version 3.0 (MDS) assessment, dated 1/29/15, was coded, (under Section M), to indicate the resident had no pressure ulcer during the assessment period. The MDS assessment was also coded to indicate the resident had [MEDICAL CONDITION], and was coded to indicate that the resident required the assistance of at least one staff for transfers and positioning. A fax "Physician Communication Form," dated 2/3/15, indicated the resident had developed three pressure ulcers: one Stage 2 on the left heel; one posterior Stage 2 on the left lower extremity and one Stage 2 on the right lower extremity. The faxed communication form, requested that the facility be allowed to use a mepiplex dressing on the right heel; an [MEDICATION NAME] dressing with dry gauze and an ace wrap on the bilateral posterior lower extremities and to use multipodus boots on both lower extremities. The physician signed the form on 2/4/15. A physician's progress note, dated 2/11/15 (seven days after the development of the three pressure ulcers), indicated that the physician ordered the staff to use padding to remove pressure from the resident's legs; to reposition the resident every two hours and to obtain a wound care consult. The physician progress notes [REDACTED]. The electronic daily wound monitoring notes, dated 2/15/15, indicated that the left buttock had two Stage II areas; a second excoriated area on the left buttock; a Stage III area on the coccyx area; an area on the left lower leg; an area on the right lower leg and an area on the left heel. The resident's medical record lacked evidence that the physician was made aware that the resident had seven pressure ulcers, two of which developed after the physician's visit of 2/11/15. A treatment note, dated 2/17/15, indicated the physician was out of the office "yesterday" and that the facility was unable to obtain treatment orders. On 2/16/15, a fax "Physician Communication Form" indicated that the pressure ulcer were not improving and were "becoming larger." The form indicated that: the resident's left lower posterior leg had declined to an unstageable area with black eschar and slough, that was treated with [MEDICATION NAME] and gauze; the unstageable area on the coccyx has eschar and was becoming larger; the lower right posterior leg was becoming larger and the left heel Stage 3 area had a small amount of slough. The communication form indicated the facility "needs further direction." The physician signed the form on 2/17/15, indicating to institute the changes as the wound nurse recommended. There was no indication that the physician was made aware of the other pressure ulcers on the resident's buttocks or that the physician had been in and seen the resident's wound areas. On 2/17/15, the resident was transferred to another nursing facility. On 2/18/15, physician's progress note from the other nursing facility indicated: the resident was transferred to this facility for long term care services. The progress note indicated, under the "A/P" section "pressure sores. This is a bigger issue and I am a bit shocked at the number and staffing of these pressure sores." This note indicated the resident will need a higher level of care for the debridment of the pressure ulcers, will need to be on an airflow bed and would be transferred to a hospital immediately. This progress note indicated the resident had [MEDICAL CONDITION] of the lower extremities and the skin exam showed the following: The resident's left halux has an oblong 3 cm sore that is just a stage I with some granulation tissue on it. The right lateral tibia area has two sores: one is 2 cm in diameter and the other one is 1.5 cm and both of these are felt to be Stage 2. The left lateral leg has a large irregular area of eschar that measures 10 by 5 cm with no ability to staff this area due to eschar. The area appears to look like a traumatic injury or sustained from pressure or compression, (the electronic progress notes from the facility indicated the resident used multipodus boots and ace wraps on his/her legs prior to the development of the pressure ulcers). The left heel has a 2 cm ulceration that is felt to be a Stage 2. On the sacrum there are two sores: one is superficial Stage 1 about 1 cm but the larger one is 4 cm and I believe is a Stage 3, it has a centimeter (cm) of depth but it has slough and eschar. On 2/18/15, the resident was transferred to the hospital for treatment of [REDACTED]. The hospital "History and Physical" form, dated 2/18/15, indicated the resident was admitted due to multiple decubitus (pressure) ulcers on the bilateral lower extremities and in the sacral area. The "History and Physical" form, documents that the resident had stated he/she was receiving physical therapy but stated he/she was being moved every "now and then". The note indicated that the resident indicated the frequency of the positioning was not as much as he/she thinks it should have been. On 2/24/15 at approximately 12:50 p.m., a surveyor discussed this finding with the Administrator.