Every finding on record at High Hope Care Center of Brenham

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three of eight residents (Resident # 9, Resident #19, and Resident # 37) reviewed for ADL care.The facility failed to ensure Resident #9, Resident #19 and Resident #37's nails were cleaned on 03/24/2026.This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.Findings included:Resident #9Record review of Resident #9's face sheet, dated 03/26/2026, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: type 2 diabetes mellitus with unspecified complications (the body develops insulin resistance and cannot use insulin effectively, leading to high blood glucose (sugar) levels. The person did not reported specific complications or acute, severe symptoms at the time of examination), anxiety disorder (involve more than occasional worry or fear, does not go away, is felt in many situations, and can get worse over time), and unspecified dementia, unspecified severity, with other behavioral disturbance (when a person shows significant memory decline- affecting thinking and daily functioning. However, the specific cause and severity are not yet determined) and, major depressive disorder, single episode, unspecified (a low mood or loss of pleasure or interest in activities lasting at least two weeks), Record review of Resident #9's Quarterly MDS Assessment, dated 02/19/2026, reflected Resident #9 was rarely/never understood. Staff was unable to complete Brief Interview for Mental Status (BIMS). She had poor short- and long-term memory recall. Her decision-making abilities was severely impaired (she rarely /never made decisions) Resident #9 did not refuse care. Resident #9 was totally dependent on staff for the following ADLs: eating, oral hygiene, toileting hygiene, showers, lower and upper body dressing, personal hygiene, bed mobility, and transfers.Record review of Resident #9's Comprehensive Care Plan, revised on 03/04/2026, reflected Resident #9 was dependent on staff for ADLs at all times related to dementia. Intervention: Resident #9 was dependent on staff with the following:Grooming- dependent on staffPersonal hygiene- dependent on staffDressing- dependent on staffBed mobility- dependent on staffEating -dependent on staffToileting- dependent on staffOral hygiene- dependent on staff Observation and interview on 03/24/26 at 12:00 p.m. revealed Resident #9 was lying in bed in her room. She had a blackish/brownish substance underneath her middle, ring and fore fingernails on her right hand. Resident #9 was not interview able.Observation and interview on 03/25/2026 at 8:00 a.m. revealed Resident #9 was lying in bed in her room. She had a blackish/brownish substance underneath her middle, ring and fore fingernails on her right hand. Resident #9 was not interview able.Resident#19Record review of Resident #19's face sheet, dated 03/26/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #19 had diagnoses of major depressive disorder, single episode, severe without psychotic features ( a low mood or loss of pleasure or interest in activities lasting at least two weeks), unspecified lack of coordination ( a general inability to control or coordinate muscle movements that cannot be linked to a specific underlying diagnosis), and spastic hemiplegia affecting right dominant side ( brain damage causing stiffness, muscle tightness, and diminished control of the right arm and leg).Record review of Resident #19's MDS assessment dated [DATE], reflected Resident #19 had a BIMS score of 15 which indicated his cognition was intact. Resident #19 did not refuse care. He was dependent on staff for the following ADLs: dressing, showers, and toileting hygiene. Resident #19 required substantial/ maximal assistance (helper does more than half the effort) with personal hygiene.Record review of Resident #19's revised care plan dated 03/03/2026, reflected Resident #19 had an ADL self-care performance deficit related to right side paresis (weakness on the right side of the body). Interventions: Resident #19 required assistance with dressing, grooming and personal hygiene.Record review of Resident #19's Skin Observation Tool Assessment, dated 03/18/2026 reflected Resident #19 did not refuse nail care.Record review of Resident #19's Skin Observation Tool Assessment, dated 03/25/2026 reflected Resident #19 did not refuse nail care.Observation and interview on 03/24/2026 at 12:50 p.m. revealed Resident #19 was sitting in his room sitting in his wheelchair. Resident #19's fingernails on his right hand underneath his middle and ring fingernails had a blackish/brownish substance. He had blackish/brownish substance underneath his middle and fore fingernails on his left hand. Resident #19 stated he did not like his nails to be dirty. He stated he asked someone Saturday (03/21/2026) to clean his nails and the person stated they would get someone to clean them sometime next week. Resident #19 stated he did not recall the staff name. He stated she worked with the nurses.Resident #37Record review of Resident #37's face sheet, dated 03/26/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #37 had diagnoses unspecified dementia, unspecified severity, with other behavioral disturbance (when a person shows significant memory decline- affecting thinking and daily functioning and with behaviors), unspecified lack of coordination ( type 2 diabetes mellitus with other diabetic circulatory problems ( occurs when chronic high blood sugar damages blood vessels, narrowing them and restricting blood flow throughout the body), unspecified lack of coordination ( a general inability to control or coordinate muscle movements that cannot be linked to a specific underlying diagnosis), major depressive disorder, recurrent severe without psychotic features ( a severe mental condition characterized by persistent low mood, loss of interest, and physical/cognitive symptoms lasting at least two weeks), unqualified visual loss in both eyes ( vision impairment such as blindness or low vision, where the specific category of severity of the impairment. The exact visual deficit was not clearly classified), and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side (a neurological deficit caused by bleeding in the brain (non-trauma) that damages the right hemisphere- controls left side of the body)Record review of Resident #37's MDS assessment dated [DATE], reflected Resident #37 had a BIMS score of 2 which indicated his cognition was severely impaired. Resident #37 was dependent on staff for the following:Eating- dependent on staffOral Hygiene- dependent on staffToileting Hygiene- dependent on staffShower/Bathe - dependent on staffUpper and lower body dressing- dependent on staffPersonal Hygiene - dependent on staffTransfers - dependent on staffBed mobility - dependent on staffRecord review of Resident #37's care plan was revised on 02/18/2026 reflected Resident #37 had an ADL self-care performance deficit due to dementia (memory loss that is severe enough to interfere with daily life) and visual impairment ( a person's eyesight cannot be corrected to a normal level). Resident #37 required assistance with personal hygiene and bathing and report any refusals. Resident #37 was dependent on staff for eating, personal hygiene, showers, dressing, transfers, and bed mobility.Record review of Resident #37's skin observation tool assessment, dated 03/16/2026, reflected Resident #37 did not refuse nail care.Record review of Resident #37's skin observation tool assessment, dated 03/23/2026, reflected Resident #37 did not refuse nail care.Observation and interview on 03/24/2026 at 10:00 am revealed Resident #37 was lying in her bed located in her room. Resident #37's fingernails on her left hand underneath his middle and ring fingernails had a blackish/brownish substance. Resident #37 was not interview able.In an interview on 03/26/2026 at 8:14 am, LVN A stated the nurses were responsible for all residents' nail care such as trimming, cleaning, and filing. LVN A stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill, such as stomach problems nausea and vomiting. LVN A stated if a resident refuses showers, nail care or any type of care the nurses documents the refusal on weekly skin tool assessment. He stated there was one person who refused a lot of care and it was not Resident # 37 and Resident #9, or Resident #19. He stated he had been in-service on nail care, and all staff was to report any nail issues with the resident to the nurse.In an interview on 03/26/2026 at 9:35 am, CNA D stated the nurses was responsible for all nail care. She stated if a CNA observed any problems with a residents nails the CNA was to report it to the nurse supervisor. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA D stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. CNA A stated anytime a resident refused any type of care she reported it to the charge nurse and the charge nurse would document it in the resident's medical record. She stated she was not aware of anyone on central hall (the hall where Resident #9 and Resident #19 resided) refused care.In an interview on 03/26/2026 at 9:50 am, LVN B stated the Nurses were responsible for cleaning, trimming, and filing all residents' nails. LVN B stated the residents' nails were usually cleaned when nurses completed weekly skin assessments or as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as infection in the stomach. LVN B stated the infection possibly may have symptoms such as vomiting. LVN B stated she was more familiar with Resident # 19, and she was not aware of him refusing care including nail care. She stated if a resident refused nail care the nurse would document it on the skin observation tool assessment.In an interview on 03/26/26 at 1:40 pm, the Administrator stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become ill with stomach issues such as vomiting and nausea if they ingested the blackish/ brownish substance. She stated the Nurses were responsible for all residents' nails such as cleaning, trimming, and filing. The DON stated the ADON and DON was responsible for monitoring ADL care which included nail care. She stated anyone observe Residents needing any type of nail care was instructed to report to the nurse. She stated an in-service had been given to the staff on nail care and reporting any issues with nails when CNAs are giving residents a shower.Record review of the Facility's Activities of Daily Living (ADL), Supporting Policy, dated 2001, reflected Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:Hygiene (bathing, dressing, grooming, and oral care);

Based on interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 (Residents #9, and #37) of 6 residents reviewed for activities. The facility failed to provide activities for Resident #9, and Resident #37to meet their psycho-social and mental well-being for the months of January, February and March 2026.This failure could place residents at risks of boredom, depression, behavior, diminished quality of life and decreased cognitive function. Findings includeResident #9Record review of Resident #9's face sheet, dated 03/26/2026, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: anxiety disorder (involve more than occasional worry or fear, does not go away, is felt in many situations, and can get worse over time), and unspecified dementia, unspecified severity, with other behavioral disturbance (when a person shows significant memory decline- affecting thinking and daily functioning. However, the specific cause and severity are not yet determined) and, major depressive disorder, single episode, unspecified (a low mood or loss of pleasure or interest in activities lasting at least two weeks).Record review of Resident #9's Significant Change MDS Assessment, dated 11/20/2026, reflected Resident #9 was rarely/never understood. Staff was unable to completed Brief Interview for Mental Status (BIMS). She had poor short- and long-term memory recall. Her decision-making abilities was severely impaired ( she rarely /never made decisions). Resident #9 Activity Preferences for Customary Routine and Activities section revealed the was no interest in the following :Choosing clothes to wearCaring for personal belongingsReceiving tub bathReceive showerReceive bed bathReceive sponge bathSnacks between mealsStaying up past 8:00 p.m.Family or significant other involvementUse of phone in privatePlace to lock personal belongingsReadingListen to musicBeing around animals such as petsKeep up with the newsDoing things with group of peopleParticipating in favorite activitiesSpending time away from the nursing homeSpending time outdoorsParticipating in religious activities or practices Record review of Resident #9's Quarterly MDS Assessment, dated 02/19/2026, reflected Resident #9 was rarely/never understood. Staff was unable to completed Brief Interview for Mental Status (BIMS). She had poor short- and long-term memory recall. Her decision-making abilities was severely impaired ( she rarely /never made decisions) Resident #9 did not refuse care. She was totally dependent on staff for the following ADLs: eating, oral hygiene, toileting hygiene, showers, lower and upper body dressing, personal hygiene, bed mobility, and transfers.Record review of Resident #9's Comprehensive Care Plan, revised on 03/09/2026, reflected Resident #9 was dependent on staff for meeting emotional, intellectual, physical and social needs. Resident #9 will participate in 1-3 programs on unit as tolerated and sensory stimulation 3 times per week. Intervention: Encourage Resident #9's family involvement. Invite Resident #9's family to attend special events, activities, and meals. Invite Resident #9 to scheduled activities. Record Review of the activity participation records for the year 2026 reflected Resident #9 did not attend or receive sensory stimulation three times per week in the month of January 2026 and March 2026. Observation and interview on 03/24/2026 at 12:00 pm Resident #9 was lying in bed and the lights were off in the room. Resident #9 was staring toward wall in front of her and her eyes were moving. The television was not on in Resident #9's room.Observation and interview on 03/24/2026 at 2:00 pm Resident #9 was lying in bed and the lights were on in her room. The television was not on in Resident #9's room. Her eyes were opened and she was staring toward the ceiling. Resident was not interview able. Observation and interview on 03/25/2026 at 10:30 am Resident #9 was lying in bed and the lights was on in her room. The television was not on in Resident #9's room. Her eyes were open and she would move her eyes from side to side as she looked toward the ceiling. Resident was not interviewableObservation on 03/26/2026 at 11:00 am Resident #9 was lying in bed and the lights was off in her room. She was asleep.Resident #37Record review of Resident #37's face sheet, dated 03/26/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #37 had diagnoses unspecified dementia, unspecified severity, with other behavioral disturbance (when a person shows significant memory decline- affecting thinking and daily functioning and with behaviors), unspecified lack of coordination unspecified lack of coordination ( a general inability to control or coordinate muscle movements that cannot be linked to a specific underlying diagnosis), major depressive disorder, recurrent severe without psychotic features ( a severe mental condition characterized by persistent low mood, loss of interest, and physical/cognitive symptoms lasting at least two weeks), unqualified visual loss in both eyes ( vision impairment such as blindness or low vision, where the specific category of severity of the impairment. The exact visual deficit was not clearly classified), and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side (a neurological deficit caused by bleeding in the brain ( non-trauma) that damages the right hemisphere- controls left side of the body).Record review of Resident #37's Annual MDS assessment dated [DATE], reflected Resident #37 had a BIMS score of 8 which indicated her cognition was moderately impaired. Resident #37 did not respond to the questions about her activity preferences.Record review of Resident #37's MDS assessment dated [DATE], reflected Resident #37 had a BIMS score of 2 which indicated her cognition was severely impaired. Resident #37's vision was severely impaired- no vision or sees only light, color or shapes; eye do not appear to follow objects.Record review of Resident #37's care plan was revised on 02/18/2026 reflected Resident #37 had visual impairments. She enjoyed socializing with the staff and visits with her family member. Resident #37 will participate in 1:1 ( in room activities) 5 times per week. Interventions: Interview Resident #37 for her activity preferences and provide activities of known interest when possible. Invite Resident #37's family to attend activities with the resident in order to support participation. Offer to turn on television for resident to hear. Place monthly activities calendar in resident room, alert resident of activities due to visual impairments.Record review of Resident #37's Activity Assessment, dated 09/25/2025, reflected Resident #37's activity preferences was the following: 1:1 visits ( in room activities), devotional readings, stop and chat ( when she is in the hall people stop and talk to her), visits with family and likes to talk with staff with a good sense of humor. She loves to listen to music. Signed by Activity Director.Record review of Resident #37's activity participation record for the months of January , February and March of 2026 reflected Resident #37 did not receive 1:1 activities ( in room activities) five times per week as assessed on her care plan. Observation and interview on 03/24/2026 at 10:00 am Resident #37 was lying in bed. She stated I can't see anything when introduced self to Resident #37. She stated she liked music and would listen to music. Resident #37 stated can you turn radio on so I can hear it. There was not a radio in her room. Resident #37's television was not turned on in her room. Resident #37 stated yes when asked if she wanted to listen to music on the television. She also stated yes when asked if she liked listening to news or have someone to read to her. She was in a quiet room. Observation and interview on 03/25/2026 at 8:15 am Resident #37 was lying in bed. She stated yes when asked if she liked listening to music, listening to news on television or have someone to read to her. She stated yes when asked if became lonely sometimes. She stated, I like to talk. The television in her room was not on at the time of visit. She was in a quiet room.Observation and interview on 03/26/2026 11:10 am Resident #37 was lying in bed in a quiet room She stated yes when asked if she liked listening to music and if she wanted to listen to music. She stated yes I do when asked if she became lonely sometimes during the day. Resident #37 did not answer any further questions. The television was not on in resident #37's room.Interview on 03/24/2026 at 11:05 a.m. the Activity Assistant stated the Activity Director was on leave and would be off for a few months. She stated she was trained by the Activity Director prior to her taking a leave of absence from work. She stated the Activity Director did explain to her about activities and in-room activity program. She stated she was trained on care plans and to follow the Residents activity care plan. The Activity Assistant stated stop and chat was an activity the activity staff would do when a resident was in hallway or in dining room and the activity staff would stop and speak to the resident. She stated they would ask how the resident was doing and if the resident was not interview able the activity staff would report the weather and the day of week. She stated the activity staff did not sit and do an actual activity with the residents and the activity staff would speak to the resident. She stated if a resident was not receiving activities there was a possibility a resident may become depressed, bored and become isolated in their room. The Activity Assistant stated she had been doing the job for a few weeks. She stated she was trained on how to document in the computer when she did any activity with a resident. The Activity Assistant reviewed the participation records with surveyor and stated Resident # 9 and Resident # 37 did not receive the activities they were expected to receive according to their care plan during the months of January, February and March of 2026. Interview on 01/08/2026 11:45 a.m. the Administrator stated she expected a variety of activities to be provided for all residents. She stated each resident's activity preference needed to be assessed, and each resident's activity was expected to be planned according to their activity preferences. She stated activities such as independent, in-room, and/or group activities were to be documented on participation records. The Administrator stated she expected all residents to be interviewed, and their activity preferences updated and all care plans to be revised to reflect each resident's activity preferences. She stated the activity department was already discussed and a Performance Improvement Project known as a PIP was in place to improve the activity program in the facility. She stated if a resident was not receiving activities there was a potential a resident would have a decline in their cognition, mental status, physical status and quality of life. She stated a resident with a history of depression may become depressed and isolate themselves in their rooms. The Administrator stated the Activity Director and Activity Assistant was responsible for the activity programming and documentation of all activities department including participation records. She stated she was the Activity Director supervisor. Record review of the Activity Director's Personnel revealed the Activity Director completed the 45 hours of study and testing for Activity Director and received her activity certification on 01/07/2026. Reviewed Activity Assistant training from the Activity Director.Record review of the Facility Activity Programs Policy, dated June 2018, reflected Activity programs are designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident. The activities program was provided to support the well-being of residents and to encourage both independence and community interaction. Activities offered are based on the preferences of each resident. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs.

Based on observations, interviews and record review, the facility failed to ensure each resident was treated with respect, dignity and care for 1 of 4 residents ( Resident #9) observed for resident rights. The facility failed to ensure Resident # 9's privacy curtain was used or the door to her room was closed when she her private area was exposed when lying in bed. This failure could place residents at risk of feeling embarrassed and diminish the resident's quality of life.Findings included Record review of Resident #9's face sheet, dated 03/26/2026, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: unspecified dementia, unspecified severity, with other behavioral disturbance (when a person shows significant memory decline- affecting thinking and daily functioning. However, the specific cause and severity are not yet determined) and, major depressive disorder, single episode, unspecified( a low mood or loss of pleasure or interest in activities lasting at least two weeks), and anxiety disorder ( mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily functioning). Record review of Resident #9's Quarterly MDS Assessment, dated 02/19/2026, reflected Resident #9 was rarely/never understood. Staff was unable to completed Brief Interview for Mental Status (BIMS). She had poor short- and long-term memory recall. Her decision-making abilities was severely impaired ( she rarely /never made decisions) Resident #9 did not refuse care. Resident #9 was totally dependent on staff for the following ADLs: eating, oral hygiene, toileting hygiene, showers, lower and upper body dressing, personal hygiene, bed mobility, and transfers.Record review of Resident #9's Comprehensive Care Plan, revised on 03/04/2026, reflected Resident #9 was on an anti-anxiety medication related to anxiety. Intervention: Monitor Resident #9 for any mood or behavior indicators and notify physician as needed. Resident #9 was dependent on staff for ADLs at all times related to dementia. Intervention: Resident #9 was dependent on staff with the following:GroomingPersonal hygieneDressingBed mobilityEatingToiletingOral hygiene Observation and interview on 03/24/2026 at 12:00 pm Resident #9 was lying in her bed. The door to her room was opened and the privacy curtain was not used to provide privacy for Resident #9. She did not have a sheet over her and her brief was below the top of her vagina area. Anyone passing Resident #9's room was able to see top portion of her vagina area. Resident was not interviewable.Observation on 03/24/2026 at 12:05 pm staff passing Resident #9's room and was looking in her room and did not enter the room to cover Resident #9 or use the privacy curtain. Interview on 03/24/2026 at 12:09 pm the housekeeping supervisor stated she did enter Resident #9's room and she did not notice if Resident #9 was exposed. She stated she looked toward Resident #9 but did not notice she was exposed. She stated she went in to check things in the room and did not notice Resident #9. She stated she had been in serviced on resident rights and dignity. She did not recall the date of the in-service. The Housekeeping Supervisor states she could have covered Resident #9 with her blanket or asked nursing staff to check on Resident #9. She stated there was a possibility a person may become embarrassed if their private areas were exposed to other people. Interview on 03/26/2026 at 9:35 a.m., CNA D stated she had been trained on resident rights. She stated it was recently but did not recall the exact date. CNA D stated staff were responsible for providing privacy to the residents to ensure their private areas was not exposed where other people walking in the hall could see a resident private area. She stated she was not aware Resident #9 removed her sheets or bedspread when she was lying in bed. She stated if privacy was not provided a resident may feel ashamed or embarrassed. CNA D stated the charge nurse or the DON monitored to ensure staff were providing privacy. CNA D did not respond when asked if she was assigned to Resident #9 on 03/26/2026. Interview on 03/26/2026 at 9:50 a.m., LVN B stated she had been trained on resident rights. She stated she did not recall the last time she had in-service on resident rights. She stated any staff observed a resident private area exposed to people walking in the hallway was responsible to cover resident with blanket, bedspread or use the privacy curtain. She said it could be a dignity issue if a resident private area was exposed for anyone to view when walking down the hall. She stated a resident could feel embarrassed or humiliated. LVN B stated this was against a resident rights to be exposed for visitors or other residents to see a person's private area while the person was lying in bed. LVN B stated he was the nurse assigned to the hall where Resident #9 resided.Interview with the Administrator on 03/26/2026 at 1:40 p.m., she stated in-services had been given to all staff regarding dignity and resident rights. She stated she did not recall the date of the last in-service. The Administrator stated it was a resident right to preserve the resident's dignity. She stated if the Housekeeping Supervisor went into Resident #9's room she was expected to notice the resident and if she had observed Resident #9 exposed, she could have asked for assistance used privacy curtain or pull the bedspread over the resident and report it to the nurse. The Administrator stated all staff was responsible to ensure Resident Rights are being followed including dignity. She stated if a resident was exposed there was a possibility the resident may become embarrassed, feel humiliated or can become upset by other people in the hall observing their private area.Record review of the Facility's Policy on Quality of Life- Dignity, dated 08/2009, reflected Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Resident shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 ( Resident #37) reviewed for accidents hazards and supervision.The facility failed to ensure Resident # 37's fall mat was in place on 03/19/2026.This failure could place resident at risk for falls with the possibility of injury, including fractures. Findings included:Record review of Resident #37's face sheet, dated 03/26/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #37 had diagnoses unspecified dementia, unspecified severity, with other behavioral disturbance (when a person shows significant memory decline- affecting thinking and daily functioning and with behaviors), unspecified lack of coordination ( a general inability to control or coordinate muscle movements that cannot be linked to a specific underlying diagnosis), unqualified visual loss in both eyes ( vision impairment such as blindness or low vision, where the specific category of severity of the impairment. The exact visual deficit was not clearly classified), and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side (a neurological deficit caused by bleeding in the brain (non-trauma) that damages the right hemisphere- controls left side of the body)Record review of Resident #37's MDS assessment dated [DATE], reflected Resident #37 had a BIMS score of 2 which indicated his cognition was severely impaired. Resident #37 was dependent on staff for the following:Toileting HygieneTransfersBed mobilityRecord review of Resident #37's care plan was revised on 02/18/2026 reflected Resident #37 was at risk for falls related to dementia. She was unaware of safety needs. Interventions: Resident #37 required fall mat beside bed. Assure call light within reach and encourage resident to call for assistance as needed. Resident #37's bed needed to be in low position when resident is in bed. Anticipate and meet Resident #37's needs.Record review of Resident #37's physician order, dated 3/18/2026, reflected Resident #37 had an order dated on 06/02/2025 -fall mat next to bed. Observation and interview on 03/24/2026 at 10:00 am Resident # 37 was lying in bed. The rolling bedside table was located beside Resident #37's bed. The fall mat was located at the foot of the bed. Resident #37 stated I am afraid of falling and I did not need to break a bone. Observation and interview on 03/26/2026 at 8:53 am Resident #37's bed was moved at an angle, and the head of bed was beside tall chest of drawers. Resident #37's fall mat was not beside her bed. Resident #37 stated I don't want to fall I am afraid of falling. Interview on 03/26/2026 at 9:05 am The Director of Nurses stated if a fall mat was on a resident care plan it was expected to be beside the resident's bed. She stated the fall mat was not to be at an angle and was to be placed directly beside from the head of the bed to the foot of the bed. She stated there was a possibility Resident #37 hit her head on chest of drawers or the floor. She stated the resident could possibly sustain an injury such as broken bone. The Director of Nurses stated anytime a resident has a fall precaution in place she expected all staff to ensure the fall precaution is in place at all times. Record Review of Fall Prevention, dated April 2012, reflected Review thoroughly at-risk individuals in team conference, formulate interdisciplinary goals addressing safety, identify specify strategies for fall prevention in the care plan, related to the resident's specific risk factors and condition, and communicate level of risk to staff caring for resident.

Based on interview and record review the facility failed to maintain an Antibiotic Stewardship program for 1 of 1 facility's reviewed for Antibiotic Stewardship. The facility failed to provide the track and trending log to include Resident #45 and Resident #48, who were receiving UTI prophylactic antibiotics. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: Resident #45Record review of Resident #45's face sheet, dated 03/25/2026, revealed a seventy-two-year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her admitting diagnosis was urinary tract infection (a bacterial infection in the urinary system (kidneys, ureters, bladder, or urethra), commonly causing burning pain when urinating, a frequent urge to pee, and cloudy or foul-smelling urine), dementia (a progressive syndrome causing cognitive decline-memory loss, thinking, and behavior changes-that interferes with daily life), and major depressive disorder (a serious mental health condition characterized by persistent sadness, loss of interest in activities, and low energy). Record review of Resident #45's Quarterly MDS dated [DATE] revealed Section C - Cognitive Patterns indicated a BIMS score of 14 indicating no cognitive issues. Record review of Resident #45's care plan revealed a focus, undated, Resident #45 was on an antibiotic as prophylactic (intended to prevent disease) related to a UTl hospitalization from 02/15/2025 - 02/15/2025. Resident #45 had chronic UTl's with intervention, undated, administer medication as ordered, notifying MD and RP of any changes. Resident #48Record review of Resident #48's face sheet, dated 05/25/2026, revealed a ninety-five-year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her admitting diagnoses included unspecified kidney failure (occurs when kidney function stops, but the underlying cause remains unknown, or when it is not immediately classified as acute or chronic), and personal history if UTIs (a documented record of recurring urinary tract infections. It is defined as having at least two infections within six months or three within a year). Record review of Resident #48's Quarterly MDS (clinical assessment to determine resident's strength and needs) dated 11/24/2025 revealed Section C - Cognitive Patterns revealed no BIMS score. Record review of Resident #45's care plan revealed a focus dated 02/28/2024 Resident #48 was on prophylaxis antibiotics due to history of UTI due to overactive bladder with intervention dated 06/11/2021 administer antibiotic as ordered observing effectiveness and for side effects and notify physician as needed. Record review of antibiotics and infection tracking revealed facility had not maintained tracking for Resident #45 and Resident #48. During an interview on 03/26/2026 at 9:49 AM the DON said she did not like prophylactic antibiotics for UTIs because it opened the residents to C.Diff (a bacterium causing severe, watery diarrhea, abdominal pain, and fever, often after antibiotic use disrupts normal gut flora) and helped contribute to building up a resistance to antibiotics. The DON said she had discussed Resident #45 and Resident #48s' antibiotic use with the MD, but she did not record this in the facility track and trending log. The DON said she was responsible for monitoring infection control for the facility, and the Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcome infection control facility policy was not followed. Record review of facility Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes dated 2001 reflected antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.

Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #46) of three residents reviewed for pressure ulcers. The facility failed to ensure Resident #46 who was admitted to the facility on [DATE] without a pressure ulcer to his right lateral calf did not develop a pressure ulcer. The facility failed to ensure interventions were in place to perform skin checks under his right leg brace and Resident #46 developed an unstageable DTI (deep tissue injury, a pressure-related injury to subcutaneous tissues under intact skin.) to his right lateral calf on 09/27/2024 . The facility further failed to ensure once a pressure ulcer developed it was assessed routinely and failed to perform a wound assessment from 12/18/2024 until 01/08/2025. These failures resulted in an Immediate Jeopardy (IJ) situation on 01/08/2025. The IJ template was provided to the facility on [DATE] at 5:00 PM. While the IJ was removed on 01/10/2025, the facility remained out of compliance at a severity level of no actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing worsening pressure ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. Finding Include: Review of Resident #46's face sheet dated 01/08/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses, fracture lower end of right femur (a break in the thigh bone near the knee joint.), diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.), and atherosclerotic heart disease (A condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall). Review of Resident #46's quarterly MDS dated [DATE] reflected Resident #46 was assessed to have a BIMS score of 13 indicating he was cognitively intact. Resident #46 was assessed to require moderate assist with ADLs. Resident #46 was further assessed be at risk for pressure ulcers and was assessed to have one stage four unhealed pressure ulcer. Review of Resident #46's comprehensive care plan not dated reflected a focus area not dated Resident has potential for alteration in skin due to decline in mobility related to fracture of right femur and wearing a splint to right leg. Open area to the right calf. Interventions included Apply treatment as ordered per MD or Wound MD; Apply Wound VAC as ordered, notifying MD & RP of any changes; Encourage good nutrition and hydration in order to promote healthier skin; Identify potential causative factors and eliminate when possible; Keep skin clean and dry, use lotion on dry scaly skin. The care plan did not address a current pressure ulcer or detailed interventions for splint management. Review of Resident #46's hospital discharge instructions dated 09/13/2024 reflected Distal femur fracture treated with immobilization .if you have a removable splint: wear the splint as told by your health are provider. Remove it only as told by your health care provider. Check the skin around the splint every day. Tell your health care provider about any concerns. Loosen the splint if your toes [NAME], become numb . Further review of Resident #46's hospital discharge packet reflected medication orders, post op wound care and therapy orders. Review of Resident #46's admission assessment under the skin integrity section dated 09/14/2024 reflected no open areas to his right lateral calf. Further review of Resident #46's admission assessment reflected the DON signed the skin integrity section as completed by her. Review of Resident #46's nursing progress note dated 09/27/2024 reflected Resident has an open blister on right calf under leg stabilizer. New order to apply Calcium Alginate, gauze and cover with Border Island dressing every day. Signed by RN A. Review of Resident #46's consolidated physician orders dated September 2024 reflected an order dated 09/28/2024 to cleanse right calf open area with wound cleanser or normal saline, pat dry, apply Calcium alginate and cover with gauze dressing every day. Further review reflected an order dated 09/27/2024 Remove splint every shift every and examine skin every shift to monitor skin under the knee immobilizer. Further review of Resident #46 consolidated physician orders dated September 2024 reflected no order to remove the splint and examine Resident #46 skin under the splint prior to 09/27/2024. Review of Resident #46's TAR dated September 2024 reflected an entry dated 09/28/2024 Cleans right calf open area with wound or normal saline, pat dry , apply calcium alginate and cover with gauze and border island dressing every day. With signatures beginning on 09/28/2024. Further review reflected an entry dated 09/27/2024 Remove splint every shift and examine skin every shift to monitor skin under the knee immobilizer. With signatures beginning on 09/27/2024. Review of Resident #46's post-op follow up visit to the orthopedic physician dated 09/30/2024 reflected Resident #46's knee immobilizer was removed .Patient was advised to follow-up with wound care and utilize dressing changes outside the leg for the next 2 weeks .Notified patient we will place him on a hinge knee-brace next visit but allow for this wound to heal at this time . Review of Resident #46's wound care physician notes dated 10/02/2024 reflected etiology-pressure, classified as an unstageable DTI within and around wound measuring 4 cm x 4 cm x 0.1 cm deep. Review of Resident #46's EMR reflected his last wound care MD visit was 12/18/2024 which reflected a Stage 4 pressure ulcer extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments.) of the right, lateral calf full thickness 2.6 cm x 1.2cm x 0.5 cm depth with 30% slough (slough in a wound indicates a healing process that is stalled in the inflammatory phase.) Review of Resident #46's EMR reflected his 12/18/2024 wound assessment was the last wound assessment conducted until 01/08/2025. Observation on 01/08/2025 at 1:45 pm revealed the Treatment Nurse in Resident #46's room to do wound care. She removed the dressing to his right lateral calf to reveal a Stage IV pressure ulcer 0.4 x .03 approximately .5 deep with moderate drainage no odor 100% granulation tissue no slough. In an interview on 01/08/2025 at 1:55 PM Resident #46 stated he was not admitted with the pressure ulcer to his right leg. He stated he got the pressure ulcer at the facility when his brace was digging into his leg. Resident #46 stated he told the facility the brace was rubbing his leg, but they did not look at it right away. He stated it was only when he continued to complain about the brace rubbing and pushing into his leg that they took it off. He stated they told him he had a sore on the outside of his calf from the brace. Resident #46 stated he did not remember them taking the brace off his right leg to look at his skin before he went to his post op appointment about two weeks after he was admitted to the facility. In an interview on 01/08/2025 at 2:10 PM the DON stated the pervious wound care nurse was in charge of wound assessments and she was supposed to assess Resident #46 on admission and develop a plan of care. She stated she realized she had not done that and that orders for removing the splint were missed only after Resident #46 developed his pressure ulcer. In an interview on 01/08/2025 at 3:58 PM the Wound Care MD stated the first time he saw Resident #46 was 10/02/2024. He stated at that time he had an unstageable DTI to his right lateral calf. The Wound Care MD stated the last time he saw Resident #46 was 12/18/2024. He stated he was out of town after that. The Wound Care MD stated the pressure ulcer on Resident #46 right lateral calf was definitely avoidable if the splint had been removed regular. In an interview on 01/08/2025 at 4:09 PM the DON stated after reviewing Resident #46's EMR that there had not been a wound assessment done for Resident #46 since 12/18/2024. The DON stated she did not know a wound assessment had to be done weekly. She stated the wound care nurse just started on 01/06/2025 to replace the last wound care nurse whose last day was 11/15/2024. She stated she had not conducted recent wound assessment for Resident #46 and did not see one in his medical record. The DON stated the wound care MD was at the facility and a wound assessment would be performed. In an interview on 01/09/2025 at 10:34 AM RN A stated her last day at the facility was 11/15/2024. She stated she did not know it was her responsibility for the wound care plans. She stated the facility had the wound care MD seeing Resident #46 for wound care and she thought he was doing the splint care. RN A stated the splint was in place for Resident #46 when he was admitted but they never had instructions to remove it. RN A stated the DON or MDS coordinator were in charge of doing care plans. RN A stated she did the assessments of the current wounds not the new wounds. She stated Resident #46's surgeon put the brace on Resident #46, and she did not remove it because she did not have orders to remove it. RN A stated she was not aware of any discharge instructions for splint care. She stated she did not do care plans. RN A stated she was not the only one taking care of Resident #46 and she only did his wounds periodically. RN A stated there were other nurses, the charge nurses doing his wounds as well. She stated she was in charge of following up on skin assessments the charge nurse did. She stated she would follow up after an assessment if they found any new skin areas and she would do the weekly skin reports. She did not remember the DON asking her about Resident #46's splint and stated she believed the DON did that. RN A stated the charge nurses would tell her if they found something, and she would check it out. RN A stated it would have been the charge nurses who did the weekly skin checks and who should have checked the splint for Resident #46 but since they did not have instructions to remove the splint and perform skin checks they would not have. In an interview on 01/09/2025 at 10:40 AM the DON stated she was ultimately responsible for ensuring that once a residents was admitted that the baseline care plan was done, a full skin assessment was complete and the plan for wound care or splints was completed. She stated RN A was her wound care nurse and she asked her to look at all of Resident #46 wounds and to make sure orders were in place for care and pressure ulcer prevention interventions. She stated she asked RN A to check Resident #46's splint for pressure points. The DON stated she did not follow up with RN A. The DON stated she was not aware of the issue with Resident #46 until the pressure ulcer had already developed. She stated a full assessment and order review just did not get done and she should have followed up. She stated, I relied on her (RN A) to take care of it. In an interview on 01/09/2025 at 12:40 PM the Administrator stated the facility had a wound care nurse that monitored the wounds but she left in November, she stated she expected the DON to follow up on new wound orders and new admits to make sure the residents had everything they needed for care and to prevent pressure ulcers. In an interview on 01/10/2025 at 11:13 AM the Nurse Consultant stated it was facility policy that an RN complete weekly wound assessment. The Nurse Consultant stated it was also the facility policy that residents who admitted with splints were to have orders to remove and monitor the skin under any splints or removable casts. Review of the facility's policy Skin assessment dated (no month) 2024 reflected It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury .Begin head to toe, thoroughly examining the resident's skin for conditions. Pay close attention to pressure points, bony prominences, and underneath medical devices. Review of the facility's policy Stabilization and Securement devise dated 02/2022 reflected .The device is removed regularly, and the resident assessed for the following: a. Circulation; b. Skin integrity ;c. Catheter functionality; and d. Range of motion . Review of the facility's policy Prevention of pressure ulcers/injuries dated 07/2017 reflected The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors .Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries. b. Tissue tolerance - the ability of the skin (and supporting structures) to endure the effects of pressure; and c. Areas of impaired circulation due to pressure from positioning or medical devices . The Administrator was notified on 01/08/2025 at 5:47 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 01/09/2025 at 4:55 PM. On 01/08/2025 an abbreviated survey was initiated at[name of facility]. On 01/08/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: _____1/8/2025_________) All residents with a pressure ulcer were assessed and measured by the wound care MD on 1/8/25. Resident #46 was assessed by the wound MD on 1/8/25. No other individuals were found to be affected by this practice. The wound care doctor assessed all other residents with wounds. The medical director was notified of the IJ on 1/8/25. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 1/9/25 and ongoing for PRN staff before returning to the floor). All facility policies and procedures related to skin care, wound care, and pressure injury prevention were reviewed 1/8/25. Corporate Nurse/Consultant Nurse provided education to the Administrator, DON and facility nurses on facility policies and procedures related to skin/wound care, as well as appropriate wound treatment measures, including weekly assessment and measuring by a RN. A self-test will be completed by all nurses. The treatment nurse will be responsible for daily wound care. A self-test will be monitored by DON or designee. A direct in-service was done with the facility DON/RN that wound measurements must be done by a RN weekly in the weekly wound assessment UDA (User Defined Assessment,. following physician orders, splints/brace care and plans of care for any resident. We will do a self with Physician orders, braces, and splints. DON/Corporate Nurse/Consultant Nurse Monitoring will continue to monitor/audit the following: Weekly skin assessments/wound assessments. Corporate nurse will complete system validation checklist weekly for compliance. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. The Survey Team monitored the POR on 01/09/2025 through 01/10/2025 as followed: In an interview on 1/10/2025 at 11:10 AM the Nurse consultant stated she reviewed all the facility policies with the DON on 1/8/25 that included: skin and wound care and pressure injury prevention. In an interview on 01/10/2025 at 11:13 AM the Nurse Consultant stated I did in-service with DON that a RN has to complete a weekly wound assessment for all wounds and pressure weekly, also trained administrator, DON, and all nursing staff on site to make sure any resident admitted with a splint that the splint is removed and a skin assessment is completed and to make sure they get with the residents MD so they have an order to remove and monitor the skin under any splints or removable casts. She stated she made an audit sheet for her monitoring, she stated she will go into PCC and check that all wound assessments and measurements were done. She stated the facility was to send her a weekly wound report. She stated the wound report was updated on 1/8/2025 and she reviewed the report and checked the wound assessments. She stated the facility was supposed to notify her of any residents admitted with splints or removable cast. She stated after the training with the Administrator , DON, and nurses on duty she turned the training over to the Administrator to complete for nurses that were not on duty or coming in later. In an interview on 01/10/2025 at 12:46 PM the administrator stated the NC in-serviced her on the proper precautions that need to be in place for residents with splints and devices and that she instructed the nurses to notify the administrator so she can assist in tracking and monitoring to ensure orders are in place for monitoring skin She stated they will review the skin reports and audits in the morning meetings and in QA she stated the NC will notify her of all audit results she stated they had a QA meeting on 12/19/24 and did discuss the wound care system because we had an aid out for a wound care nurse she stated they also reviewed the current pressures ulcers. In an interview on 01/10/2025 at 12:55 the DON stated the nurse consultant performed her training on 01/09/2025 regarding the need for a RN to perform weekly wound assessment, the wound care system and splint management. She stated she will be sending the weekly wound tracker to her and will be making rounds with the wound care doctor on Wednesday and hospice nurses for the hospice residents with wounds. She stated the QA team did discuss the pressure ulcers at the last QA meeting, she stated they went over the wounds, stages, and measurements. She stated during the meeting they did discuss the fact that they did not have a wound care nurse and one was hired but did not start till this week. She stated she was out for about 10 days at the end of November and did not come back till the beginning of December and at that time the wound care nurse was gone. She stated she took full responsibility for the current situation, I just had so much going on I did not look at his wounds or catch the issue. In an interview on 01/10/2025 at 12:06 PM the MDS Coordinator stated she was in-serviced on skin assessments on weekly basis and as needed. She stated the DON was going to assess the skin once a week. If anyone comes in with splint, brace or wrap it needs to be removed and checked on a daily basis. They were to check the physician order and follow the physician orders. If they remove the splint and see a new wound she will do assessment, document my information, call the doctor, family and get an order for the treatment if the doctors' orders a treatment will document it in physician orders. She stated she would notify the DON, the administrator, and the Treatment nurse. She stated they had a quiz on skin assessments and splints. She stated she was in-serviced on care planning for splint and skin care. She said an order needs to be written about the splint and brace such as what type of care the resident needs for the splint brace and all orders need to be reviewed on admission. In an interview on 01/10/2025 at 12:17 PM the Treatment Nurse stated they had a quiz. She stated she learned the splint/ brace and skin care needed to be care planned and documented on physician order. She further stated she learned that the physician orders needed to be reviewed on new admits check residents' skin under and around splint this is supposed to be checked daily. Check splints, boot, wrapping, Geri- sleeves we are to check the resident's skin daily. The residents wearing any device such as splint check daily - Q Shift. She stated if you see a new wound or red area on residents' skin she would call the doctor and see if the doctor has a referral for wound care. She further stated she would contact the wound care doctor if needed and would report to the DON and report to the family. She stated If the resident received a new order from the doctor for any type of skin treatment she would input the order in the medical record PCC and would follow the order. She further stated she was in-serviced on skin assessments- they were to be completed weekly on every resident in the facility. In an interview on 01/10/2025 at 12:48 PM LVN O stated she was in-serviced on skin assessments, and they were to be completed weekly, but they do not do skin assessments on night shift, and she worked night shift. She stated if she worked during the day if it was time for a resident to have a skin assessment she would make sure it was completed. She stated the staff was to take off any type of medical device on resident skin including splint every shift and check skin for any redness of new wounds or decline in an existing wound. She stated if she observed any new skin concerns she would call the physician and follow his orders, call the DON, call the treatment nurse, and call the family. She stated if there was a new treatment she would enter it in PCC and do a skin assessment and a nurses note. She stated she would document everything she did and who she called. She stated she took a quiz about skin issues and splints. She stated she learned all orders needs to be reviewed and any device a resident has needed to be on the care plan and physician order and that skin needs to be check under the splints. In an interview on 01/10/2025 at 1:21 PM LVN N stated she completed a wound care in-service this morning. She learned that mobilizing and checking the skin was necessary to avoid wounds and if she notices a wound they instructed her on when to report it and to whom. She would report it to the DON and notify the physician. If she had a resident with a splint she would remove it if the orders allowed, check the area, and determine if there were any skin concerns. If she does find a skin concern she will ask for a second set of eyes. She will notify the DON and the physician of any concerns. She will provide wound care according to physician orders received. In an interview on 01/10/2025 12:39 PM LVN M stated she completed two in-services today, one on Splints and the other on Skin Assessments. She said she learned that RNs have to do skin assessments on residents. She said all residents with any skin concerns should be reported immediately to the DON. She said anything new or different observed on a resident was an immediate report and it was important to keep the integrity of the resident's skin. It is important to inspect the area of the splint and ensure can wiggle fingers or toes, review physician orders, and follow any treatment directions. In an interview on 01/10/2025 02:15 PM LVN D stated he completed an online training yesterday and was tested on skin assessments. He said he learned when to assess and to check the pulse and the area. He said if he found any concerns with a skin assessment he would report to his supervisor and wound care staff. He said if he had a resident with a splint he would ensure he check the area thoroughly and report any new or changes to an area. Any concerns identified he would report directly to his supervisor to move forward with notifying the physician. Review of the weekly wound tracking worksheet completed on 01/10/2025 reflected all current pressures ulcers were documented. Review of Resident #46's wound MD assessment reflected it was completed on 01/8/2025. Review of in-service training reflected in-service dated 01/10/2025 attended by all nine nurses including DON reflected the training topic was Wounds must be evaluated by an RN weekly. If a resident has a device the device must be removed frequently to check skin integrity, wounds must be evaluated by a RN to include measurements. Review of Knowledge check for nursing regarding splint care reflected training taken by all nurses and covered the following areas: 1) All orders should be reviewed on new admission 2) Use of a splint should be included in the resident's care plan. 3) The resident's skin under and around the splint should be checked and results documented at least daily. 4) An order should be written for skin assessment under a splint/brace. Review of the weekly wound tracking worksheet completed on 01/10/2025 reflected all current pressures ulcers were documented. The Administrator was informed the IJ was removed on 01/10/2024 at 3:30 PM, the facility remained out of compliance at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of its corrective systems.

Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. 1. The test tray of the lunch meal included foods that were bland, unappealing, and inedible. 2. The facility failed to follow the recipe of the cabbage and did not include spices or prepare the dish as the recipe was written. These failures could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life. Findings included: Observation on 01/08/2025 at 10:21 AM reveled [NAME] L chopped heads of cabbage and boiled the chopped cabbage on the stove. [NAME] L was not observed adding additional spices or vegetables to the cabbage. During an interview on 01/08/2025 at 11:01 AM, [NAME] L stated that she did not add anything to the cabbage. [NAME] L stated she boiled the cabbage, and no spices were added. Food test tray was received at 1:10 PM on 01/08/2025 and the cabbage lacked flavor. Surveyor tested the tray and the corn casserole was inedible and had chunks of dough with no flavor. The corn bread had a powdery texture and lacked flavor. Review of 2024 Fall Winter Menu revealed meal for January 08, 2025 revealed southern fried chicken, corn casserole, southern style cabbage, cornbread, mock pecan pie and beverage/water on the menu. Review of recipe titled Southern Style Cabbage revealed bacon, cooked and crumbed, vegetable oil, fresh onion, light brown sugar, Worcestershire sauce, black pepper and salt were included in the recipe. During an interview on 01/09/25 at 01:34 PM, Dietary Manager stated that a cook knew to look into the recipe books to know how to cook the food and what to put in it. The Dietary Manager stated it was important to follow the recipe to ensure to not make anyone sick. She stated it was also important to follow the recipe, so it had the appropriate flavor. The Dietary Manager stated she did not know why the spices and other foods were not added to the cabbage. She stated maybe onion was added but she was not sure. The Dietary Manager stated she had not tried the corn casserole. She stated that the recipe for southern style cabbage should've been followed. During an interview on 01/09/2025 at 1:50 PM. [NAME] L stated she knew what to add to food or how to cook based on the menus in the binder. [NAME] L stated that she did not add anything to cabbage, she did not have any onion available and thought it was just supposed to be boiled cabbage and did not know she was supposed to add anything. She stated she tried the cabbage and thought it tasted fine. She stated she would describe the flavor as cabbage and could not further elaborate. [NAME] L stated she did not try the corn casserole because she does not care for corn. During an interview on 01/09/2025 at 5:21 PM, the DON stated she has tried food from the kitchen and stated she has tried the fried chicken, fried fish, some breakfast foods. The DON stated she did get complaints that the food isn't seasoned enough and it was usually that it does not have enough salt. The DON stated she did not have any concerns with the food. During an interview on 01/09/2025 at 5:32 PM, the Administrator stated she tried food all the time from the kitchen and has not received complaints about the food. The Administrator stated the resident council minutes reflected there were compliments about the food. The Administrator stated she expected staff to follow recipes as written, unless the residents do not care for the recipe. She stated if the residents do not like the food then they would talk to the dietician and get a substitute. The Administrator stated as long as the substitute was nutritionally adequate and follows guidelines. She stated on these particular set of menus, there may have only been one menu that the residents may not be found of. The administrator stated that they did not voice complaints but there was leftover on their trays. Review of facility policy dated August 2024, titled Puree Food Preparation revealed it is the policy of this facility to provide food that has been prepared in a manner to conserve nutritive value, palatable flavor and attractive appearance. The policy defined food palatability as the taste and flavor of the food.

Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen observed for food storage, preparation, and distribution. 1. The facility failed to ensure the low-temperature dishwasher reached manufacture temperature settings for each cycle. 2. [NAME] L and Dietary Manger failed to perform hand hygiene when preparing food and performing tasks in kitchen. These failures could place residents at risk for health complications, foodborne illnesses and decreased a quality of life. Findings include: Observation on 01/07/2025 at 11:25 AM revealed [NAME] L removed gloves and threw them away. [NAME] L put on new gloves without performing hand hygiene. Observation on 1/7/2025 at 11:46 PM of revealed [NAME] L transferred pureed pork loin from blender to serving container. Pureed meat spilled onto food prep area. [NAME] L turned on faucet and proceeded to wipe spilled meat into sink with gloves. Observation revealed water splashed in pureed meat serving container. Further observation revealed serving contained on food preparation area while [NAME] L grabbed wash rag from red bucket and proceeded to food preparation surface next to open serving container of pureed pork loin. [NAME] L placed rag back into bucket and then placed pork loin on serving station and did not change gloves. Observation on 01/08/2025 at 10:00 AM revealed dishwasher cycle run at 118 degrees. Observation on 01/08/2025 at 10:17 revealed dietary manager grab rag from sanitation bucket, wipe down hydration cart and place rag back into sanitation bucket. Further observation revealed dietary manager grab ice scoop without performing hand hygiene. Observation on 01/08/2025 at 10:21 AM revealed [NAME] L left food preparation area with gloves on, grabbed door handle of cooler and cabbage. [NAME] L proceeded to place unwashed cabbage on cutting board and washed head of cabbage with gloves on. Further observation revealed [NAME] L sliced cabbage. Observation on 01/08/2025 at 10:24 PM revealed [NAME] L left food preparation table and turned knobs on stove with gloves and returned to cut cabbage. Observation on 01/08/2025 at 10:50 PM revealed [NAME] L wash hands and replaced gloves. Observation on 1/08/2025 at 10:53 AM revealed [NAME] L rinse used food preparation bowl in sink with gloves on. Further observation revealed [NAME] L kept opened package of brown gravy and stirred cabbage with same gloves on. Observation on 01/08/2025 at 10:57 AM revealed [NAME] L coughing into arm and proceeded to stir brown gravy without performing hand hygiene. Observation on 1/08/2025 at 10:59 AM revealed [NAME] L grabbed a rag from the sanitation bucket under food prep area and cleaned the area. Further observation revealed [NAME] L removed gloves and put new gloves on without hand hygiene. During an interview on 1/08/2025 at 11:01 AM [NAME] L stated that red buckets included sanitizer water. Observation on 1/08/2025 at 11:06 AM revealed [NAME] L removed gloves, lifted trash can lid with arm and grabbed clean cooking containers. Observation on 01/08/2025 at 11:17 AM revealed dishwasher operating requirements from manufacturer as water temperature to reach 125 degrees Fahrenheit minimum. Observation on 1/08/2025 at 11:18 AM revealed the dishwasher reached 95 degrees Fahrenheit in the rinse cycle. Observation on 1/08/2025 at 11:26 AM revealed the dishwasher reached 99 degrees Fahrenheit during wash and reached 116 degrees Fahrenheit during rinse cycle. During an interview on 01/08/2025 at 11:31 AM [NAME] K stated the temperature during the dishwasher wash cycle was 110 Fahrenheit degrees and 116 degrees Fahrenheit during the rinse cycle. [NAME] K stated it was supposed to be between 125- and 130-degrees Fahrenheit. Observation of dishwasher wash and rinse cycle on 01/08/2025 at 3:55 PM revealed temperature reached 110 degrees Fahrenheit during cycle. Observation and interview on 01/08/2025 at 3:56 PM revealed [NAME] L ran dishwasher and stated the temperature was at 118 degrees Fahrenheit. [NAME] K stated they were currently washing dishes. During an observation and interview on 1/8/2025 at 3:58 PM, [NAME] L stated the temperature during the wash should be at 122 degrees Fahrenheit. Observation revealed [NAME] L view the dishwasher log. [NAME] L stated it was supposed to be between 125- and 130-degrees Fahrenheit. During an interview 01/09/25 at 11:55 AM, the maintenance supervisor stated the dishwasher had to be ran three or four times to warm up. He stated he ran the dish washer a few times and the gauge read it 131 degrees Fahrenheit. He stated the dishwasher stated it needed to be at least reached 125 degrees Fahrenheit in order to sanitize the dishes. He stated on the log in the kitchen it stated that it needs to be at least 125 degrees. He stated he did not have the manual for the dishwasher. He stated if the dishwasher did not reach the temperature, it was not cleaning the dishes. He stated that once you warm it up you should not have to run it several more times. He stated that the staff in the kitchen were aware they needed to warm up the dishwasher. He stated usually if they had problems they would let him know and he could address it right away. During an interview on 01/09/2025 at 1:34 PM, the dietary manger stated that hand hygiene should be performed as soon as staff enter the door to the kitchen. She stated that if staff was prepping food and they touched a handle they should wash their hands. The Dietary manager stated that staff should wash their hands when they take their gloves off. The Dietary manager stated the dishwasher was supposed to reach 125 degrees Fahrenheit. She stated that when staff first started to run the dishwasher it needed to warm up. She stated once it warmed up it could be used to wash dishes. She stated that if the dishwasher sat it would need to be ran at least three times to warm up. Dietary manager stated if the correct temperature was not reached during the wash the dishes should not be washed as they may not be cleaned. The Dietary manager stated that the red buckets have sanitizer water. She stated staff should sanitize when they are done prepping food. She stated if you used the rag in the sanitizer buckets while [NAME] food it could splash into the food. During an interview on 01/09/2025 at 1:50 PM, [NAME] L stated that staff were supposed to perform hand hygiene before cooking and before working with food. [NAME] L stated that if you take your gloves off you should wash your hands. [NAME] L stated if you leave the food preparation area you were supposed to wash your hands. [NAME] L stated that the food preparation was anything on the same side as the food preparation table and this included the stove and cooler. [NAME] L stated she was supposed to sanitize the food preparation station before you prepared food and after. She stated you change the sanitation water every two hours, when you see particles, or it was cloudy. She stated there is sanitizer water in the red buckets in the kitchen. She stated you should not wipe near the food but stated she was done with the cabbage and was holding the container of food away from where she was wiping the puree clean. She stated you should not wipe or clean near food as it could cause cross contamination. During an interview on 01/09/2025 at 5:21 PM, the DON stated that hand hygiene in-services were done with the entire building, and this included kitchen staff. She stated she expected hand hygiene to be done all the time in the kitchen since they were handling food. During an interview on 01/09/2025 at 05:32 PM, the administrator stated she has not been made aware of any issues with the dishwasher in kitchen before we came in. She stated staff should warm it up before using it and get it to the correct temperature. The Administrator stated if staff were not warming up the dishwasher or if it did not get to the correct temperature the dishes may not come out clean and sanitized. The Administrator stated she expected staff to perform hand hygiene as needed in kitchen. She stated between dirty task to clean task hand hygiene was expected. Review of maintenance log for the last 6 months reflected no issues noted with the dishwasher. Review of facility policy dated October 2008 titled Sanitation revealed the food service area shall be maintained in a clean and sanitary manner. Further review revealed low-temperature dishwasher (chemical sanitation) wash temperature should reach 120 degrees Fahrenheit. Review of facility policy dated October 2023 titled Handwashing/Hand Hygiene, revealed all personnel are expected to adhere to hand hygiene policies and practice to help prevent the spread of infection to other personnel, residents and visitors. Further review revealed staff should perform hand hygiene before applying non-sterile gloves. Review of facility policy dated April 2019 titled Food Preparation and Service revealed food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Review revealed, areas for cleaning dishes and utensils are located in a separate area from the food service line to assure a sanitary environment. Gloves are worn when handling food directly and changed between tasks.

Based on observation, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for three (Resident # 33, Resident # 49 and, Resident #162) of seven residents reviewed for resident rights. 1. The facility failed to ensure Resident #33 and Resident #49 were served their lunch tray at the same time as other residents that were seated at the same table. 2. The facility failed to treat Resident #162 with respect and dignity when the staff was standing while feeding Resident #162. This failure placed residents at risk of a diminished quality of life and embarrassment. Findings included: 1. Review of Resident #33 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia (clinical syndrome that describes a group of symptoms that impact memory, thinking, and social abilities), muscle weakness, and unspecified lack of coordination (a condition where a person has difficulty coordinating their movements). Review of Resident #33's undated care plan revealed interventions that Resident required total assistance with meals and was unable to feed self. Review of Resident #49 face sheet revealed an [AGE] year-old man admitted on [DATE] with diagnoses of unspecified dementia, anxiety, and senile degeneration of brain. Review of Resident #49 undated care plan revealed Resident #49's ADL self-performance varies. Resident interventions included total assist with eating. Observation on 01/07/2025 at 12:42 PM revealed CNA H served Resident #41 her meal tray. Observation on 01/07/2025 at 12:43 PM revealed CNA H served Resident #48 her meal tray. Observation on 01/07/2025 at 12:49 PM revealed Resident #49 and Resident #33 did not have their meal tray. Resident #49 and Resident #33 were seated at the same dining table as Resident #41 and Resident #48. Observation on 01/07/2025 at 12:48 PM revealed Resident #7 was served her tray and was seated at a different table . Observation on 01/07/2025 at 12:51 PM revealed Resident #17 was served her tray. Observation on 01/07/2025 at 12:52 PM revealed CNA H asked Resident #17 if she was ready to eat as she sat down to assist the resident with eating. Further observation revealed Resident #49 responded yes from the other dining table. Observation on 01/07/2025 at 12:54 PM revealed hospitality aide J sat to feed Resident #49. Observation on 01/07/2025 at 12:55 PM revealed Resident #33 sat without her tray while all other residents at her table had been served. Observation on 01/07/2025 at 1:05 PM revealed Resident #33 still had not been served her tray. Observation on 01/07/2025 at 1:10 PM revealed Resident #33 still had not been served her tray. Resident's tray sat on the dining cart with her name on the meal slip. During an interview on 01/09/2025 at 11:01 AM, hospitality aide J stated that she usually served residents who ate in their rooms first. She stated when trays were served in the dining room, residents who were able to feed themselves were served first and then residents who needed assistance with feeding. She sated it was not okay for residents to sit there when everyone else at their table is eating. She stated she was aware Resident #33 sat without being fed. She stated that it was usual for a resident who needed assistance with feeding being left to wait to eat. During an interview on 01/09/2025 at 11:15 AM, CNA E stated that Resident #33 and Resident #49 required assistance with feeding. She stated that residents who could feed themselves get their trays first and then the residents who need assistance are given their trays. She stated that residents who need assistance sit at different tables. She stated residents were supposed to get their trays at the same time if they are sitting at the same table. During an interview on 01/10/2025 at 9:20 AM the DON stated all residents sitting at the same table were expected to be served first before serving residents at another table. She stated if a resident or residents waited 15 minutes or longer after their table mates received their meal tray, this was too long for the other residents to wait before they received their meal. She stated this was against resident rights and the resident's dignity. She stated if a resident watched another resident eat at least 15 minutes this could affect the resident self-esteem due to feeling they was not going to get any food. 2. Record review of Resident #162's face sheet dated, 01/08/2024, reflected a [AGE] year-old male admitted on [DATE] with diagnosis of unspecified dementia, moderate, with other behavioral disturbance ( a person with illnesses that affect a person's thinking, memory, reasoning, mood and/or behavior), unspecified glaucoma ( damage of the eyes which can lead to vision loss or blindness), and senile degeneration of the brain ( cause a gradual decline of cognitive abilities such as the person's inability to recall information and to properly judge a situation). Record review of Resident #162's MDS Admission Assessment was in progress. Record review of Resident #162's Baseline Care Plan, dated 12/27/2024, reflected Resident #162 required substantial/maximal assistance ( helper does more than half the assistance) with eating, upper body assistance, and transfers. Resident #162 had poor cognition. He had dietary risks such as: risk for swallowing and chewing problems. Observation on 01/07/2024 at 12:15 PM, LVN C delivered Resident #162's tray to his table. She set up Resident #162's tray and stood partially behind him and at his side. LVN C was not facing Resident #162 or was not completely standing on the right side of him. LVN C began feeding the resident at an angle from the back to side of him. Resident #162 was turning his head and was not able to locate the utensil when LVN C asked Resident #162 to open his mouth for his lunch. He became agitated when LVN C would attempt to feed him. LVN C stood approximately 10 minutes when feeding Resident #162. LVN C stated to Resident #162 she would get a chair and sit and feed him. LVN C sat in chair and faced Resident #162 and he was able to open his mouth when she was feeding him without being cued. Resident #162 decreased his agitation during feeding after LVN C sat in the chair and faced him. In an interview on 01/07/2024 at 12:50 PM LVN C stated she had been in serviced to always sit when feeding a resident. She stated she made a mistake when she stood and fed Resident #162 for several minutes before she obtained a chair and sat where he could see her. LVN C stated Resident #162 was not able to see her or the utensil where she was standing. She stated she was not standing completely at his right side. LVN C stated part of her body was behind him. She stated she did not introduce herself or explain what was on his plate. LVN C stated this was a dignity issue for someone to stand and feed a resident. She stated he was agitated when she was standing and feeding him. LVN C stated his agitation decreased when she sat in a chair, faced him, and fed him. In an interview on 01/07/2024 at 1:10 PM the Corporate Nurse stated all staff were expected to sit and face the resident when feeding any of the residents. She stated it was a dignity issue if staff stood over a resident when feeding and there was a potential the resident may have difficulty with swallowing the food if they had dysphagia (difficulty with swallowing). In an interview on 01/10/2024 at 9:20 AM, the DON stated she required all staff to sit when feeding a resident. She stated this could affect a resident ability to see the utensil if a staff was feeding at an angle. The DON stated it was a dignity issue for the resident if someone was standing during feeding. She stated staff had been in-service to sit in a chair and face the resident when a resident required assistance with eating. In an interview on 01/10/2024 at 9:45 AM CNA I stated she had been in serviced on feeding residents. She stated all staff was expected to sit in a chair and face the resident during feeding. CNA I stated it was a resident right issue when staff stood and fed a resident. She stated it was a possibility a resident may become embarrassed for someone to stand over them when feeding their meal. Record review of the Facility's Policy on Quality of Life- Dignity, revised in August 2009, reflected Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 42600

Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 4 of 9 residents reviewed for environment (Residents #7, #22, #26 and #46). A) The facility failed to ensure Resident #7's wheelchair was clean. B) The failed to ensure Resident #22 and Resident #26's wheelchairs were maintained. C) The facility failed to ensure Resident #46's room was at a comfortable temperature on 01/07/2025 and 01/08/2025 and failed to ensure a broken window in his room was repaired. These failures placed residents at risk of discomfort and diminished quality of life. Findings included: A) Review of Resident #7's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform daily tasks), mood disorder (a mental health condition that causes a person's mood to be persistently disturbed, leading to changes in their emotional state), dementia (a general term for a group of brain conditions that cause a decline in mental abilities) and other schizoaffective disorders (a rare mental illness that combines symptoms of schizophrenia and a mood disorder). Review of Resident #7's quarterly MDS dated [DATE] revealed the BIMS were not completed due to resident being rarely understood. Further reviewed revealed Resident #7 normally used her wheelchair. Review of Resident #7's undated care plan revealed Resident #7 had long and short-term memory deficits that impaired decision-making abilities and required her to need cues and supervision, goal included to have needs anticipated. B) 2. Review of Resident #22's face sheet revealed a [AGE] year-old-male admitted on [DATE] with diagnoses of unspecified dementia (a diagnosis given when a person has dementia but it can't be classified as a specific type), mild cognitive impairment (a condition that causes people to have more memory or thinking problems than others their age), and type 2 diabetes (a common disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels). Review of Resident #22's annual MDS dated [DATE] revealed resident normally used his wheelchair. Further review revealed Resident #22 had a BIMS score of 09 which indicates moderate cognitive impairment. Review of Resident #22's undated care plan revealed Resident #22 was at risk for skin breakdown due to impaired mobility with a goal that resident will be free from avoidable skin breakdown. Review of Resident #26's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses of other symbolic dysfunctions (disorder that affect a person's ability to perceive or perform certain activities), vascular dementia (a type of dementia that occurs when blood flow to the brain is disrupted, damaging brain tissue and impairing memory, thinking, and behavior), and aphasia (a language disorder that affects a person's ability to understand and express language, as well as read and write). Review of Resident #26's quarterly MDS dated [DATE] revealed Resident normally used wheelchair. Further reviewed revealed Resident had a BIMS score of 10 which indicated moderate cognitive impairment. Review of Resident #26's undated care plan revealed Resident #26 was at risk for skin breakdown due to wheelchair mobility, goal included Resident will have minimal complications with skin breakdown through the next review date. During an interview on 01/08/2025 at 9:03 AM, Resident #26 stated that his seat bothered him when he was sitting in it and it had scratched him in the past. Observation and interview on 01/08/2025 9:43 AM revealed Resident #22's arm rest on right wheelchair was cracked. Review #22 denied any issues with the arm rest scratching him. Observation on 01/09/2025 at 12:10 PM revealed Resident #22's right arm rest was still cracked. Observation and interview on 01/08/2025 at 9:03 AM revealed seat of Resident #22's wheelchair was worn and cracked on the edge with filling exposed. Resident stated that the chair does bother him when sitting in it and has scratched him in the past. Observation on 01/09/2025 at 12:12 PM revealed Resident #26's back seat of wheelchair was separating from the frame. During an interview on 01/09/2025 at 11:55 AM, the maintenance supervisor stated that if a wheelchair was broken he would try to fix it or provide the resident with a new wheelchair. He stated that he has to speak with therapy first to ensure what type of wheelchair would work. He stated if the seat or arm rest was torn he would be able to replace it. He stated that today (01/09/2025) they were going to replace Resident #26's wheelchair. He stated that he was notified about Resident #26's wheelchair few days ago and he ordered a new one as soon as he was told. The Maintenance supervisor stated that he usually wrote things in the maintenance book but it does not always dawn on him to write things he has addressed in the book. He stated that at night DON has CNAs washing wheelchair but it was overall a team effort. He stated if a wheelchair was very dirty any staff could wash it. The Maintenance supervisor stated he was not aware of Resident #22's arm rest being cracked. During an interview on 01/09/2025 at 1:19 PM, CNA F stated that if she saw a wheelchair torn or worn, she would let her nurse and maintenance know. She stated that sometimes she writes things in the maintenance log but usually she will just go and tell the maintenance supervisor. CNA F stated she did not notice anything wrong with Resident #22 or Resident #26's wheelchairs. She stated that the aides that worked evening and night shift were responsible for cleaning wheelchairs. CNA F stated that if she saw a wheelchair that was dirty she would wipe it down. She stated she was unsure how often wheelchairs were cleaned. She stated if it was very dirty she would take it to the shower room and spray it down. During an interview on 01/09/2025 at 2:15 PM, hospitality aide J stated she does not know when wheelchairs were cleaned. She stated it has changed a few times as to who and when they would be cleaned. Hospitality aide J stated that if she noticed a cracked seat or arm rest she would usually tell therapy or maintenance. During an interview on 01/09/2025 at 2:16 PM, CNA G stated she was unsure who was responsible for cleaning wheelchairs. During an interview on 01/09/2025 at 5:15 PM, the DON stated that CNAs were responsible for cleaning wheelchairs. She stated she had two programs in which aides were assigned different wheelchairs but the book disappeared. She stated that day shift had two wheelchairs, evening had two wheelchairs and night shift had four wheelchairs they were responsible for cleaning. She stated that wheelchairs were supposed to be cleaned once a week, but she had a hard time getting them washed. She stated all staff were responsible for monitoring the condition of wheelchairs. She stated if staff found a wheelchair that was tearing or loose they were supposed to report to DON or the maintenance supervisor. She stated if the maintenance supervisor cannot fix or repair the wheelchair it can be sent out for repair. The DON stated the potential harm from residents using torn or worn wheelchairs was that the resident could fall, it could rip and it could damage their skin. During an interview on 01/09/2025 at 5:39 PM, the administrator stated everyone was responsible for cleaning wheelchairs and they should be cleaned as necessary. She stated that they have used a power washer to clean wheelchairs in the past and they were sat out to dry. The Administrator stated the maintenance supervisor and all staff monitor condition of wheelchairs. She stated that if seats were torn or worn, staff were expected to tell the maintenance supervisor to get arm rests swapped out. She stated seats were different but the facility could get new wheelchairs if needed. She stated worn or torn wheelchairs could cause skin impairments. Review of the facility policy titled Maintenance Service dated December 2009 revealed maintenance service shall be provided to all areas of the building, grounds, and equipment. Maintenance department is responsible for maintain the buildings, ground, and equipment in a safe and operable manner at all times. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Review of the maintenance log for last 6 months (August 2024- January 2025) reflected no issues noted with resident wheelchairs. Review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment dated September 2022 revealed resident-care equipment, including reusable and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Non-critical environment surfaces included bed rails, bedside tables etc. DME is cleaned and disinfection before reuse by another resident. C) Review of Resident #46's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses fracture lower end of right femur (a break in the thigh bone near the knee joint.), diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.), and atherosclerotic heart disease (A condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall). Review of Resident #46's quarterly dated 12/22/2024 reflected Resident #46 was assessed to have a BIMS score of 13 indicating he was cognitively intact. Resident #46 was assessed to require moderate assist with ADLs. Resident #46 was further assessed be at risk for pressure ulcers and was assessed to have one stage four unhealed pressure ulcer. Review of Resident #46's comprehensive care plan not dated reflected Resident #46 ADL self-performance varies, may need more assist at times than other times due to functional limitations related to fracture of lower end of right femur. Interventions included bed mobility extensive to total assist with 1-2 staff and to check every 2 hours and as needed and to provide assist as needed. Observation and interview on 01/07/2025 at 3:05 PM revealed Resident #46 in room in bed with multiple covers on. Resident #46 stated it was cold in his room. He stated his window was broken and it had been taped like that for 2 months. Observation of Resident #46's window which his bed was pushed up against revealed it was a double pane window with one of the panes open 1/3 of the way and the other pane was broken. Blue tape was observed loosely applied to a piece of plexiglass that was taped to the window. Air could be felt blowing through the window on the left side where the tape was completely loose. Observation on 01/07/2025 at 4:00 PM revealed Resident #46's room temperature to be 67 to 69 degrees using [NAME] Tools thermometer that measures ambient temperature. Observation on 01/08/2025 at 8:36 AM revealed Resident #46's room temperature to be 67 to 69 degrees using [NAME] Tools thermometer that measures ambient temperature. In an interview on 01/09/2025 at 12:25 PM the MS regarding window in Resident 46's room stated he was aware the window was broken. The MS stated an aide bumped into it while providing care and broke the glass. The MS stated he put a piece of plexiglass over the window. He stated he usually fixes these things himself. He stated he did feel the air flow through the window and has re-taped it. He stated he was not sure how long the window had been broken. He stated Resident #46 did complain about it being cold in the room and he went to check on it. He stated the vent to the room was also closed and he did not realize that. He stated the room temperatures should be between 74 and 76 degrees. He stated the room temp should not be 67. He stated he contacted a glass company, and the window will be replaced on 01/15/2025. In an interview on 01/09/2025 at 12:45 PM the Administrator stated she did not know about the broken window in Resident #46's room and she expected the MS to maintain the facility. She stated she expected the MS to tell her when things needed to be fixed and keep her updated on his progress of current projects. She stated the resident rooms temperature should be maintained at a comfortable level for the resident. Review of the facility policy Quality of life- Homelike environment dated 05/2017 reflected Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible . The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include . Clean, sanitary, and orderly environment; .Comfortable and safe temperatures (71 F - 81 F). 32452 C) Review of Resident #46's face sheet dated 01/08/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses fracture lower end of right femur (a break in the thigh bone near the knee joint.), diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.), and atherosclerotic heart disease (A condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall). Review of Resident #46's quarterly dated 12/22/2024 reflected Resident #46 was assessed to have a BIMS score of 13 indicating he was cognitively intact. Resident #46 was assessed to require moderate assist with ADLs. Resident #46 was further assessed be at risk for pressure ulcers and was assessed to have one stage four unhealed pressure ulcer. Review of Resident #46's comprehensive care plan not dated reflected Resident #46 ADL self-performance varies, may need more assist at times than other times due to functional limitations related to fracture of lower end of right femur. Interventions included bed mobility extensive to total assist with 1-2 staff and to check every 2 hours and as needed and to provide assist as needed. Observation and interview on 01/07/2025 at 3:05 PM revealed Resident #46 in room in bed with multiple covers on. Resident #46 stated it was cold in his room. He stated his window was broken and it had been taped like that for 2 months. Observation of Resident #46's window which his bed was pushed up against revealed it was a double pane window with one of the panes open 1/3 of the way and the other pane was broken. Blue tape was observed loosely applied to a piece of plexiglass that was taped to the window. Air could be felt blowing through the window on the left side where the tape was completely loose. Observation on 01/07/2025 at 4:00 PM revealed Resident #46's room temperature to be 67 to 69 degrees using [NAME] Tools thermometer that measures ambient temperature. Observation on 01/08/2025 at 8:36 AM revealed Resident #46's room temperature to be 67 to 69 degrees using [NAME] Tools thermometer that measures ambient temperature. In an interview on 01/09/2025 at 12:25 PM the MS regarding window in Resident 46's room stated he was aware the window was broken. The MS stated an aide bumped into it while providing care and broke the glass. The MS stated he put a piece of plexiglass over the window. He stated he usually fixes these things himself. He stated he did feel the air flow through the window and has re-taped it. He stated he was not sure how long the window had been broken. He stated Resident #46 did complain about it being cold in the room and he went to check on it. He stated the vent to the room was also closed and he did not realize that. He stated the room temperatures should be between 74 and 76 degrees. He stated the room temp should not be 67. He stated he contacted a glass company, and the window will be replaced on 01/15/2025. In an interview on 01/09/2025 at 12:45 PM the Administrator stated she did not know about the broken window in Resident #46's room and she expected the MS to maintain the facility. She stated she expected the MS to tell her when things needed to be fixed and keep her updated on his progress of current projects. She stated the resident rooms temperature should be maintained at a comfortable level for the resident. Review of the facility policy Quality of life- Homelike environment dated 05/2017 reflected Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible . The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include . Clean, sanitary, and orderly environment; .Comfortable and safe temperatures (71 F - 81 F).

Based on observation, interview, and record review the facility failed to ensure each room was designed or equipped to assure full visual privacy for 6 (Rooms 35, 36, 38, 39, 40, 41) of 6 dual occupancy rooms and 4 of ( Rooms 92, 93, 94 and 95) of 4 single occupancy rooms reviewed for privacy in the facility. The facility failed to ensure that dual occupancy rooms and single occupancy rooms were provided with ceiling suspended curtains, which extended around the bed, to provide total visual privacy. This failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being. Findings included: Observation on 01/08/2025 at 10:44 AM of Rooms 35, 36, 38 and 41 revealed that each room had dual occupancy with an A and B bed in each. The rooms had a single ceiling to floor curtain that divided the center of the room but stopped approximately four feet from the opposite wall. The rooms did not have a second connecting curtain or partition that would allow for bed A or B to have total visual privacy. Observation on 01/08/2025 at 10:50AM of rooms [ROOM NUMBERS] revealed that each room had dual occupancy with an A and B bed in each. The rooms had a single ceiling to floor curtain that divided the center of the room but stopped approximately four feet from the opposite wall. The rooms did have a rail for a curtain for A bed, but no curtain was hung. Observation on 01/08/2025 at 10:50 AM of Rooms 92, 93, 94 and 95 revealed the rooms had no curtain and no rail to hang a privacy curtain in the room. In an observation and interview on 01/09/2025 at 12:40 PM the MS stated he thought he got all the rooms curtains fixed. Observation on rounds MS he stated that no, rooms 35-41 did not have curtain for A bed and the rooms that had the rail for a curtain did not have a curtain hanging. The MS stated that maybe they got dirty, and they took them down. The MS stated the single rooms 92-94 did not have a curtain or a rail at all which could expose the residents if the doors were open during care. He stated he did not know every room needed a privacy curtain; he thought if they were in the room alone they did not need one. Interview on 01/09/25 at 01:30 PM CNA F stated most of the rooms do not have the curtain for the A-bed. She stated when the door was opened if someone comes in it can expose the resident. Interview on 01/09/25 at 01:35 PM LVN B stated regarding rooms without privacy curtains that without the curtain the resident can be exposed. She stated you would have to make sure the resident was covered when anyone come in or out of the room. In an interview on 01/09/2025 at 12:45 PM the Administrator stated she thought the MS had installed all the privacy curtains since they had been cited for them last year. She stated all rooms should have privacy curtains to ensure resident privacy. She stated she expected the MS to maintain the facility. The Administrator stated they started putting up the curtains in double occupancy rooms and worked from there, but she had not done audit to make sure the work was being done. She stated she expected the MS to tell her when things needed to be fixed and keep her updated on his progress of current projects. Review of the facility's Quality of Life - Dignity policy dated August reflected, Each Resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation indicated: 6. Residents' private space and property shall be respected at all times. 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of the facility's policy Bedrooms dated May 2017 reflected .Each room is designed to provide full visual privacy for each resident (in the form of ceiling-suspended curtains that extend around the bed) and equipped for adequate nursing care .

Based on observation, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for two of six residents ( Resident #43 and Resident #59) reviewed for quality of life. The facility failed to ensure Resident #43 and Resident #59 nails were cleaned, trimmed, and did not have any rough edges on 01/07/2025. These failures could place residents at risk for not receiving adequate care and services to prevent infection, injury, and diminished quality of life. Findings included: 1. Record review of Resident #43's face sheet, dated, 01/08/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #43 had diagnoses which included type 2 diabetes mellitus with circulatory complications ( chronic condition where the body does not use insulin effectively, causing blood sugar levels to become too high because the cells cannot absorb glucose properly, leading to a buildup of sugar in the blood stream. Circulatory- diabetes associated with circulatory complications a person has increased risk of heart disease), peripheral vascular disease, unspecified ( a chronic circulatory condition that occurs when blood vessels outside the brain and heart narrow, spasm or become blocked), and unspecified age-related cataract (clouding of the eye's lens that can lead to vision loss). Record review of Resident #43's Quarterly MDS Assessment, dated, 12/30/2024, reflected the resident had a BIMS score of 11, which indicated her cognition was moderately impaired. Resident #43 required substantial/maximal assistance ( helper does more than half the effort) with personal hygiene, oral hygiene, and upper body dressing. Resident #43 was total dependent on staff with toileting, showers, and lower body dressing. Record review of Resident #43's Comprehensive Care Plan, not dated, reflected Resident #43 had impaired vision. Resident #43's ADL self-performance varies, may need more assistance sometimes due to general weakness and fatigue. Intervention: Resident #43 required total assistance with showers. Resident #43 needed one staff extensive to total assistance with personal hygiene. Resident #43 had cognitive deficit related to vascular dementia. Intervention: Notify physician of any cognitive changes. Resident #43 was at risk for dehydration related to diabetes. Intervention: Diet as ordered. Observe/ document signs and symptoms of dehydration every shift. Record review of Resident #43's Nurses Notes, dated 01/01/2025 thru 01/07/2025 reflected Resident #43 did not refuse nail care. Observation and interview on 01/07/25 10:02 AM revealed Resident #43 were in her room lying in bed. Her nails on her right hand were not smooth around the edges and had a blackish/brownish substance underneath her middle, ring, and fore fingernails on her right hand. Resident #43 also had a blackish/brownish substance on the tip of her middle and ring finger on her right hand. Resident #43 stated she asked someone few days ago to cut and clean her fingernails and the person stated they would sometime during the week. She did not recall the name of the staff, the date or time she made the request. Resident #43 stated she did not want to discuss her nails anymore. 2. Record review of Resident #59's face sheet, dated 01/08/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #59 had diagnoses which included muscle weakness (a reduction in the strength of muscle or muscles), unspecified glaucoma (an eye disease that occurs when fluid builds up in the eye which can lead to vision loss or blindness), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( a person with mild cognitive impairment has not yet been diagnosed ). Record review of Resident #59's Admission MDS Assessment, dated 12/27/2024, reflected Resident #59 had a BIMS score of 7, which indicated her cognition was severely impaired. Resident #59 required partial/moderate assistance ( helper does less than half the effort) with personal hygiene and, oral hygiene. Resident #59 was dependent on staff for showers and, toileting. Record review of Resident #59's Comprehensive Care Plan, dated 01/06/2025, reflected Resident #59 ADL self-performance varies, she sometimes may need more assistance related to impaired cognition. Intervention: Resident #59 required assist of one staff for personal hygiene and oral hygiene. Record review of Resident #59's Nurses Notes, dated 01/01/2025 thru 01/07/2025, reflected Resident #59 did not refuse nail care. Observation and interview on 01/07/25 at 11:03 AM revealed Resident #59 were in her room lying in bed, on her right hand underneath her middle and ring fingernails was blackish/brownish substance. Resident #59 had rough edges around her fingernails on her right hand and around her middle and fore fingernails on her left hand. Resident #59 stated she did not like her nails to be dirty. She stated she did not remember if she asked someone to help her with her nails. Resident #59 stated she was tired and wanted to go to sleep. In an interview on 01/10/2024 at 8:56 AM, LVN B stated the nurses was responsible for filing and trimming all residents' nails and the CNAs was responsible to clean all residents' nails except the residents with diagnosis of diabetes. She stated nail care on residents was completed weekly by the nurse. She stated this usually occurred on Sundays. LVN B stated CNAs were to clean underneath residents' nails as needed . She stated it depended on what type of bacteria was underneath the residents' nails if a resident became ill such as stomach issues. LVN B stated she was not a physician and was unable to answer what type of illness a resident may receive if the resident swallowed some type of bacteria. LVN B stated she had trimmed and cut residents nails. She stated she was not aware of Resident #43 or Resident #59 refusing nail care. She stated the nurses documented in nurse's notes anytime a Resident refused any type of care including nail care. LVN B stated if a resident's nail was not trimmed properly and was jagged, there was a possibility the resident may scratch themselves, staff or other residents and cause a skin tear. In an interview on 01/10/2025 at 9:10 AM the Director of Nurses stated she expected the nurse on duty to do all nail care on a resident. She stated the nurse or CNA can clean resident's nails. The Director of Nurses stated if a resident nails was not smooth around the edges of the nails, there was a potential the resident may scratch themselves or another resident and cause a skin tear. She stated also the resident may scratch their eye and may cause issues such as a tear on the eyeball. She stated the CNAs were expected to check resident's nails on shower days and report to the nurse supervisor if a resident nails needed to be trimmed, filed or any issues the CNA observed with the Residents fingernails. She stated if a resident had a blackish/brownish substance on tip of their finger or underneath their nails it was a possibility a resident may ingest the blackish/brownish substance and become ill such as vomiting and/or diarrhea. She stated if a resident refused nail care or any type of care the nurse was to document the refusal in the nurses' notes. In an interview on 01/10/2024 at 9:25 A, CNA I stated the CNAs were responsible for cleaning the resident's nails and the nurses was responsible for cutting and filing all residents' nails. CNA I stated residents' nails were usually cleaned on their shower days or when needed. She stated if a resident's nails were dirty, nail care was expected to be completed immediately. CNA I stated if any staff observed resident's nails needed to bet cut or filed, the staff was to report the observation to the nurse supervisor. CNA I stated if a resident had nails not trimmed or was rough on top of the nail, there was a possibility a resident may scratch themselves and develop a skin tear. CNA I stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues such as vomiting and being nauseated. CNA I stated he had been in-serviced on cleaning, filing and trimming residents' nails. CNA I stated she did not remember the date of the in-service. CNA I stated she was not aware of Resident #43 or Resident #59 refuse nail care. CNA I stated she worked at least 1-2 times a week on the halls where Resident #43 and Resident #59 lived. In an interview on 01/10/2024 at 11:05 AM CNA M stated the nurses completed all nail care on residents except cleaning resident's nails. She stated the Nurses were responsible to complete nail care such as trimming, filing, and cleaning once a week or as needed. CNA M stated if staff observed a resident's nails needed to be trimmed or filed, the staff was to report it to the nurse supervisor. She stated the nurse or CNA can clean resident's nails but ultimately it was the CNAs responsibility during showers and/or as needed. CNA M stated if a resident had blackish substance underneath their nails there was a possibility a resident may become ill such as nausea or diarrhea depending on the type of bacteria. CNA M stated if a resident had rough edges around their nails, it was a possibility the resident may scratch themselves and develop an infection or a skin tear. She stated she was not aware of Resident #43 or Resident #59 refusing nail care. CNA M stated Resident #59 may refuse to change clothes sometimes, but she was not aware of Resident #59 refusing nail care. Record review of the Facility's Activity of Daily Living Policy, revised in March 2018, reflected Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).

Based on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of (Resident #33) of five residents reviewed for quality of care. The facility failed to ensure Resident #33's geri sleeves were applied daily as ordered. This failure could place residents at risk of not receiving necessary preventative measures, and result in medical care, harm, and hospitalization . Findings include: Review of Resident #33 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia (clinical syndrome that describes a group of symptoms that impact memory, thinking, and social abilities), muscle weakness, and unspecified lack of coordination (a condition where a person has difficulty coordinating their movements). Review of Resident #33 quarterly MDS dated [DATE] revealed resident had application of nonsurgical dressing as a skin treatment. Review of Resident #33's physician's order dated 01/12/2024 revealed to apply geri sleeves to bilateral arms to help prevent bruise and skin tears and to check every shift that resident has them on. Further revealed reviewed additional order dated 01/12/2024 revealed to apply geri sleeves bilateral lower legs to help prevent bruises and skin tears. Review of Resident #33's undated care plan revealed Resident #33 was at risk for alteration of skin. Goal included Resident will have minimal complications with skin breakdown through next review date. Review also revealed Resident #33 had potential for skin impairment due to fragile skin. Interventions included to apply geri sleeves to bilateral upper and lower extremities and remove each shift to observe for changes in skin condition and then replace. Review of Resident #33's nursing progress note dated 01/03/2025 revealed sleeves were not present. Review of Resident #33's nursing progress note dated 01/04/2025 revealed geri sleeves were missing. Review of Resident #33's nursing progress note dated 01/04/2025 revealed no leg sleeves were available. Observation on 01/07/2025 at 10:26 AM revealed Resident #33 was sitting in the common area of the secured unit. The resident's geri sleeves were not observed on her legs or arms. Skin on resident's ankle appeared to have discoloration of healed scar. Observation on 01/08/2025 at 3:39 PM revealed Resident #33 sitting in a wheelchair in the common area with no geri sleeves on legs or arms. Observation on 01/09/2025 at 9:50 AM revealed Resident #33 sitting in the common are with no geri sleeves on her legs. During an interview on 01/09/2025 at 11:13 AM hospitality aide J said Resident #33 usually had geri sleeves on her arms, but she has never seen them on her legs. She stated that Resident #33 sometimes hits her ankles on her footrests and slides her feet off her wheelchair footrests. She stated she has not seen Resident #33 injure or scape her ankles. During an interview on 01/09/2025 at 11:15 AM, CNA E stated that she has never been told Resident #33 needed to have geri sleeves on her legs, only her arms. She stated Resident #33 was supposed to wear them every day. She stated the aides or nurses can put them on and Resident #33 wore the geri sleeves to protect her skin. During an interview on 01/09/2025 at 11:25 AM, LVN D stated that he was the nurse working for the secured unit. LVN D stated that he was familiar with Resident #33 and he did not know if she was supposed to wear geri sleeves but he could look it up in her chart. LVN D stated he did not know if Resident #33 had geri sleeves on. LVN D stated that Resident #33 was just supposed to have geri sleeves on her legs. He stated that geri sleeves were to protect the skin. During an interview on 01/09/2025 at 1:19 PM, CNA F stated she was familiar with Resident #33 and she worked with her regularly. She stated that normally the nurse puts geri sleeves on. She stated she worked with Resident #33 yesterday and she did not think she had them on. She stated she did not usually see geri sleeves on Resident #33's legs only her arms. During an interview on 01/09/2025 at 1:30 PM, LVN B stated that geri sleeves were used so a resident does scratch themselves or get skin tears. She stated it would be important for geri sleeves to be put on if the resident had an order to wear them everyday. LVN B stated that if a resident does not have their geri sleeves on and were supposed to they could get a skin tear or if they had an IV in place, pull out their IV. She stated the nurse was responsible for putting geri sleeves on residents. During an interview on 01/09/2025 at 2:17 PM, CNA G stated that Resident #33 wore geri sleeves on her arms and not her legs. She stated that she usually saw Resident #33 with geri sleeves on and she wore them every day. During an interview on 01/09/2025 at 5:21 PM, the DON stated she expected staff to apply geri sleeves daily if a resident had an order for it. She stated Resident #33 wore upper geri sleeves and compression hose or geri sleeves on her legs. The DON stated that geri sleeves disappear in the laundry. She stated Resident #33 wore geri sleeves because she had very fragile skin and gets skin tears easily. The DON stated the purpose of geri sleeves was to protect the skin and keep the skin from direct contact with anything. During an interview on 01/09/2025 at 5:32 PM the Administrator stated she expected nursing staff to follow physician's orders. She stated that she would expect a resident to have their geri sleeves applied if they have an order for it. She stated that the potential harm of not follow physician orders for geri sleeves was the resident could get a skin tear. Record review of the facility policy related to geri sleeves was requested from ADM on 01/09/2025 at 2:25 PM. The facility did not provide policy related to geri sleeves.

Based on interviews and record reviews, the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for one (Resident #35) of two residents reviewed for quality of care. The facility failed to ensure that Resident #33's potential triggers were care planned. This failure could place residents at increased risk for psychological distress due to re-traumatization. Findings included: Record review of Resident # 35's face sheet, dated 01/08/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #35 had a diagnosis of post-traumatic stress disorder, unspecified (a mental health condition develop after experiencing or witnessing a traumatic event), emotional liability ( a condition where a person experiences rapid and intense mood swings, often characterized by sudden outbursts of emotions like laughing or crying may be inappropriate for that situation), and major depressive disorder, recurrent, mild ( a type of depression characterized by repeated episodes of mild depressing - feelings of sadness, hopelessness, and emptiness). Record review of Resident 35's Annual MDS Assessment, dated 10/25/2024, reflected the resident had a BIMS score of 11, which indicated his cognition was moderately impaired. Resident #35 was diagnosed with depression, PTSD (post-traumatic stress disorder- (a mental health condition develops after experiencing or witnessing a traumatic event) ), and emotional liability. ( a condition where a person experiences rapid and intense mood swings, often characterized by sudden outbursts of emotions like laughing or crying may be inappropriate for that situation) Record review of Resident #35's Comprehensive Care Plan, completed date of 10/28/2025, reflected Resident #35 was at risk for altered status due to a traumatic life experience (PTSD). Interventions: Approach from the front and speak in a calm, unhurried manner. Observe for changes in mental status and document noted changes. Identify causes/triggers for behavior and reduce factors that may provoke resident. Refer to a psychological counseling/mental health specialize as ordered. In an interview on 01/09/2025 at 10:45 AM, Resident #35 was sitting in his wheelchair in his room. He stated he did not have anxiety and there were times when he did have triggers of his PTSD. He stated he had several triggers especially when someone comes in her room and he does not know they are in the room and they don't knock on the door . He stated he did become depressed when he was having difficulty with his PTSD and sometimes became very nervous. Resident #35 stated if the staff bumped his bed and he was lying in bed or sitting on his bed this was a trigger for him. Resident #35 stated it startled him and brought back bad memories. Resident #35 stated it would help his anxiety and PTSD if the staff did know his triggers. He stated sometimes after the staff left his room he becomes more anxious and it affects his PTSD. Resident #35 did not specify how it affected her PTSD. He stated he did receive psychiatry services. Resident #35 stated no one at the facility had asked him what triggered his PTSD or his depression. In an interview on 01/10/2024 at 8:56 AM LVN B stated if a resident had triggers from diagnosis of PTSD, the residents' triggers needed to be care planned. LVN B stated if a resident was having major behaviors such as throwing things, the staff may prevent these behaviors of the residents if they knew the residents' triggers . LVN B stated the staff will sometimes ask the residents about their triggers. In an interview on 01/10/2025 at 9:10 AM, The Director of Nurses stated if a resident had PTSD ( post-traumatic stress disorder) the residents' triggers were expected to be documented on their comprehensive care plan. She stated if the staff was not aware of the triggers for the resident there was a possibility it could affect their quality of life. She did not respond to any further questions about PTSD triggers such as how it would affect their quality of life. The Director of Nurses stated the MDS Coordinator was responsible to care plan triggers of any resident with PTSD. In an interview on 01/10/2024 at 9:25 AM CNA I stated she did not know Resident #35 had PTSD. She stated she knew he had depression. CNA I stated now she understands now why his mood and behaviors sometimes changes. She stated it would help the staff to know Resident #35 triggers of his PTSD. CNA I stated it was a possibility the staff could avoid doing anything that caused Resident #35's PTSD to trigger. She stated it was according to what his triggers were and she thought his triggers of PTSD needed to be on his care plan. In an interview on 01/10/2024 at 11:20 AM, MDS Coordinator stated that a resident with a diagnosis of PTSD the resident's triggers needed to be identified on the resident's care plan. The MDS Coordinator stated failure to properly care plan a resident for PTSD and triggers could result in a resident being re-traumatized. She stated she was responsible for including PTSD triggers in the resident's care plan . MDS Coordinator stated she would need to check with her supervisor to determine if there was a forms she could use to identify residents' triggers. In an interview on 01/10/2025 at 9:10 AM, The Director of Nurses stated if a resident had PTSD ( post-traumatic stress disorder) the residents' triggers were expected to be documented on their comprehensive care plan. She stated if the staff was not aware of the triggers for the resident there was a possibility it could affect their quality of life. She did not respond to any further questions about PTSD triggers such as how it would affect their quality of life. The Director of Nurses stated the MDS Coordinator was responsible to care plan triggers of any resident with PTSD. The facility policy on Care Plans, Comprehensive Person-Centered, revised on December 2016, reflected A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will : 1. Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. 2. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one of one medication aides (MA P) observed for infection control practices during medication pass. MA P failed to sanitize the blood pressure cuff during medication pass after using it on Resident #40. This failure could place residents who require assistance with medication administration at risk for healthcare associated cross-contamination and infections. Findings include: Observation on 01/08/2025 at 9:58 AM revealed MA P removing a blood pressure cuff from her cart and entered Resident #40's room to perform a blood pressure check. After the blood pressure check she placed the blood pressure cuff back in her cart. MA P did not clean the blood pressure cuff before or after use. In an interview on 01/08/2025 at 10:29 AM MA P stated she did not clean the blood pressure cuff after she used it on Resident #40 or before putting it back in her cart. She stated by not cleaning it, it could lead to cross contamination and potential spread of infection. In an interview on 01/09/2025 at 11:50 AM the DON stated she expected MA P to sanitize resident care equipment between residents to prevent cross contamination and the spread of infection. Review of the facility's policy cleaning and disinfection of resident-care items and equipment dated 09/2022 reflected Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard .non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers .non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA registered disinfectant products are followed (e.g., use-dilution, shelf life, storage, material compatibility, safe use and disposal) . 42600

Based on observation, interview, and record review the facility failed to ensure each room was designed or equipped to assure full visual privacy for 11 (Rooms 13, 17, 35, 39, 40, 41, 55, 56, 63, 72, and 79) of 11 dual occupancy rooms reviewed for privacy in the facility. The facility failed to ensure that dual occupancy rooms were provided with ceiling suspended curtains, which extended around the bed, to provide total visual privacy. This failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being. Findings included: Observation on 11/28/2023 at 2:28 PM of rooms [ROOM NUMBERS] revealed that each room had dual occupancy with an A and B bed in each. The rooms had a single ceiling to floor curtain that divided the center of the room but stopped approximately four feet from the opposite wall. The rooms did not have a second connecting curtain or partition that would allow for bed A or B to have total visual privacy. Observation on 11/28/2023 at 2:32 PM of rooms [ROOM NUMBERS] revealed that each room had dual occupancy with an A and B bed in each. The rooms had a single ceiling to floor curtain that divided the center of the room but stopped approximately four feet from the opposite wall. The rooms did not have a second connecting curtain or partition that would allow for bed A or B to have total visual privacy. In an interview on 11/29/2023 at 10:40 AM, RN A was asked about the partial center divide curtain in the dual occupancy rooms. RN A stated that they were to knock before entering the room but stated that not having a curtain at the bottom of either resident bed could pose a privacy issue for the resident. RN A stated that there was no way to ensure full privacy for residents in a dual occupancy room with the single curtain. In an interview on 11/29/2023 at 3:25 PM the DON was asked about the lack of full privacy in the rooms. The DON stated that the dual occupancy rooms only have a partial divider. The DON stated that staff had been instructed to ensure doors were closed and that they knock before entering. The DON stated that there was not full privacy available in the dual occupancy rooms and that it could pose a privacy issue for residents. Observations on 11/30/2023 at 7:45 - 7:50 AM revealed that Rooms 35, 40, 55, 56, 63, 72, and 79 were also dual occupancy rooms and only had one partial center room divide curtain present, which did not allow for full privacy. In an interview on 11/30/2023 at 8:05 AM, the Administrator stated that all dual occupancy rooms in the facility do only have one partial center divide curtain. The Administrator stated that staff were instructed to always knock before entering a residents' room but stated that the partial curtain did not allow for full privacy for either resident in the dually occupied room. The Administrator stated that the building was forty years old and that the partial curtain has never been an issue. The Administrator stated that they do not have a policy that directly relates to privacy curtains. In an interview on 11/30/2023 at 10:50 AM, CNA A was asked about the partial privacy curtains in the dual occupancy rooms. CNA A stated that they always knock before entering a room. CNA A stated that the partial curtain did not provide full privacy for either resident in the room. CNA A stated that residents not assigned to the room could also enter without knocking, which would pose a privacy issue for residents. In an interview on 11/30/2023 at 2:10 PM, the MS was asked if the facility had a policy in reference to the privacy curtains for their dual occupancy rooms. The MS stated that they did not, and that staff will tell him if they were dirty or need repair. The MS stated that the current partial center divide curtain did not provide full privacy for either resident in their dual occupancy rooms. Record Review of the facility's Quality of Life - Dignity policy with a revision date of August 2009 revealed a policy statement which read, Each Resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation indicated: 6. Residents' private space and property shall be respected at all times. 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review the facility failed to ensure 1of 18 residents reviewed with limited range of motion (Resident #11), received appropriate treatment and services to prevent a decline in range of motion. The facility failed to ensure Resident #11 had interventions in place for his bilateral hand contractures (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in his hands. This failure could place residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: Review of Resident #11's Face Sheet dated 03/15/2023 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnosis Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side (Hemiplegia and hemiparesis are related conditions that cause weakness or paralysis on one side of the body), Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.) and Parkinson's Disease (A progressive disorder that affects the nervous system and the parts of the body controlled by the nerves.) Review of Resident #11's Quarterly MDS dated [DATE] reflected Resident #11 was assessed to have a BIMS score of 0 indicating severe cognitive impairment. Resident #11 was further assessed to have range of motion impairments of the upper and lower extremity on one side. Review of Resident #11's Comprehensive Care Plan reflected a focus area dated 06/14/2023 Resident #11 has functional limitations due to contracture to bilateral hands. Interventions included For hand/finger contractures, keep fingernails cut short to prevent skin breakdown to palm, place handroll in contracted hand/fingers daily. Remove during bath and as needed and wash hand. Dry hand thoroughly before placing handroll back in hand . Review of Resident #11's Consolidated Physician orders reflected an order dated 11/14/2023 Check that hand rolls are in both hands. Reapply if they are out . Further review reflected another order dated 11/16/2023 which reflected Cleanse hands and apply hand rolls in both hands every day and evening shift. Review of Resident #11's TAR for November 2023 reflected documentation that the physician order cleanse Resident #11's hands and apply hand rolls in both hands every day and evening shift was completed with the start date of 11/17/2023. Observation on 11/28/2023 at 11:40 AM revealed Resident #11 in bed. Resident #11 had hand contractures to bilateral hands. Resident #11's fingernails to both hand was observed to be extending past the tip of his fingers. Observation on 11/28/2023 at 3:00 PM revealed Resident #11 in bed. Resident #11 had hand contractures to bilateral hands. Resident #11's fingernails to both hand was observed to be extending past the tip of his fingers. Observation and interview on 11/29/2023 at 10:25 AM revealed CNA C and D in Resident #11's room to provide incontinent care. Resident #11 was observed to not have hand rolls in either of his hands. CNA C stated after Resident #11 was provided care, that he should have hand rolls in both of his hands at all times to prevent his fingers from digging into his hands. CNA C stated she did not know why his hand rolls were not in his hands. CNA C then looked around room and stated sometimes Resident #11's hand rolls get dirty and get sent to the laundry. In an interview on 11/29/2023 at 10:30 AM CNA D stated Resident #11 should have his hand rolls in at all times and they usually use wash cloths. She stated she was not sure why Resident #11 did not have the rolls in his hands. In an interview on 11/29/2023 at 10:35 AM the DON stated after observing Resident #11's hands, that Resident #11 should have hand rolls in both hands and stated his fingernails were a little long and could dig into his palms. The DON stated the nurses, or the nurse aides could put Resident #11's hand rolls in and both should check when they were in the room to ensure they were in place. She further stated the hand rolls were used to prevent pressure ulcers and without them Resident #11 could develop pressure ulcers. Review of the facility's policy Resident Mobility and Range of Motion dated 07/2017 reflected 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable . 6. Interventions may include therapies, the provision of necessary equipment, and/or exercise and will be based on professional standards of practice and be consistent with state law and practice acts .

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 4 residents (Resident #11 and Resident #45) reviewed for respiratory care. A) The facility failed to ensure Resident #11's oxygen concentrator filter were kept clean for his use. B) The facility failed to ensure Resident #45's oxygen concentrator filter were kept clean for his use. These failures could place all residents who use respiratory equipment at risk for respiratory infections. Findings included: A) Review of Resident #11's Face Sheet dated 03/15/2023 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnosis Chronic obstructive pulmonary disease (COPD) (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.), Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side (Hemiplegia and hemiparesis are related conditions that cause weakness or paralysis on one side of the body), Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.) and Parkinson's Disease (A progressive disorder that affects the nervous system and the parts of the body controlled by the nerves.) Review of Resident #11's Quarterly MDS dated [DATE] reflected Resident #11 was assessed to have a BIMS score of 0 indicating severe cognitive impairment. Resident #11 was assessed to have oxygen use during the assessment period. Review of Resident #11's Comprehensive Care Plan reflected a focus area dated 06/14/2023 Resident #11 has COPD. Interventions included .Oxygen settings-O2 vial nasal cannula at 3 LPM PRN . Review of Resident #11's Consolidated Physician orders reflected an order dated 04/06/2022, O2 at 3 LPM keep O2 sats >92%. Further review reflected an order dated 11/21/2022 change out oxygen tubing, humidifier, and nasal canula. Clean filters on the concentrator every night shift every Sunday for infection control. Observation on 11/28/2023 at 10:00 AM revealed Resident #11 in bed. Resident #11 was on oxygen with the oxygen concentrator set at 3LPM. Further observation revealed the air intake filters on the concentrator to be covered with a thick gray substance. B) Review of Resident #45's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Acute respiratory failure with hypoxia (is a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide.) and pulmonary hypertension (A condition in which high blood pressure affects arteries of the lungs, and right side of the heart. This results in chest pain and shortness of breath.) Review of Resident #45's quarterly MDS dated [DATE] reflected Resident #45 was assessed to have a BIMS score of 15 indicating he was cognitively intact. Resident #45 was assessed to use oxygen therapy continuously. Review of Resident #45's Comprehensive Care Plan reflected a focus area dated 08/17/2023 Resident #45 is at risk for shortness of breath related to COPD . Interventions included O2 at 4 LPM via nasal cannula continuously Review of Resident #45's Consolidated Physician orders reflected an order dated 07/07/2023 O2 vial nasal cannula at 4 LPM. Further review of Resident #45's physician orders reflected an order dated 07/04/2023 to change O2 tubing, humidification bottle and to cleanse concentrator filters weekly. Observation and on 11/28/2023 at 9:56 AM revealed Resident #45 in room up in his chair with oxygen on at 4 LPM. Further observation revealed the air intake filters on the concentrator to be covered with a thick gray substance. Observation and interview on 11/28/2023 at 2:16 PM, LVN E in an observation with surveyor of Resident #11 and Resident 45's oxygen concentrator filters stated the filters were dirty and defiantly needed to be cleaned. She stated the night nurse usually was in charge of that task bust anyone can clean them. She stated they were supposed to be cleaned weekly. In an interview on 11/28/2023 at 2:40 PM the DON stated the night nurse was supposed to clean the oxygen concentrator weekly. She further stated she called up to the facility and asked if she had completed the task including changing the oxygen tubing and she stated she had. The DON after observing the oxygen concentrator filters stated they needed to be cleaned, and it placed residents at risk for upper respiratory infections. Review of the facility's policy for Oxygen Administration dated 10/2010 reflected The purpose of this procedure is to provide guidelines for safe oxygen administration . The policy did not address cleaning or maintain procedures.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater for when the facility had a medication error rate of 9.38% based on 3 of 32 opportunities, which involved 2 of 6 residents (Resident #7 and Resident #24) observed during medication administration. 1) The facility failed to ensure MA A administered Resident #24's physician's orders for Pataday solution 0.2% (olopatadine HCL) and artificial tears solution 1%. 2)The facility failed to ensure MA A administered Resident #7's physician's order for Patanol solution 0.1% (olopatadine HCL). These deficient practices could place residents at risk of not receiving therapeutic dosage of medications. Findings Include: Review of Resident #24's face sheet, dated 10/05/2022, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses schizoaffective disorder bipolar type (is a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania.), dry eye syndrome, and allergic rhinitis (A disorder caused by allergy-causing substance, called allergens.) Review of Resident #24's quarterly MDS assessment, dated 08/15/2022, reflected Resident #24 was assessed to have a BIMS score of 11 indicating moderate cognitive impairment. Resident #24 was assessed to not have vision impairment. Review of Resident #24's comprehensive care plan reflected a focus area, dated 06/09/2022, of Allergic Rhinitis .med use ongoing. Interventions included administer related medication as ordered . Review of Resident 24's consolidated physician orders, dated 10/05/2022, reflected orders dated 08/19/2021 for Pataday solution 0.2% (olopatadine HCL) instill one drop in both eyes two times a day for allergic rhinitis and an order dated 09/29/2022 for artificial tears solution 1% instill one drop in both eyes three times a day for dry eye syndrome. Review of Resident #24's MAR, dated October 2022, reflected both eye drops were to be given at 9:00 AM. Observation on 10/04/2022 at 08:34 AM revealed MA A outside of Resident #24's room gathering Resident #24's medication for administration. MA A did not offer or administer Resident #24's eye medication Pataday solution 0.2% (olopatadine HCL) or his eye medication artificial tears solution 1%. Review of Resident #7's face sheet dated 10/05/2022 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Alzheimer's disease (A brain disorder that causes problems with memory, thinking and behavior.) and dry eye syndrome of unspecified lacrimal gland (dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface.) Review of Resident #7's annual MDS assessment, dated 09/16/2022, reflected Resident #7 was assessed to have a BIMS score of 99 indicating the resident was unable to complete the interview due to severe cognitive impairment. Resident #7 was further assessed to have moderately impaired vision. Review of Resident #7's comprehensive care plan reflected a focus area with the revision date of 07/14/2022 reflected Resident #7 has impaired vision .she does have dry eye syndrome that is managed by her optometrist . Interventions included administer eye drops as ordered . Review of Resident #7's consolidated physician orders dated 10/05/2022 reflected orders dated 05/16/2022 for Patanol solution 0.1% (olopatadine HCL) instill one drop in both eyes two times a day for eye irritation and an order dated 12/19/2018 for Systane complete solution instill one drop in both eyes three times a day related to dry eye syndrome of unspecified lacrimal gland. Review of Resident #7's MAR, dated October 2022, reflected both eye drops were to be given at 9:00 AM. Observation on 10/04/2022 at 9:32 AM revealed MA A outside of Resident #7's room gathering Resident #7's medication for administration. MA A removed a bottle of Systane eye drops to administer to Resident #7 (Resident #7 refused the eye drop). MA A then returned to the medication cart and gathered Resident #7's oral medication and administered them to Resident #7. MA A did not offer or administer Resident #7's eye medication Patanol. In an interview on 10/04/2022 at 11:36 AM, MA A stated when asked if she gave Resident #24's eye medication, she stated she did not give Resident #24 his eye drops. When asked why the medication was not given, she stated she just forgot. MA A was asked what the consequence of not giving the eye drops would be to Resident #24 she stated she did not know. MA A was then asked if she offered Resident #7 both her eye drops and she stated she did not. MA A was asked if the facility monitors her competencies and provided training, she stated she had training and was observed by the pharmacy consultant monthly. In an interview on 01/04/2022 at 11:45 AM the DON, she stated she expected the MAs to ensure they were giving all the medications. The DON stated the consequence of the residents not getting their eye drops would be dry or itching eyes. Review of the facility's policy Medication Administration, dated 2022, reflected Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .review MAR to identify medication to be administered .administer mediation as ordered .

Based on observations interviews and record reviews, the facility failed to provide a safe and comfortable environment for 15 out of 70 rooms and 3 of 4 halls reviewed for safe/comfortable environment, in in that: 1. Rooms with shared bathroom 55 and 57, 62 and 64, 74 and 76, 78 and 80, and 82 and 84 had hot water temperatures above 110 degrees F (Fahrenheit). 2. Rooms 10, 12 and 14 (shared bathroom), and 20 and 22 (shared bathroom) had hot water temperature below 100 degrees F. This deficient practice could affect staff, visitors and residents who use water in the facility and could result in discomfort and [CONDITION(S)]. The findings were: 1. Observation on 7/12/21 at 9:53 a.m. of the hot water temperature in the shared bathroom of rooms 62 and 64 revealed it was 118 degrees F. Observation on 7/12/21 at 10:00 a.m. of the hot water temperature in the shared bathroom of rooms 55 and 57 revealed it was 118 degrees F. Observation on 7/13/21 at 12:13 pm in the shared bathroom of rooms #74 and #76, revealed the hot water temperature in the bathroom sink registered a temperature of 124 degrees F (measured with the surveyor's thermometer). Observation on 7/13/21 at 3:05 pm in the shared bathroom of rooms #82 and #84, revealed the hot water temperature in the bathroom sink registered a temperature of 97.3 degrees F (measured with the surveyor's thermometer). 2. Observation on 7/12/21 at 10:13 a.m. of the hot water temperature in room #20 revealed it was 80 degrees F. Observation on 7/13/21 at 9:42 am in resident room #10, revealed the hot water temperature in the bathroom sink registered a temperature of 84.7 degrees F (measured with the surveyor's thermometer). Observation on 7/13/21 at 9:46 am in the shared bathroom of rooms #12 and #14, revealed the hot water temperature in the bathroom sink registered a temperature of 97.3 degrees F (measured with the surveyor's thermometer). During an interview 7/13/21 at 3:26 p.m., the Maintenance Director reported that checked temperatures every Monday of one room on each hall. The Maintenance Director reported he last checked water temperatures on 7/12/21 and no temperatures were above code. The Maintenance Director reported he has not had any report from residents or staff of high temperatures. The Maintenance Director reported when checking the temperature in the room her makes sure is thermometer is calibrated to 32 degrees F. Then when in the room he leave it in until the temperature stops moving to get the final temperature. Record review of the Water Temperature Weekly Checklist Audit Tool, dated 7/12/21, revealed water temperatures taken in shared bathrooms 16 and 18, 38 and 40, 54 and 56, 61 and 59, and 82 and 84 were all within 100-110 degrees F. Observation on 7/13/21 at 3:32 pm in the shared bathroom of rooms #74 and #76 with the Maintenance Director, revealed the hot water temperature in the bathroom sink registered a temperature of 111 degrees F and was still going up when the Maintenance Director remove his thermometer. During an observation and interview on 7/13/21 at 3:33 pm, revealed in the shared bathroom of rooms #78 and #80 the hot water temperature in the bathroom sink registered a temperature of 113 degrees F and still going the Maintenance Director reported that he had checked the temperatures yesterday so maybe the circulating pumps are not working. Observation on 7/13/21 at 4:26 pm in the shared bathroom of rooms #34 and #35 revealed the hot water temperature in the bathroom sink registered a temperature of 113 degrees F (measured with the surveyor's thermometer). During an observation and interview with the Maintenance Director on 7/13/21 at 5:17 pm, 121 F was the temperature in the shared bathroom of rooms #74 and #76 and was confirmed by the Maintenance Director with his thermometer. The Maintenance Director reported he has never had a problem with his water temperatures. Observation on 7/13/21 at 5:19 pm in the shared bathroom of rooms #74 and #76, revealed the hot water temperature in the bathroom sink registered a temperature of 122 degrees F (measured with the Maintenance Director's thermometer). Interview on 7/13/21 at 5:48 pm with the Maintenance Director, Plumber and VP of Operations, the Plumber reported the mixing valve was what he had to adjust for the building to get the water temperatures to go down. The Plumber revealed the temperature on the water heater now was set at 109. The Maintenance Director and Plumber reported the facility had four water heaters and one tankless water heater. Record review of the facility policy on Water Temperatures, Safety Of, dated December 2009, revealed water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees F or the maximum allowable temperature per state regulation.

Based on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for four (4) of four (4) residents reviewed for pressure ulcers. A) The facility failed to ensure Resident #2 who was admitted to the facility without pressure ulcers and was ambulatory did not develop pressure ulcers. The facility failed to do weekly skin assessments for Resident #2 who was found with two (2) Stage III pressure ulcers (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) to her sacral area on 08/25/2019. Once developed the facility failed to ensure Resident #2's pressure ulcers were assessed routinely and accurately, that she was provided with wound care within professional standards regarding infection control and providing the physician ordered treatment. The facility further failed to provide Resident #2 with pressure ulcer prevention measures to promote healing and prevent further pressure ulcer development and failed to notify her physician when there was a decline in her pressure ulcers. B) The facility failed to ensure Resident #3 who was admitted to the facility without pressure ulcers and was ambulatory did not develop pressure ulcers. The facility failed to do weekly skin assessments or develop a plan of care for Resident #3 who was found with two (2) Stage III pressure ulcers to her right buttock on 08/28/2019. Once developed the facility failed to notify Resident #3's Physician and provided Resident #3 with a treatment that was not appropriate for a Stage III pressure ulcer until surveyor intervention on 08/30/2019. The facility further failed to provide wound care within professional standards regarding infection control and routine wound care and failed to provide Resident #3 with pressure ulcer prevention measures to promote healing and prevent further pressure ulcer development. C) The facility failed to ensure Resident #4 who was admitted with an unstageable pressure ulcer (An unstageable pressure ulcer is a full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) to his right heel did not experience a decline in his pressure ulcer. The facility failed to assess Resident #4's unstageable pressure ulcer routinely to ensure the pressure ulcer was not declining. The facility further failed to ensure Resident #4 had a plan of care for his pressure ulcer that included interventions to prevent decline and prevent new pressure ulcers, ensure treatment orders were in place and performed as ordered, and notify the physician of signs of infection and worsening of his pressure ulcer. D) The facility failed to ensure Resident #5's in-house stage III and unstageable pressure ulcers did not worsen. The facility also failed to ensure Resident #5 did not develop another pressure ulcer to the bottom of her right foot or buttocks. She did not have an air mattress or a heel protector for her left foot. The hard walking boot on her right foot continued to be odorous and worsen the pressure ulcer to her heel and caused another on the sole of her foot. Resident #5's treatment by LVN C also did not promote healing, the collagen and calcium alginate overlapped the wound bed. The skin assessments were not complete, most did not have the measurements or describe the wound. Also, the NP was not notified immediately when changes were noted in the wound. These failures resulted in an Immediate Jeopardy (IJ) situation on 08/30/2019. While the IJ was removed on 08/31/2019, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing worsening pressure ulcers, [MEDICAL CONDITION] (skin infection), [DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain or death. Finding Include: A) Review of Resident #2's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #2 was assessed to have a Brief Interview of Mental Status (BI[CONDITION]) score of five (5) indicating severe cognitive impairment. Resident #2 was assessed to require limited assistance with ambulation and was assessed to ambulate with a walker. Resident #2 was assessed to be incontinent of bowel and bladder, was assessed to be at risk for developing pressure ulcers and was assessed to not have pressure ulcers. Review of Resident #2's Comprehensive Care reflected a focus area dated 06/11/2019 Resident #2 is a risk for skin breakdown due to urinary/ bowel incontinence, medication use. Listed under interventions, administer medication/treatment as ordered, observing for adverse changes and or signs and symptoms of infection. Notify physician as needed. Assist with incontinent needs. Complete skin assessments weekly and PRN (as needed). Review of Resident #2's Weekly Skin Assessments reflected a skin assessment was performed on 08/16/2019. No skin issues were assessed. Review of Resident #2's Medical Record reflected no weekly skin assessments done from 08/16/2019 to 08/25/2019. Review of Resident #2's New Pressure assessment dated [DATE] reflected Resident #2 was assessed to have a 4 cm x 2 cm x 0.1 cm depth open area to sacrum (2 side by side). No drainage noted, wound bed pink and red, wound edges intact. No complaints of pain at this time. Review of Resident #2's Wound Care physician progress notes [REDACTED].#2 had Sacrum and Left buttock Stage III pressure ulcer for some weeks with moderate pain and discomfort . Wound #1 was assessed to be on her sacrum measuring 2 cm x 2 cm with 0.2 cm depth with moderate serous exudate. Wound #2 to left buttock was assessed to measure 2 cm x 2 cm with 0.2 cm depth with moderate serous exudate. Orders listed on the assessment Clean wound with saline or wound cleanser, apply [MEDICATION NAME], [MED], [MED] to wound bed and cover with dry dressing. Review of the website: www.[MEDICATION NAME] [MED].com reflected [MED] Ointment is an FDA-approved prescription medicine that removes dead tissue from wounds, so they can start to heal. Proper wound care management is important to help remove nonliving tissue from your wound properly. Review of the website: www.drugs.com [MEDICATION NAME] is a wide spectrum antibiotic that provides highly effective topical treatment in primary and secondary bacterial infections of the skin. Review of Resident #2's Wound Assessment signed by RN A dated 08/26/2019 reflected Resident #2 had two (2) open areas to buttock. The assessment did not include description of area, measurements or location. Review of Resident #2's Treatment Administration Record (TAR) dated August 2019 reflected the Wound Care physician's orders [REDACTED]. The TAR indicated this treatment was performed until 08/29/2019. On 08/29/2019 the new treatment documented on the TAR was to cleanse coccyx/ sacrum with normal saline, pat dry, apply calcium and dry dressing every day. Observation/ Interview on 08/30/2019 at 9:10 AM revealed Resident #2 in her recliner in her room, restless and scooting down saying, help me, help me. No pressure relief cushion was noted in the recliner. When resident was asked if she was ok she only stated help me. Observation of Resident #2's bed revealed a regular foam mattress. Observation/ Interview on 08/30/2019 at 9:12 AM revealed LVN B in Resident #2's room to provide wound care. LVN B stood Resident #2 up and pulled down her pants and brief to reveal two (2) Stage III pressure ulcers to her coccyx/ sacral area. Resident #2's pressure ulcers had no dressing in place and her brief was saturated with urine. Resident #2's Stage III pressure ulcer to her left upper buttock was approximately 2 cm by 2.5 cm with >0.2cm depth with yellow granulation tissue to wound bed, the wound edges were beveled and red. The Stage III pressure ulcer to her right upper buttock was approximately 3 cm by 2 cm with >0.2 depth with yellow granulation tissue to wound bed with red beveled edges. LVN B gathered her supplies and placed them on the residents overbed table on a paper towel without cleaning the table. LVN B stated, I know I am supposed to use wax paper for the table, but the administrator told me it was not in the budget. LVN B stated she asked the Administrator all the time for supplies, but the Administrator would never get them for the nurses. With Resident #2 standing LVN B cleaned across both pressure ulcers using the same saline soaked gauze. LVN B then patted over both pressure ulcers using the same dry gauze. LVN B then applied calcium alginate to both wound beds and applied a dry dressing. LVN B stated she did Resident #2's treatment the previous day but was not aware the dressing was off because nobody told her. When LVN B was asked if Resident #2 was ambulatory she stated yes, that she walked all day. LVN B stated Resident #2 should not even have a pressure ulcer. LVN B stated It is sad, I have never seen this place this bad. There is no DON or anything. LVN B stated the staff are not taking care of the residents and they have agency staff that do not care. LVN B stated the administrator told her and all the nurses that they are not allowed to measure the wounds that only the wound care doctor could and that was why the DON left. LVN B stated the administrator would not let the DON do her job. LVN B stated the Administrator fired the Wound Care Doctor the other day after he saw the residents and some new company was coming in. LVN B stated she didn't think anyone was doing the weekly skin assessments. LVN B stated she found Resident #2's pressure ulcers on the 08/25/2019 when a CNA came and told her about it. LVN B stated the Wound Care Doctor came to the facility and saw the pressure ulcers on 08/26/2019 and ordered [MED] and [MEDICATION NAME] but she did not feel like that was an appropriate order because the pressure ulcers were not Stage III pressure ulcers, so she got the order changed. LVN B stated she never used the [MED] and [MEDICATION NAME] on Resident #2's pressure ulcers. When LVN B was asked if Resident #2's pressure ulcers were improving she stated no they were getting worse. In an interview on 08/30/2019 at 10:10 AM Resident #2's Nurse Practitioner (NP) stated Resident #2 should not have a pressure ulcer. She stated, it makes no sense because she is ambulatory. Resident #2's NP stated she did see Resident #2's pressure ulcers on Monday. Resident #2's NP stated care is not being provided. For someone like her to get a pressure ulcer, when she eats good, it just does not make since. Resident #2's NP stated Resident #2 should have supportive surfaces to promote healing and weekly skin checks should be performed to catch pressure ulcers when they are Stage I's not Stage III's. Resident #2's NP stated she consults the wound care doctor and the nurses should follow his orders. Observation/ Interview on 08/30/2019 at 10:30 AM Resident #2's NP assessed Resident #2's pressure ulcers with Surveyor and stated Resident #2's pressure ulcers were worse since she saw them on Monday. Resident #2's NP stated no one from the facility ever calls her when wounds have a decline. In an interview on 08/30/2019 at 11:00 AM CNA E (who was assigned to Resident #2) stated Resident #2 was ambulatory and required incontinent care. CNA E stated she doesn't know how these residents are getting pressure ulcers when they are ambulatory. In an interview on 08/30/2019 at 11:41 AM the DON stated she resigned from the facility on 08/28/2019. The DON stated Resident #2's pressure ulcers were shear and they were not pressure ulcers and the doctor ordered [MED] and [MEDICATION NAME] and now the wounds are looking worse because he is having them put [MED] on the wounds. She stated the Administrator had an in-service and stated that no RN or LVN could measure or document wound sizes in the chart that only the Wound Care Doctor can do that. The DON stated the Administrator also did not want anything written or done without her approval. The DON stated she was not allowed to keep normal books like a DON does including skin books. The DON stated the Administrator would snatch them from her hands and take it to her office. Observation on 08/30/2019 at 2:00 PM revealed Resident #2 ambulatory around her room on her own. In an interview on 08/30/2019 at 4:50 PM CNA F assigned to Resident #2 stated Resident #2 was incontinent of bladder a lot. CNA F stated Resident #2 will sleep in her chair sometimes and stated, maybe that's how she got the pressure ulcer. CNA F was asked if the facility had low air loss mattresses or pressure relief cushions for the residents, CNA F stated she did not want to say. B) Review of Resident #3's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3's Skin Observation Tool dated 08/08/2019 reflected she had a scab/sores red area to right buttock. Under the note section was documented skin is warm dry and intact. No other information was documented. Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3 was assessed to have a BI[CONDITION] score of zero indicating severe cognitive impairment. Resident #3 was assessed to ambulate with supervision and require limited assist with toilet use. Resident #3 was assessed to use a walker for ambulation. Resident # 3 was assessed to be occasionally incontinent of bladder and frequently incontinent of bowel. Resident #3 was assessed to be at risk for pressure ulcers and was assessed to not have pressure ulcers. Review of Resident #3's Comprehensive Care Plan (no date) reflected her care plan did not address pressure ulcers or pressure ulcer prevention. Review of Resident #3's Medical Record reflected no weekly skin assessments were performed. Review of Resident #3's Nurse Progress notes reflected an entry dated 08/13/2019 .Resident has 6 fading/healing finger print bruises to lower right buttocks. There are 2 small finger print healing scratches to lower left buttock. No open [MEDICAL CONDITION] are noted to the coccyx, bilateral ischial tuberosities or at bilateral trochanters . No other skin assessment entries were noted. Review of Resident #3's Nurse Progress note dated 08/28/2019 reflected Open area to right buttock x 2, #1 1 cm x 1 cm and #2 0.5 cm by 1 cm. Wound bed pink, peri wound intact, no drainage or odor. Patient denied pain upon assessment. Area cleansed with normal saline, applied [MEDICATION NAME], physician, DON and ADON made aware for possible wound consult. Review of Resident #3's Physician order [REDACTED]. Review of Resident #3's TAR dated 08/2019 reflected Resident #3's treatment to cleanse open areas to right buttock with normal saline, pat dry and apply [MEDICATION NAME] dressing was signed as being provided only once on 08/28/2019. Observation/ Interview on 08/30/2019 at 9:30 AM revealed Resident #3 up in activity room on the locked unit ambulating with a cane. Resident #3 ambulated to her room with LVN B for wound care. LVN B pulled Resident #3's pants and brief down to reveal two Stage III pressure ulcers to her right buttock. No dressing was in place. Resident #3's right buttock (#1) Stage III pressure ulcer was approximately 2 cm by 2.5 cm with 0.2 cm depth, the wound edges were beveled, wound bed with area of yellowish slough from eight o'clock to 2 o'clock, right buttock (#2) Stage III pressure ulcer was approximately 1 cm by 1cm with >0.2 cm depth, the wound edges were beveled, wound bed pink with pen head size area of slough in the middle of the wound bed. The peri wound around both pressure ulcers was macerated. LVN B placed her supplies on Resident #3's bedside table on a paper towel without cleaning the table. LVN B cleansed across both pressure ulcers from the outside inward with the same saline soaked gauze. LVN B then padded over both pressure ulcers then applied a [MEDICATION NAME] dressing over both pressure ulcers. (LVN B did not perform hand hygiene or change her gloves throughout the procedure.) LVN B stated there was no reason Resident #3 to have a pressure ulcer since she goes to the bathroom most of the time and walks around. LVN B stated sometimes there were only four CNA's for the whole building and they were not changing these residents enough. LVN B stated Resident #3 was not seen by the wound care doctor when he came. Further observation revealed Resident #3's bed used a regular foam mattress. In an interview on 08/30/2019 at 3:25 PM CNA G stated she was assigned to Resident #3. When CNA G was asked about Resident #3's pressure ulcer she stated she was not aware Resident #3 had a pressure ulcer and stated How? She ambulates. In an interview on 08/30/2019 at 4:00 PM Resident #3's Physician (and Facility Medical Director) stated he was not aware Resident #3 had pressure ulcers. Resident #3's Physician stated Resident #3 ambulates and is a fall risk but should not have pressure ulcers. When Resident #3's Physician was informed the pressure, ulcers were found at a Stage III he stated, That place disappoints me. Resident #3's Physician stated the nurses should notify him of changes in resident conditions. When asked about the treatment for [REDACTED].#3's Physician stated he did not know where they got that order since he did not even know about the pressure ulcers until the surveyor informed him. C) Review of Resident #4's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses; Malnutrition, Debility, Dementia, [MEDICAL CONDITION] and Diabetes Mellitus. Review of Resident #4's MDS assessments reflected an entry assessment was done on 08/21/2019. Review of Resident #4's Baseline Care plan reflected a focus area dated 08/21/2019 impaired skin integrity related to admitted with wounds Listed under interventions was treatment as ordered, skin assessment weekly, remind resident to make frequent position changes. Further review reflected a focus area dated 08/23/2019 Resident has infection of the left heel and right foot surgical wound where toes were amputated. [MEDICATION NAME] 100 mg per mouth twice a day times 10 days. No interventions for pressure relieving devices or pressure ulcer care were listed on the care plan. (Resident #4's pressure ulcer was to his right heel and the surgical wound was on his left foot.) Review of Resident #4's Admit/ Readmit Screening dated 08/21/2019 reflected Right foot heel has wound, 2 cm wound with [MEDICAL CONDITION] drainage and odor. No other information was documented on the form. Review of Resident #4's Wound Care physician progress notes [REDACTED]. Listed under plan Cleanse wound with saline or wound cleanser, apply [MEDICATION NAME], [MED], [MED] and cover with dry dressing daily and as needed. Follow pressure ulcer prevention policy/ protocol offload heels per facility policy/protocol. Review of Resident #4's TAR reflected an entry dated 08/24/2019 Please clean right foot heel with normal saline, pat dry, apply calcium alginate and cover with dry dressing one time daily for wound care infection. The entry was signed as completed on 08/24/2019 to 08/26/2019. Further review reflected an entry dated 08/29/2019 Cleanse right foot heel with normal saline, pat dry and apply [MEDICATION NAME], [MED], and calcium alginate, cover with dry dressing. Change daily and as needed. The entry was signed as completed on 08/29/2019 and 08/30/2019. Further review of Resident #4's TAR reflected no treatment done from 08/21/2019 to 08/24/2019 or 0[DATE] and 08/28/2019. Review of Resident #4's Medical Record reflected no weekly skin assessments or wound assessments. Observation on 08/30/2019 at 9:30 AM reveled Resident # 4 up in wheelchair (no pressure relief cushion was noted in wheelchair) Resident #4 right heel was on the floor with a dressing on. Observation of Resident #4's bed reveled a regular foam mattress. Observation/ Interview on 08/30/2019 at 9:55 AM revealed LVN B in Resident #4's room to provide wound care. LVN B removed dressing from Resident #4's left foot to reveal an infected amputation wound, using the same gloves LVN B then removed dressing from Resident #4's right foot to reveal an unstageable pressure ulcer to the back side of his heel approximately 4 cm by 3 cm. The wound bed was 100% slough the pressure ulcer had purulent drainage, the wound edges were red and macerated. In an interview on 08/30/2019 at 10:10 AM Resident #4's NP stated Resident #4 was admitted with his right heel pressure ulcer and she assessed the wound when he was admitted . Observation/ Interview on 08/30/2019 at 10:30 AM Resident #4's NP assessed Resident #4's right heel pressure ulcer and stated the pressure ulcer was much worse since she saw it last. Resident #4's NP stated she ordered a wound care consult when he was admitted . Resident #4's NP stated the facility did not notify her of the decline. Resident #4's NP stated she would get a culture of the pressure ulcer. Resident #4's NP stated she consults the wound care doctor and the nurses should follow his orders. In an interview on 08/30/2019 at 11:00 AM LVN B stated she felt Resident #4 needed a different wheelchair, so they could elevate his legs. LVN B stated Resident #4 had a heel floating pillow the CNA's were supposed to use when he is in bed. LVN B stated she did not know what treatment the nurses were doing when he first came into the facility. LVN B stated the wound care doctor saw him on 08/26/2019 and wrote new orders. D) Review of Resident #5's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 was assessed to have a BI[CONDITION] score of zero (0) indicating severe cognitive impairment. Resident #5 needed extensive assistance of two staff for ADLs. Resident #5 was frequently incontinent of bladder. Resident #5 was assessed to have risk for pressure ulcers and was assessed to not have pressure ulcers. She had [MEDICAL CONDITION] and Moisture Associated Skin Damage. Resident #5 was to have a pressure reducing device for her bed and the application of ointments and nonsurgical dressings. Review of Resident #5's Comprehensive Care Plan reflected a focus area with the start date of 10/20/2016 and revised on 6/17/2019 for at risk for skin breakdown due to frequent incontinence of bladder and using the wheelchair as primary mode of locomotion. Resident #5's Comprehensive Care Plan reflected a hand-written plan dated 08/01/2019 for her left heel unstageable pressure ulcer and right heel Stage III pressure ulcer. Staff were to perform weekly skin assessments and consult the MD as needed. Another Care Plan for the left and right heel ulcers dated 08/29/2019 reflected staff needed to assure the protective devices were applied to affected areas and to monitor and document daily the wound size, depth, granulation, necrosis and notify MD and family as needed. Observation of Resident #5's feet on 08/30/2019 at 9:39 AM revealed LVN C removed the dressing on her left heel and she had a pressure ulcer to the inner side of her heel. The pressure ulcer measured approximately 2 cm x 2 cm with 40% slough and [AGE]% granulation tissue in the wound bed. The skin around the pressure ulcer was white and slightly wet-emancipated-to the inner ankle side and a yellow color-calloused-around the rest of the pressure ulcer. The right heel had an approximately 2 cm x 2 cm unstageable pressure ulcer to the outer side of the back of the heel. The pressure ulcer wound bed was covered in a yellow slough with three red dots at 11 o'clock, 3 o'clock and 8 o'clock. The skin on the edge of the pressure ulcer was white and wet-emancipated. The skin also had a redness in color about 3 cm in diameter around the pressure ulcer. LVN C then noted an area to the sole of her right foot with open areas. It appeared to be Moisture Associated Skin Damage from the sock and walking boot she wore on this foot due to a broken ankle. This boot was odorous and had a thick, stiff sole and padding up the sides and back. The outer cover was hard plastic. Resident #5 had a regular mattress on her low bed. LVN C provided wound care and redressed the wounds separately. She placed an approximately 4 cm x 4 cm square piece of collagen and calcium alginate on the pressure ulcers, which overlapped the pressure ulcers edges, then covered each with a bandage. She also cleaned and bandaged the area to the sole of Resident #5's right foot until she could notify the Doctor. LVN C stated she provided the treatments to Resident #5 yesterday (08/29/2019) and the area to the bottom of her foot was not present. Resident #5 had no protective boot on her left foot. In an interview on 08/30/2019 at 11:25 am NP stated Resident #5 had pressure ulcers to her bilateral heels and the area to the bottom of her foot was found yesterday (08/29/2019) but she was just made aware of the area today (08/30/2019). She stated she expected the staff to assess her right foot daily since it was in a boot. She also expected the staff to protect her left foot with a protective boot, so the pressure ulcer would not worsen. Record review of the computer records for Resident #5 reflected the assessments tab pulled up the Skilled Charting and skin assessments dated 08/07/2019, 08/20/2019, and 0[DATE]. On 08/07/2019 the skin assessment reflected a pressure ulcer to the right heel measured 4.5 cm x 4.5 cm unstageable and a stage II pressure ulcer to the right outer ankle measured 1.2 cm x 0.5 cm x 0.01 cm. On 08/20/2019 the skin assessment had no measurements and only reflected in Notes: SKIN IS WARM and dry. Continues with wound care treatment to bilateral feet. On 0[DATE] the skin assessment again only had Notes: skin is warm and dry. Continues with treatment to R (right) foot heel and left foot lateral heel. Noted with redness to right groin. MD notified for observed redness to area and asked for antifungal cream. Review of the MD Progress Notes for Resident #5 dated 08/12/2019 reflected she had three diabetic ulcers. The Notes reflected the left and right heels were 1 cm x 1 cm x 0.2 cm, had moderate drainage, granulation tissue in the wound bed, and the skin around the wound was fragile. The right lateral ankle measured 0.8 cm x 0.5 cm x 0.1 cm, had moderate drainage, granulation tissue, and the skin around the ulcer was fragile. All the ulcers were failing to improve as expected. The orders were to place the collagen and calcium alginate in the wound bed after cleansing with saline or wound cleanser daily and as needed, then cover with a dry dressing. The Notes also reflected to follow the policy/protocol for the facility pressure ulcer prevention and offload the heels. Review of the MD Progress Notes for Resident #5 dated 08/19/2019 reflected the left and right heels and right lateral ankle wounds were diabetic ulcers. The Notes reflected the left and right heels measured 1 cm x 1 cm x 0.2 cm. The right lateral ankle measured 0.5 cm x 0.5 cm x 0.1 cm. The Notes reflected the treatment remained the same. Review of the Weekly Wound Tracking Worksheet for Residents with wounds dated 08/12/2019 reflected Resident #5 had three wounds: left and right heels had in-house diabetic ulcers, not staged, with granulation tissue and measured 1 cm x 1 cm. The right lateral foot was the same but measured 0.8 cm x 1 cm. Review of the Weekly Wound Tracking Worksheet for Residents with wounds dated 08/19/2019 reflected Resident #5 had three wounds: left and right heels had diabetic ulcers, not staged, with slough and some serous light drainage, and measured 1 cm x 1 cm. The right lateral foot was the same but measured 0.5 cm x 0.5 cm. Review of the Weekly Wound Tracking Worksheet for Residents with Wounds dated 08/26/2019 reflected Resident #5 had three wounds: left and right heels had in-house diabetic ulcers, not staged, with granulation tissue, and measured 1 cm x 1 cm x 0.2 cm. The right lateral foot was healed. In an interview on 08/30/2019 LVN D stated he was not aware of Resident #5's pressure ulcers. LVN D was assigned to Resident #5. In an interview on 08/30/2019 at 5:31 PM LVN C stated she did not see Resident #5's open area to the sole of her right foot yesterday (08/29/2019) when she performed the treatments to her right and left feet. Observation on 08/30/2019 at 6:50 PM revealed Resident #5 was wearing a heel protector on the left foot and the same walking boot on her right foot. She was smiling and excited about her new heel protector. Observation on 08/30/2019 at 8:55 PM revealed Resident #5's skin assessment with RN A. Resident #5 had a stage II pressure ulcer to her left upper buttock. RN A did not measure the area with the surveyor present. Review of the Skin Condition assessment for Resident #5 dated 08/30/2019 reflected the area to her left upper buttock measured 1 cm x 0.2 cm with a pink center. Observation on 08/31/2019 at 11:44 AM revealed Resident #5's bed did not have an air mattress. In an interview on 08/31/2019 at 11:45 PM RN Z stated she was not aware Resident #5 needed an air mattress. In an interview on 08/31/2019 at 11:46 AM VP stated Resident #5 's air mattress was ordered and would not be delivered until after 09/02/2019 (Labor Day Holiday). In an interview on 08/30/2019 at 4:00 PM the Medical Director (MD) stated he had been the Medical Director for the facility for seven (7) years and has had residents that never even went to the hospital. The MD stated That place disappoints me. I do not like the new administrator I do not think she is doing a good job. He stated now the facility is bad and the residents deserve better. The MD stated he talked with corporate and changes will be made. The MD stated there was always seemed to be somebody at the facility that cared but it seemed like there wasn't now. In an interview on 08/30/2019 at 11:30 AM the Administrator stated she was still in her window of correction from the survey dated 08/09/2019 and the staff were working on correcting the issues for wounds. In an interview on 08/30/2019 at 5:45 PM the facility's Corporate VP stated This is disgusting, and I hold the Administrator responsible. She stated she would terminiate the Administrator today. Review of the website Woundsource.com reflected The goal of treatment for [REDACTED]. The goal of properly unloading pressure from the area still applies. At these pressure ulc

Based on observation, interview and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for four (4) of four (4) Residents (Residents #2, #3, #4, and #5) regarding the facility's pressure ulcer prevention and treatment system. The Administrator failed to supervise and monitor the Pressure Ulcer Prevention and Treatment System for the facility since the facility currently did not have a DON to supervise, train, or monitor the staff providing care of residents with pressure ulcers for Residents #2, #3, #4, or #5. These failures resulted in an Immediate Jeopardy (IJ) situation on 08/30/2019. While the IJ was removed on 08/31/2019, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing worsening pressure ulcers, [MEDICAL CONDITION] (skin infection), [DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain or death. Finding Include: A) Review of Resident #2's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #2 was assessed to have a Brief Interview of Mental Status (BI[CONDITION]) score of five (5) indicating severe cognitive impairment. Resident #2 was assessed to require limited assistance with ambulation and was assessed to ambulate with a walker. Resident #2 was assessed to be incontinent of bowel and bladder, was assessed to be at risk for developing pressure ulcers and was assessed to not have pressure ulcers. Review of Resident #2's Comprehensive Care reflected a focus area dated 06/11/2019 Resident #2 is a risk for skin breakdown due to urinary/ bowel incontinence, medication use. Listed under interventions, administer medication/treatment as ordered, observing for adverse changes and or signs and symptoms of infection. Notify physician as needed. Assist with incontinent needs. Complete skin assessments weekly and PRN (as needed). Review of Resident #2's Weekly Skin Assessments reflected a skin assessment was performed on 08/16/2019. No skin issues were assessed. Review of Resident #2's Medical Record reflected no weekly skin assessments done from 08/16/2019 to 08/25/2019. Review of Resident #2's New Pressure assessment dated [DATE] reflected Resident #2 was assessed to have a 4 cm x 2 cm x 0.1 cm depth open area to sacrum (2 side by side). No drainage noted, wound bed pink and red, wound edges intact. No complaints of pain at this time. Review of Resident #2's Wound Care physician progress notes [REDACTED].#2 had Sacrum and Left buttock Stage III pressure ulcer for some weeks with moderate pain and discomfort . Wound #1 was assessed to be on her sacrum measuring 2 cm x 2 cm with 0.2 cm depth with moderate serous exudate. Wound #2 to left buttock was assessed to measure 2 cm x 2 cm with 0.2 cm depth with moderate serous exudate. Orders listed on the assessment Clean wound with saline or wound cleanser, apply [MEDICATION NAME], [MED], [MED] to wound bed and cover with dry dressing. Review of the website: www.[MEDICATION NAME] [MED].com reflected [MED] Ointment is an FDA-approved prescription medicine that removes dead tissue from wounds, so they can start to heal. Proper wound care management is important to help remove nonliving tissue from your wound properly. Review of the website: www.drugs.com [MEDICATION NAME] is a wide spectrum antibiotic that provides highly effective topical treatment in primary and secondary bacterial infections of the skin. Review of Resident #2's Wound Assessment signed by RN A dated 08/26/2019 reflected Resident #2 had two (2) open areas to buttock. The assessment did not include description of area, measurements or location. Review of Resident #2's Treatment Administration Record (TAR) dated August 2019 reflected the Wound Care physician's orders [REDACTED]. The TAR indicated this treatment was performed until 08/29/2019. On 08/29/2019 the new treatment documented on the TAR was to cleanse coccyx/ sacrum with normal saline, pat dry, apply calcium and dry dressing every day. Observation/ Interview on 08/30/2019 at 9:10 AM revealed Resident #2 in her recliner in her room, restless and scooting down saying, help me, help me. No pressure relief cushion was noted in the recliner. When resident was asked if she was ok she only stated help me. Observation of Resident #2's bed revealed a regular foam mattress. Observation/ Interview on 08/30/2019 at 9:12 AM revealed LVN B in Resident #2's room to provide wound care. LVN B stood Resident #2 up and pulled down her pants and brief to reveal two (2) Stage III pressure ulcers to her coccyx/ sacral area. Resident #2's pressure ulcers had no dressing in place and her brief was saturated with urine. Resident #2's Stage III pressure ulcer to her left upper buttock was approximately 2 cm by 2.5 cm with >0.2cm depth with yellow granulation tissue to wound bed, the wound edges were beveled and red. The Stage III pressure ulcer to her right upper buttock was approximately 3 cm by 2 cm with >0.2 depth with yellow granulation tissue to wound bed with red beveled edges. LVN B gathered her supplies and placed them on the residents overbed table on a paper towel without cleaning the table. LVN B stated, I know I am supposed to use wax paper for the table, but the administrator told me it was not in the budget. LVN B stated she asked the Administrator all the time for supplies, but the Administrator would never get them for the nurses. With Resident #2 standing LVN B cleaned across both pressure ulcers using the same saline soaked gauze. LVN B then patted over both pressure ulcers using the same dry gauze. LVN B then applied calcium alginate to both wound beds and applied a dry dressing. LVN B stated she did Resident #2's treatment the previous day but was not aware the dressing was off because nobody told her. When LVN B was asked if Resident #2 was ambulatory she stated yes, that she walked all day. LVN B stated Resident #2 should not even have a pressure ulcer. LVN B stated It is sad, I have never seen this place this bad. There is no DON or anything. LVN B stated the staff are not taking care of the residents and they have agency staff that do not care. LVN B stated the administrator told her and all the nurses that they are not allowed to measure the wounds that only the wound care doctor could and that was why the DON left. LVN B stated the administrator would not let the DON do her job. LVN B stated the Administrator fired the Wound Care Doctor the other day after he saw the residents and some new company was coming in. LVN B stated she didn't think anyone was doing the weekly skin assessments. LVN B stated she found Resident #2's pressure ulcers on the 08/25/2019 when a CNA came and told her about it. LVN B stated the Wound Care Doctor came to the facility and saw the pressure ulcers on 08/26/2019 and ordered [MED] and [MEDICATION NAME] but she did not feel like that was an appropriate order because the pressure ulcers were not Stage III pressure ulcers, so she got the order changed. LVN B stated she never used the [MED] and [MEDICATION NAME] on Resident #2's pressure ulcers. When LVN B was asked if Resident #2's pressure ulcers were improving she stated no they were getting worse. In an interview on 08/30/2019 at 10:10 AM Resident #2's Nurse Practitioner (NP) stated Resident #2 should not have a pressure ulcer. She stated, it makes no sense because she is ambulatory. Resident #2's NP stated she did see Resident #2's pressure ulcers on Monday. Resident #2's NP stated care is not being provided. For someone like her to get a pressure ulcer, when she eats good, it just does not make since. Resident #2's NP stated Resident #2 should have supportive surfaces to promote healing and weekly skin checks should be performed to catch pressure ulcers when they are Stage I's not Stage III's. Resident #2's NP stated she consults the wound care doctor and the nurses should follow his orders. Observation/ Interview on 08/30/2019 at 10:30 AM Resident #2's NP assessed Resident #2's pressure ulcers with Surveyor and stated Resident #2's pressure ulcers were worse since she saw them on Monday. Resident #2's NP stated no one from the facility ever calls her when wounds have a decline. In an interview on 08/30/2019 at 11:00 AM CNA E (who was assigned to Resident #2) stated Resident #2 was ambulatory and required incontinent care. CNA E stated she doesn't know how these residents are getting pressure ulcers when they are ambulatory. In an interview on 08/30/2019 at 11:41 AM the DON stated she resigned from the facility on 08/28/2019. The DON stated Resident #2's pressure ulcers were shear and they were not pressure ulcers and the doctor ordered [MED] and [MEDICATION NAME] and now the wounds are looking worse because he is having them put [MED] on the wounds. She stated the Administrator had an in-service and stated that no RN or LVN could measure or document wound sizes in the chart that only the Wound Care Doctor can do that. The DON stated the Administrator also did not want anything written or done without her approval. The DON stated she was not allowed to keep normal books like a DON does including skin books. The DON stated the Administrator would snatch them from her hands and take it to her office. Observation on 08/30/2019 at 2:00 PM revealed Resident #2 ambulatory around her room on her own. In an interview on 08/30/2019 at 4:50 PM CNA F assigned to Resident #2 stated Resident #2 was incontinent of bladder a lot. CNA F stated Resident #2 will sleep in her chair sometimes and stated, maybe that's how she got the pressure ulcer. CNA F was asked if the facility had low air loss mattresses or pressure relief cushions for the residents, CNA F stated she did not want to say. B) Review of Resident #3's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3's Skin Observation Tool dated 08/08/2019 reflected she had a scab/sores red area to right buttock. Under the note section was documented skin is warm dry and intact. No other information was documented. Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3 was assessed to have a BI[CONDITION] score of zero indicating severe cognitive impairment. Resident #3 was assessed to ambulate with supervision and require limited assist with toilet use. Resident #3 was assessed to use a walker for ambulation. Resident # 3 was assessed to be occasionally incontinent of bladder and frequently incontinent of bowel. Resident #3 was assessed to be at risk for pressure ulcers and was assessed to not have pressure ulcers. Review of Resident #3's Comprehensive Care Plan (no date) reflected her care plan did not address pressure ulcers or pressure ulcer prevention. Review of Resident #3's Medical Record reflected no weekly skin assessments were performed. Review of Resident #3's Nurse Progress notes reflected an entry dated 08/13/2019 .Resident has 6 fading/healing finger print bruises to lower right buttocks. There are 2 small finger print healing scratches to lower left buttock. No open [MEDICAL CONDITION] are noted to the coccyx, bilateral ischial tuberosities or at bilateral trochanters . No other skin assessment entries were noted. Review of Resident #3's Nurse Progress note dated 08/28/2019 reflected Open area to right buttock x 2, #1 1 cm x 1 cm and #2 0.5 cm by 1 cm. Wound bed pink, peri wound intact, no drainage or odor. Patient denied pain upon assessment. Area cleansed with normal saline, applied [MEDICATION NAME], physician, DON and ADON made aware for possible wound consult. Review of Resident #3's Physician order [REDACTED]. Review of Resident #3's TAR dated 08/2019 reflected Resident #3's treatment to cleanse open areas to right buttock with normal saline, pat dry and apply [MEDICATION NAME] dressing was signed as being provided only once on 08/28/2019. Observation/ Interview on 08/30/2019 at 9:30 AM revealed Resident #3 up in activity room on the locked unit ambulating with a cane. Resident #3 ambulated to her room with LVN B for wound care. LVN B pulled Resident #3's pants and brief down to reveal two Stage III pressure ulcers to her right buttock. No dressing was in place. Resident #3's right buttock (#1) Stage III pressure ulcer was approximately 2 cm by 2.5 cm with 0.2 cm depth, the wound edges were beveled, wound bed with area of yellowish slough from eight o'clock to 2 o'clock, right buttock (#2) Stage III pressure ulcer was approximately 1 cm by 1cm with >0.2 cm depth, the wound edges were beveled, wound bed pink with pen head size area of slough in the middle of the wound bed. The peri wound around both pressure ulcers was macerated. LVN B placed her supplies on Resident #3's bedside table on a paper towel without cleaning the table. LVN B cleansed across both pressure ulcers from the outside inward with the same saline soaked gauze. LVN B then padded over both pressure ulcers then applied a [MEDICATION NAME] dressing over both pressure ulcers. (LVN B did not perform hand hygiene or change her gloves throughout the procedure.) LVN B stated there was no reason Resident #3 to have a pressure ulcer since she goes to the bathroom most of the time and walks around. LVN B stated sometimes there were only four CNA's for the whole building and they were not changing these residents enough. LVN B stated Resident #3 was not seen by the wound care doctor when he came. Further observation revealed Resident #3's bed used a regular foam mattress. In an interview on 08/30/2019 at 3:25 PM CNA G stated she was assigned to Resident #3. When CNA G was asked about Resident #3's pressure ulcer she stated she was not aware Resident #3 had a pressure ulcer and stated How? She ambulates. In an interview on 08/30/2019 at 4:00 PM Resident #3's Physician (and Facility Medical Director) stated he was not aware Resident #3 had pressure ulcers. Resident #3's Physician stated Resident #3 ambulates and is a fall risk but should not have pressure ulcers. When Resident #3's Physician was informed the pressure, ulcers were found at a Stage III he stated, That place disappoints me. Resident #3's Physician stated the nurses should notify him of changes in resident conditions. When asked about the treatment for [REDACTED].#3's Physician stated he did not know where they got that order since he did not even know about the pressure ulcers until the surveyor informed him. C) Review of Resident #4's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses; Malnutrition, Debility, Dementia, [MEDICAL CONDITION] and Diabetes Mellitus. Review of Resident #4's MDS assessments reflected an entry assessment was done on 08/21/2019. Review of Resident #4's Baseline Care plan reflected a focus area dated 08/21/2019 impaired skin integrity related to admitted with wounds Listed under interventions was treatment as ordered, skin assessment weekly, remind resident to make frequent position changes. Further review reflected a focus area dated 08/23/2019 Resident has infection of the left heel and right foot surgical wound where toes were amputated. [MEDICATION NAME] 100 mg per mouth twice a day times 10 days. No interventions for pressure relieving devices or pressure ulcer care were listed on the care plan. (Resident #4's pressure ulcer was to his right heel and the surgical wound was on his left foot.) Review of Resident #4's Admit/ Readmit Screening dated 08/21/2019 reflected Right foot heel has wound, 2 cm wound with [MEDICAL CONDITION] drainage and odor. No other information was documented on the form. Review of Resident #4's Wound Care physician progress notes [REDACTED]. Listed under plan Cleanse wound with saline or wound cleanser, apply [MEDICATION NAME], [MED], [MED] and cover with dry dressing daily and as needed. Follow pressure ulcer prevention policy/ protocol offload heels per facility policy/protocol. Review of Resident #4's TAR reflected an entry dated 08/24/2019 Please clean right foot heel with normal saline, pat dry, apply calcium alginate and cover with dry dressing one time daily for wound care infection. The entry was signed as completed on 08/24/2019 to 08/26/2019. Further review reflected an entry dated 08/29/2019 Cleanse right foot heel with normal saline, pat dry and apply [MEDICATION NAME], [MED], and calcium alginate, cover with dry dressing. Change daily and as needed. The entry was signed as completed on 08/29/2019 and 08/30/2019. Further review of Resident #4's TAR reflected no treatment done from 08/21/2019 to 08/24/2019 or 0[DATE] and 08/28/2019. Review of Resident #4's Medical Record reflected no weekly skin assessments or wound assessments. Observation on 08/30/2019 at 9:30 AM reveled Resident # 4 up in wheelchair (no pressure relief cushion was noted in wheelchair) Resident #4 right heel was on the floor with a dressing on. Observation of Resident #4's bed reveled a regular foam mattress. Observation/ Interview on 08/30/2019 at 9:55 AM revealed LVN B in Resident #4's room to provide wound care. LVN B removed dressing from Resident #4's left foot to reveal an infected amputation wound, using the same gloves LVN B then removed dressing from Resident #4's right foot to reveal an unstageable pressure ulcer to the back side of his heel approximately 4 cm by 3 cm. The wound bed was 100% slough the pressure ulcer had purulent drainage, the wound edges were red and macerated. In an interview on 08/30/2019 at 10:10 AM Resident #4's NP stated Resident #4 was admitted with his right heel pressure ulcer and she assessed the wound when he was admitted . Observation/ Interview on 08/30/2019 at 10:30 AM Resident #4's NP assessed Resident #4's right heel pressure ulcer and stated the pressure ulcer was much worse since she saw it last. Resident #4's NP stated she ordered a wound care consult when he was admitted . Resident #4's NP stated the facility did not notify her of the decline. Resident #4's NP stated she would get a culture of the pressure ulcer. Resident #4's NP stated she consults the wound care doctor and the nurses should follow his orders. In an interview on 08/30/2019 at 11:00 AM LVN B stated she felt Resident #4 needed a different wheelchair, so they could elevate his legs. LVN B stated Resident #4 had a heel floating pillow the CNA's were supposed to use when he is in bed. LVN B stated she did not know what treatment the nurses were doing when he first came into the facility. LVN B stated the wound care doctor saw him on 08/26/2019 and wrote new orders. D) Review of Resident #5's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 was assessed to have a BI[CONDITION] score of zero (0) indicating severe cognitive impairment. Resident #5 needed extensive assistance of two staff for ADLs. Resident #5 was frequently incontinent of bladder. Resident #5 was assessed to have risk for pressure ulcers and was assessed to not have pressure ulcers. She had [MEDICAL CONDITION] and Moisture Associated Skin Damage. Resident #5 was to have a pressure reducing device for her bed and the application of ointments and nonsurgical dressings. Review of Resident #5's Comprehensive Care Plan reflected a focus area with the start date of 10/20/2016 and revised on 6/17/2019 for at risk for skin breakdown due to frequent incontinence of bladder and using the wheelchair as primary mode of locomotion. Resident #5's Comprehensive Care Plan reflected a hand-written plan dated 08/01/2019 for her left heel unstageable pressure ulcer and right heel Stage III pressure ulcer. Staff were to perform weekly skin assessments and consult the MD as needed. Another Care Plan for the left and right heel ulcers dated 08/29/2019 reflected staff needed to assure the protective devices were applied to affected areas and to monitor and document daily the wound size, depth, granulation, necrosis and notify MD and family as needed. Observation of Resident #5's feet on 08/30/2019 at 9:39 AM revealed LVN C removed the dressing on her left heel and she had a pressure ulcer to the inner side of her heel. The pressure ulcer measured approximately 2 cm x 2 cm with 40% slough and [AGE]% granulation tissue in the wound bed. The skin around the pressure ulcer was white and slightly wet-emancipated-to the inner ankle side and a yellow color-calloused-around the rest of the pressure ulcer. The right heel had an approximately 2 cm x 2 cm unstageable pressure ulcer to the outer side of the back of the heel. The pressure ulcer wound bed was covered in a yellow slough with three red dots at 11 o'clock, 3 o'clock and 8 o'clock. The skin on the edge of the pressure ulcer was white and wet-emancipated. The skin also had a redness in color about 3 cm in diameter around the pressure ulcer. LVN C then noted an area to the sole of her right foot with open areas. It appeared to be Moisture Associated Skin Damage from the sock and walking boot she wore on this foot due to a broken ankle. This boot was odorous and had a thick, stiff sole and padding up the sides and back. The outer cover was hard plastic. Resident #5 had a regular mattress on her low bed. LVN C provided wound care and redressed the wounds separately. She placed an approximately 4 cm x 4 cm square piece of collagen and calcium alginate on the pressure ulcers, which overlapped the pressure ulcers edges, then covered each with a bandage. She also cleaned and bandaged the area to the sole of Resident #5's right foot until she could notify the Doctor. LVN C stated she provided the treatments to Resident #5 yesterday (08/29/2019) and the area to the bottom of her foot was not present. Resident #5 had no protective boot on her left foot. In an interview on 08/30/2019 at 11:25 am NP stated Resident #5 had pressure ulcers to her bilateral heels and the area to the bottom of her foot was found yesterday (08/29/2019) but she was just made aware of the area today (08/30/2019). She stated she expected the staff to assess her right foot daily since it was in a boot. She also expected the staff to protect her left foot with a protective boot, so the pressure ulcer would not worsen. Record review of the computer records for Resident #5 reflected the assessments tab pulled up the Skilled Charting and skin assessments dated 08/07/2019, 08/20/2019, and 0[DATE]. On 08/07/2019 the skin assessment reflected a pressure ulcer to the right heel measured 4.5 cm x 4.5 cm unstageable and a stage II pressure ulcer to the right outer ankle measured 1.2 cm x 0.5 cm x 0.01 cm. On 08/20/2019 the skin assessment had no measurements and only reflected in Notes: SKIN IS WARM and dry. Continues with wound care treatment to bilateral feet. On 0[DATE] the skin assessment again only had Notes: skin is warm and dry. Continues with treatment to R (right) foot heel and left foot lateral heel. Noted with redness to right groin. MD notified for observed redness to area and asked for antifungal cream. Review of the MD Progress Notes for Resident #5 dated 08/12/2019 reflected she had three diabetic ulcers. The Notes reflected the left and right heels were 1 cm x 1 cm x 0.2 cm, had moderate drainage, granulation tissue in the wound bed, and the skin around the wound was fragile. The right lateral ankle measured 0.8 cm x 0.5 cm x 0.1 cm, had moderate drainage, granulation tissue, and the skin around the ulcer was fragile. All the ulcers were failing to improve as expected. The orders were to place the collagen and calcium alginate in the wound bed after cleansing with saline or wound cleanser daily and as needed, then cover with a dry dressing. The Notes also reflected to follow the policy/protocol for the facility pressure ulcer prevention and offload the heels. Review of the MD Progress Notes for Resident #5 dated 08/19/2019 reflected the left and right heels and right lateral ankle wounds were diabetic ulcers. The Notes reflected the left and right heels measured 1 cm x 1 cm x 0.2 cm. The right lateral ankle measured 0.5 cm x 0.5 cm x 0.1 cm. The Notes reflected the treatment remained the same. Review of the Weekly Wound Tracking Worksheet for Residents with wounds dated 08/12/2019 reflected Resident #5 had three wounds: left and right heels had in-house diabetic ulcers, not staged, with granulation tissue and measured 1 cm x 1 cm. The right lateral foot was the same but measured 0.8 cm x 1 cm. Review of the Weekly Wound Tracking Worksheet for Residents with wounds dated 08/19/2019 reflected Resident #5 had three wounds: left and right heels had diabetic ulcers, not staged, with slough and some serous light drainage, and measured 1 cm x 1 cm. The right lateral foot was the same but measured 0.5 cm x 0.5 cm. Review of the Weekly Wound Tracking Worksheet for Residents with Wounds dated 08/26/2019 reflected Resident #5 had three wounds: left and right heels had in-house diabetic ulcers, not staged, with granulation tissue, and measured 1 cm x 1 cm x 0.2 cm. The right lateral foot was healed. In an interview on 08/30/2019 LVN D stated he was not aware of Resident #5's pressure ulcers. LVN D was assigned to Resident #5. In an interview on 08/30/2019 at 5:31 PM LVN C stated she did not see Resident #5's open area to the sole of her right foot yesterday (08/29/2019) when she performed the treatments to her right and left feet. Observation on 08/30/2019 at 6:50 PM revealed Resident #5 was wearing a heel protector on the left foot and the same walking boot on her right foot. She was smiling and excited about her new heel protector. Observation on 08/30/2019 at 8:55 PM revealed Resident #5's skin assessment with RN A. Resident #5 had a stage II pressure ulcer to her left upper buttock. RN A did not measure the area with the surveyor present. Review of the Skin Condition assessment for Resident #5 dated 08/30/2019 reflected the area to her left upper buttock measured 1 cm x 0.2 cm with a pink center. Observation on 08/31/2019 at 11:44 AM revealed Resident #5's bed did not have an air mattress. In an interview on 08/31/2019 at 11:45 PM RN Z stated she was not aware Resident #5 needed an air mattress. In an interview on 08/31/2019 at 11:46 AM VP stated Resident #5 's air mattress was ordered and would not be delivered until after 09/02/2019 (Labor Day Holiday). In an interview on 08/30/2019 at 4:00 PM the Medical Director (MD) stated he had been the Medical Director for the facility for seven (7) years and has had residents that never even went to the hospital. The MD stated That place disappoints me. I do not like the new administrator I do not think she is doing a good job. He stated now the facility is bad and the residents deserve better. The MD stated he talked with corporate and changes will be made. The MD stated there was always seemed to be somebody at the facility that cared but it seemed like there wasn't now. In an interview on 08/30/2019 at 11:30 AM the Administrator stated she was still in her window of correction from the survey dated 08/09/2019 and the staff were working on correcting the issues for wounds. In an interview on 08/30/2019 at 5:45 PM the facility's Corporate VP stated This is disgusting, and I hold the Administrator responsible. She stated she would terminiate the Administrator today. Review of the website Woundsource.com reflected The goal of treatment for [REDACTED]. The goal of properly unloading pressure from the area still applies. At these pressure ulcer stages, more emphasis should be placed on proper nutrition and hydration to support wound healing. If the extent of the pressure ulcer or other factors prohibit it from healing properly, surgery may be necessary to close the wound. The following precautions can help minimize the risk of developing pressure ulcers in at-risk patients and to minimize complications in patients already exhibiting symptoms: Turn patients every two hours. Keep the skin clean and dry. Avoid massaging bony prominences. Provide adequate intake of protein and calories. Maintain current levels of activity, mobility and range of motion. Use positioning devices to prevent prolonged pressure bony prominences. Keep the head of the bed as low as possible to reduce risk of shearing. Keep sheets dry and wrinkle free. Review of the facility's policy Prevention of Pressure Ulcers dated 09/2013 reflected The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors .Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation .Pressure ulcers are often made worse by continual pressure, heat, moisture .Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. The facility should have a system/ procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed .Risk Factor- Moisture .use a moisture barrier .Place resident on a minimum of every 2 hour check and change program .address causes of moisture if possible (e.g., bladder training, scheduled toileting.) .Risk Factor- Friction and shear .provider a sitting support surface .monitor the placement of splints and casts to assure they are not placing friction on the resident's skin . Review of the facility's Policy Pressure Ulcer Treatment dated 10/2010 reflected The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers .Stage III pressure ulcer interventions/ care strategies 1. Protect; 2. Fill dead space including tunnels and undermining; 3. Manage drainage . On 08/30/2019 at 3:00 PM the Administrator, and RN A, were notified the facility had an IJ situation for the above failures. The facility's first Plan of Removal (POR) was submitted by the Administrator on 08/30/2019 at 4:22 PM. The final POR was accepted by the survey team on 08/30/2019 at 8:26 PM. Accepted Plan of Removal: August 30, 2019 Immediate Jeopardy Remediation 1. Residents, #2, #3, #4, and #5, were assessed by nursing staff. Per physician's orders [REDACTED]. MD called and notified of findings on 8-30-19, as well as family being notified. * Resident #2-New MD orders: facility to provide a pressure reducing mattress and a seat

Based on observation, interview and record review, the facility failed to assess and provide treatment in accordance with professional standards of practice and based on the comprehensive person-centered care plan for one (1) of fifteen (15) residents reviewed for quality of care. (Resident #51) The facility failed to routinely assess and treat Resident #51's right ankle surgical incision leading to an infection of her surgical incision. The facility failed to notify Resident #51's physician when Resident #51's right ankle surgical incision showed signs of infection on 07/27/2019 resulting in Resident #51 not receiving treatment for [REDACTED]. These failures could cause pain, and lead to systemic infections causing harm for residents with surgical wounds. Findings include: Review of Resident #51's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #51's 30-day Minimum Date Set ((MDS) dated [DATE] reflected Resident #51 was assessed to have a brief interview for mental status (BIMS) score of four (4) indicating severe cognitive impairment. Resident #51 was assessed to require extensive assistance with activities of daily living (ADLs). Resident #51 was assessed to have risk for pressure ulcers and was assessed to not have pressure ulcers or surgical wounds. Review of Resident #51's Comprehensive Care Plan reflected a focus area dated 7/21/2019 and revised on 08/06/2019 Resident has a skin tear due to fragile skin and lack of safety awareness. She currently has a dry scab to her left knee; a dry scab on her left heel (unstageable pressure ulcer) and surgical wound to her leg. No interventions were listed for her surgical wound care. Further review reflected a Focus area dated 08/01/2019 Resident #51 is on antibiotics and is at risk for adverse reactions. Wound infection right shin. (Resident #51's infected wound was located on her right ankle.) no interventions were listed on the care plan for her wound infection. Review of Resident #51's Consolidated Physician Orders reflected an order dated 07/18/2019 Okay to wash incision with soap and water. Do not soak and Wear boot at all times except for showering every shift for post op instructions until 08/19/2019. Further review reflected an order to cleanse open area to right ankle with normal saline, pat dry, apply calcium alginate, and cover with a dry dressing dated 07/31/2019. Review of Resident #51's Hospital Record dated 06/24/2019 reflected Resident #51 was seen for a Closed fracture of her distal end of the right fibula and tibia. No Hospital or discharge records were provided by the facility for Resident #51's hospital visit for surgery to her right ankle that occurred in July. Review of Resident #51's Nursing progress notes provided by the facility reflected no entries regarding resident going to the hospital for surgery or returning from the hospital from surgery. Review of Resident #51's post-operative visit with her orthopedic surgeon dated 07/18/2019 reflected Incisions healing well. Sutures removed, steri-strips applied. Okay to wash incisions with soap and water .wear boot at all times except for showering. Review of Resident #51's Medical Record reflected no weekly wound assessments. Further review of Resident #51's Medical Record reflected no documentation in Resident #51's nursing progress notes regarding her right ankle surgical incision. Review of Resident #51's Treatment Administration Record (TAR) for (MONTH) 2019 reflected an entry Okay to wash incisions with soap and water. Do not soak. every shift for post op instructions. Documentation on the TAR reflected the treatment was being done. In an interview on 08/07/2019 at 11:00 AM the Director of Nursing (DON) stated, when asked for a list of residents with pressure ulcers, she the facility did not have one. The DON stated she had been at the facility for two weeks and had not done an assessment of the resident's wounds yet. The DON further stated the facility used to have a wound care physician, but he no longer came to the facility. When asked when and why he stopped coming the DON stated she did not know. The DON stated she has been working with the nurses to get them to do the assessments. Observation and Interview on 08/07/2019 at 2:30 PM revealed LVN D in Resident #51's room to provide wound care. LVN D removed Resident #51's right foot from her walking boot splint and removed a dressing from Resident #51's right ankle. The dressing was covered with brownish red drainage and the drainage was noted on the padding of Resident #51's walking boot. LVN D stated Resident 51 was on antibiotics and they changed the antibiotic yesterday based on culture report. LVN D cleaned Resident #51's right ankle surgical wound with normal saline applied a small piece of calcium alginate and a [MEDICATION NAME] dressing. LVN D then treated Resident #51's right heel pressure ulcer and placed Resident #51's right foot back into her walking boot without cleaning the padding. In an interview on 08/08/2019 at 12:19 PM Resident #51's Nurse Practitioner (NP) stated she was at the facility on 08/07/2019 and assessed Resident #51's right ankle surgical wound and changed the antibiotic. Resident #51 had a fall last month and had a tib fib fracture that required surgery she stated on 07/18/2019 she was seen by the orthopedic doctor and the incision was doing well on her ankle. Resident #51's NP stated the nurses faxed her on 07/27/2019 . Resident #51's NP stated the fax stated the nurses were not washing Resident #51's right ankle surgical wound because they were confused about the order and the wound had a foul odor and drainage. Resident #51's NP stated she did not get the fax sent on 07/27/2019 until 07/31/2019 because the 27th was a Saturday. Resident #51's NP stated she saw the wound on 07/31/2018 ordered a culture, she stated it was infected with [MEDICATION NAME] and had foul-smelling drainage. Resident #51's NP stated [MEDICATION NAME] is found in feces, she stated that just goes to show you they were not cleaning it. Resident #51 NP stated her main concern was the nurses were not doing wound care. She stated the wound was in good condition on the 18th then got bad from them not cleaning it every day she stated the nurses are not assessing since they fired the wound care doctor for monetary reasons. Resident #51's NP stated the nurses should not put Resident #51's foot back in walking boot if walking boot is dirty they should wash the boot. Resident #51's NP stated if the wound is draining through the dressing they need to notify the doctor and change the dressing order. Resident #51's NP stated they should not fax information that the nurses should call and if they had called there is someone on call and the treatment could have started for Resident #51's right ankle wound infection on the 27th. In an interview on 08/08/2019 at 3:35 PM LVN C stated she was new to the facility and had only been working there a short time. LVN C stated she worked on the 07/27/2019 she stated she found issues with Resident #51's ankle not being washed, and it was draining, she stated she faxed the doctor. LVN C stated the boot smelled really bad she stated she tried to clean it in the sink. LVN C stated the nurses were not cleaning the wound because they were confused about the order. LVN C stated she did not call the doctor she faxed the notification and wrapped up the wound. LVN C stated she was not aware there were on call doctors she figured they could handle it on Monday. LVN C stated did not put the information in Resident #51's nurses note and stated she did not do a wound assessment. In an interview on 08/08/2019 at 4:00 PM the DON stated she expected the nurses to contact the physician's right away if there are changes in residents' conditions. The DON stated she expected the nurses to follow infection control procedures and follow doctors' orders. In an interview on 08/09/2019 at 9:46 AM LVN D stated she should not have put Resident #51's right foot back into her dirty walking boot without cleaning it. LVN D stated Resident #51's right ankle wound had a lot of drainage and she would benefit from a more absorbent dressing. Review of the facility's policy Wound Care dated (MONTH) 2010 reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 1. Verify that there is a physician's order for this procedure. 2. Review the residents care plan to assess for any special needs of the resident .Documentation .6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound Review of the facility's policy Infection Control Guidelines for all nursing procedures dated (MONTH) 2010 reflected To provide guidelines for general infection control while caring for residents .Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions, and excretions regardless of the whether or not they contain visible blood, non-intact skin, and/ or mucous membranes .

Based on interview and record review the facility failed to ensure they developed and implemented a person-centered care plan that described services that would maintain the resident's highest practicable physical well being for one of four residents reviewed for care plans (Resident #1). The facility failed to assess Resident #1's risk for skin tears during transfers and revise the care plan after; a. Resident #1 received a skin tear on 5/13/19 during a transfer, b. the family filed a grievance on 5/15/19 regarding skin tears during staff care and c. attended the care plan meeting to address the injuries during staff care on 05/21/2019. Resident #1 received a third skin tear during a one person transfer on 06/27/2019 that resulted in a large hematoma (due to anticoagulation therapy) that split her fragile skin open on her leg. This failure led to pain, and a hospital stay with evacuation of the hematoma. Findings included: Review of Resident #1's Face Sheet reflected she was an [AGE] year old female initially admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS 06/25/2019 reflected she had a BIMS score of 12 which indicated moderate cognitive impairment. She had no behaviors. Resident #1 required extensive assistance of one person for transferring, hygiene, and dressing. Resident #1 received anticoagulants seven days a week. Resident #1 was on physical therapy from 04/29/2019 to 06/24/2019 three times a day. Review of Resident #1's Care Plan dated 04/10/2019 reflected Resident requires extensive assistance of one staff member for transfers. An additional care plan dated 05/13/2019 for her skin tear to her right leg had a goal of Will have no skin tears during this quarter and an intervention of applying new Steri-Strips, ensure skin is clean and dry, and facility protocol for wound treatment. There was no intervention to prevent future skin tears (such as two person transfers). Review of faxes in Resident #1's chart reflected; 05/13/19 - Resident received a skin tear during transfer from recliner to bed. Will monitor until healed. 05/24/2019 - Resident #1 acquired a skin tear to her right ankle area during ADL care will continue to monitor. Review of Resident #1's Family Grievance form dated 05/15/2019 reflected; Brother concerned that patient did not receive skin tear on her own, wants to know how it happened, wants to know that staff are aware of her sensitive skin, and what will be done to prevent future skin tears. Signed (Social Worker). Follow up: Family contacted to schedule care plan meeting to discuss their concerns and to develop plan of care scheduled for 5/21/19. Resolution: A care plan meeting will be held 05/21/2019. Review of Resident #1's Care Plan Conference Summary Sheet dated 05/21/19 reflected: Risk and consequences: falls, skin tear. Plan of care Nursing: Wound care. The MDS Coordinator, SW, AD, BOM and another staff member whose signature was not readable signed the document along with Resident #1 and her two brothers. The Summary Sheet did not reflect there would be any changes to prevent future injuries during staff care. Review of Resident #1's Progress Notes reflected: -06/25/2019 documented by the SW; Resident (#1) is alert and oriented to person but is disoriented to time and place. She has long and short term memory deficits and impaired decision-making abilities that require her to need cues and supervision. No hallucinations, delusions, or behavior issues. -06/27/2019 at 9:31 AM; As resident was being transferred from bed to wheelchair resident bumped her left leg (shin area) and sustained a hematoma and swelling to area. Dr. made aware. [MEDICATION NAME] given as ordered. Dr. stated give extra dose due to her pain level of 10 of 10. -6/27/19 at 12:57 PM Will discontinue x-ray order due to resident being sent out to ER for bleeding profusely. MD aware. In an interview on 07/02/2019 at 10:05 AM Resident #1 stated while she was being transferred to the bed a screw hit her leg and ripped her leg open. They got too close to the bed and ripped a hole in my leg. This is the second time. This one is much more severe. I don't remember exactly how it happened the first time. It didn't seem to be as severe. It was on the right leg the first time. Observation on 07/02/2019 at 1:00 PM revealed Resident #1's bed was nearly new and there were no sharp edges. There were round smooth joint covers where the joints on the bed allowed the head or lower part of the bed to be raised. In an interview on 07/02/2019 at 1:28 PM CNA [NAME] stated I have transferred (Resident #1). There were two of us. She has a hard time pivoting her feet. Normally an aide will ask another aide to help out. In an interview on 0702/2019 at 1:53 PM CNA F stated, When I transferred her, she was two person and a gait belt. I have noticed she had a dressing on her leg. Her condition made me think (she required) a gait belt and two people (for transfers). She can straighten her legs and she can plant her feet. The thing I saw was she would pull back when you were transferring her. Every day that I have had her (assigned to her unit), she has been in her recliner when I get here at 2:00 PM so I would get her from the recliner to the chair to go eat, then to the bed. Always two person transfer for Resident #1. She bore weight, but the pushing back was the problem. It is hard to transfer her with one person because of the pushing. In an interview on 07/02/2019 at 5:10 PM CNA D stated Resident #1 was sitting on the side of the bed and I went to transfer her (one person transfer), and her leg got kicked out and hit on the bed because she pulls back when I lift her. She stiffens up when you transfer her. That has happened before. She has had a skin tear already. It wasn't that big though. No, I don't think I saw her leg hit the bed. She hollered out and I looked at it and thought 'Thank God' it wasn't bleeding. Yes, it made some little holes in her leg. She stiffens up and pulls back on you. She stands fine and you can take her to the bathroom but then she got a potty chair. She wasn't stiffening up when she first came. She started that quite a while ago. She bears weight. In an interview on 7/02/19 at 2:30 PM the facility RN stated she had observed Resident #1's skin tear (that developed a hematoma) on the date it occurred: 06/27/2019. She stated at first it was a small skin tear with an approximately three by four inch hematoma, then over a short time the hematoma began to enlarge. After a couple hours the hematoma continued to enlarge, and the skin split approximately two to three inches and the blood begin escaping from the hematoma. She stated due to Resident #1's anticoagulant therapy the facility could not stop the bleeding and transferred her to the hospital. Observation of a facility photograph taken just after Resident #1's skin tear occurred reflected there were three small circular openings and an approximately three to four inch flat, bruised area to Resident #1's leg when the injury first occurred. Observation of a hospital photograph taken on 06/27/2019 after Resident #1's hematoma (which had continued to enlarge after she was sent to the hospital) was evacuated at the hospital, reflected her leg was opened approximately more than six inches to remove the blood clot. In an interview on 07/02/2019 at 10:20 AM Resident #1's family member stated The MD stated my sister's skin is too fragile to try to suture the opening and they chose to leave it open to heal. In an interview on 07/02.2019 at 4:40 PM the MDS Coordinator stated Resident #1's care plan was not updated after the skin tear on 05/13/2019 or after the skin tear on 05/24/2019. She stated there were no new interventions put in place after the two skin tears (which occurred during staff care). In an interview on 07/02/2019 at 5:05 PM the facility RN stated, When the son came to the facility after the skin tear/hematoma (that occurred on 06/27/2019) I told him we might could get the spongy sleeve protectors to put on her legs. I also told him we could get a two person transfer to watch her legs (during transfers) to make sure she wasn't bumping into things. In an interview on 07/02/2019 at 5:36 PM the Administrator stated, The staff should have communicated to the nurse that Resident #1 was stiffening with transfers. That part failed. Our care plan should have been updated to include measures to prevent further skin tears for Resident #1. Review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (MONTH) (YEAR) For Use Effective (MONTH) 1, (YEAR) reflected: As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident's unique path toward achieving or maintaining his or her highest practical level of well-being. Persons generally enter a nursing home because of problems with functional status caused by physical deterioration, cognitive decline, the onset or exacerbation of an acute illness or condition, or other related factors. Sometimes, the individual's ability to manage independently has been limited to the extent that skilled nursing, medical treatment, and/or rehabilitation is needed for the resident to maintain and/or restore function or to live safely from day to day. While we recognize that there are often unavoidable declines, particularly in the last stages of life, all necessary resources and disciplines must be used to ensure that residents achieve the highest level of functioning possible (quality of care) and maintain their sense of individuality (quality of life).

Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of four residents reviewed for accidents (Resident #1). The facility failed to revise the care plan and continued to transfer Resident #1 with one person after; a. Resident #1 received a skin tear on 5/13/19 during a transfer, b. the family filed a grievance on 5/15/19 regarding skin tears during staff care (5/13/2019) and c. attended the care plan meeting on 05/21/19 to address the injuries during staff care. Resident #1 received a skin tear on 5/24/19, and a third skin tear during a one person transfer on 06/27/2019 that resulted in a large hematoma (due to anticoagulation therapy) that split her fragile skin open on her leg. This failure led to pain, and a hospital stay with evacuation of the hematoma. Findings included: Review of Resident #1's Face Sheet reflected she was an [AGE] year old female initially admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS 06/25/2019 reflected she had a BIMS score of 12 which indicated moderate cognitive impairment. She had no behaviors. Resident #1 required extensive assistance of one person for transferring, hygiene, and dressing. Resident #1 received anticoagulants seven days a week. Resident #1 was on physical therapy from 04/29/2019 to 06/24/2019 three times a day. Review of Resident #1's Care Plan dated 04/10/2019 reflected Resident requires extensive assistance of one staff member for transfers. An additional care plan dated 05/13/2019 for her skin tear to her right leg had a goal of Will have no skin tears during this quarter and an intervention of applying new Steri-Strips, ensure skin is clean and dry, and facility protocol for wound treatment. There was no intervention to prevent future skin tears (such as two person transfers). Review of faxes in Resident #1's chart reflected; 05/13/19 - Resident received a skin tear during transfer from recliner to bed. Will monitor until healed. 05/24/2019 - Resident #1 acquired a skin tear to her right ankle area during ADL care will continue to monitor. Review of Resident #1's Family Grievance form dated 05/15/2019 reflected; Brother concerned that patient did not receive skin tear on her own, wants to know how it happened, wants to know that staff are aware of her sensitive skin, and what will be done to prevent future skin tears. Signed (Social Worker). Follow up: Family contacted to schedule care plan meeting to discuss their concerns and to develop plan of care scheduled for 5/21/19. Resolution: A care plan meeting will be held 05/21/2019. Review of Resident #1's Care Plan Conference Summary Sheet dated 05/21/19 reflected: Risk and consequences: falls, skin tear. Plan of care Nursing: Wound care. The MDS Coordinator, SW, AD, BOM and another staff member whose signature was not readable signed the document along with Resident #1 and her two brothers. The Summary Sheet did not reflect there would be any changes to prevent future injuries during staff care. Review of Resident #1's Progress Notes reflected: -06/25/2019 documented by the SW; Resident (#1) is alert and oriented to person but is disoriented to time and place. She has long and short term memory deficits and impaired decision-making abilities that require her to need cues and supervision. No hallucinations, delusions, or behavior issues. -06/27/2019 at 9:31 AM; As resident was being transferred from bed to wheelchair resident bumped her left leg (shin area) and sustained a hematoma and swelling to area. Dr. made aware. [MEDICATION NAME] given as ordered. Dr. stated give extra dose due to her pain level of 10 of 10. -6/27/19 at 12:57 PM Will discontinue x-ray order due to resident being sent out to ER for bleeding profusely. MD aware. In an interview on 07/02/2019 at 10:05 AM Resident #1 stated while she was being transferred to the bed a screw hit her leg and ripped her leg open. They got too close to the bed and ripped a hole in my leg. This is the second time. This one is much more severe. I don't remember exactly how it happened the first time. It didn't seem to be as severe. It was on the right leg the first time. Observation on 07/02/2019 at 1:00 PM revealed Resident #1's bed was nearly new and there were no sharp edges. There were round smooth joint covers where the joints on the bed allowed the head or lower part of the bed to be raised. In an interview on 07/02/2019 at 1:28 PM CNA [NAME] stated I have transferred (Resident #1). There were two of us. She has a hard time pivoting her feet. Normally an aide will ask another aide to help out. In an interview on 0702/2019 at 1:53 PM CNA F stated, When I transferred her, she was two person and a gait belt. I have noticed she had a dressing on her leg. Her condition made me think (she required) a gait belt and two people (for transfers). She can straighten her legs and she can plant her feet. The thing I saw was she would pull back when you were transferring her. Every day that I have had her (assigned to her unit), she has been in her recliner when I get here at 2:00 PM so I would get her from the recliner to the chair to go eat, then to the bed. Always two person transfer for Resident #1. She bore weight, but the pushing back was the problem. It is hard to transfer her with one person because of the pushing. In an interview on 07/02/2019 at 5:10 PM CNA D stated Resident #1 was sitting on the side of the bed and I went to transfer her (one person transfer), and her leg got kicked out and hit on the bed because she pulls back when I lift her. She stiffens up when you transfer her. That has happened before. She has had a skin tear already. It wasn't that big though. No, I don't think I saw her leg hit the bed. She hollered out and I looked at it and thought 'Thank God' it wasn't bleeding. Yes, it made some little holes in her leg. She stiffens up and pulls back on you. She stands fine and you can take her to the bathroom but then she got a potty chair. She wasn't stiffening up when she first came. She started that quite a while ago. She bears weight. In an interview on 7/02/19 at 2:30 PM the facility RN stated she had observed Resident #1's skin tear (that developed a hematoma) on the date it occurred: 06/27/2019. She stated at first it was a small skin tear with an approximately three by four inch hematoma, then over a short time the hematoma began to enlarge. After a couple hours the hematoma continued to enlarge, and the skin split approximately two to three inches and the blood begin escaping from the hematoma. She stated due to Resident #1's anticoagulant therapy the facility could not stop the bleeding and transferred her to the hospital. Observation of a facility photograph taken just after Resident #1's skin tear occurred reflected there were three small circular openings and an approximately three to four inch flat, bruised area to Resident #1's leg when the injury first occurred. Observation of a hospital photograph taken on 06/27/2019 after Resident #1's hematoma (which had continued to enlarge after she was sent to the hospital) was evacuated at the hospital, reflected her leg was opened approximately more than six inches to remove the blood clot. In an interview on 07/02/2019 at 10:20 AM Resident #1's family member stated The MD stated my sister's skin is too fragile to try to suture the opening and they chose to leave it open to heal. In an interview on 07/02.2019 at 4:40 PM the MDS Coordinator stated Resident #1's care plan was not updated after the skin tear on 05/13/2019 or after the skin tear on 05/24/2019. She stated there were no new interventions put in place after the two skin tears (which occurred during staff care). In an interview on 07/02/2019 at 5:05 PM the facility RN stated, When the son came to the facility after the skin tear/hematoma (that occurred on 06/27/2019) I told him we might could get the spongy sleeve protectors to put on her legs. I also told him we could get a two person transfer to watch her legs (during transfers) to make sure she wasn't bumping into things. In an interview on 07/02/2019 at 5:36 PM the Administrator stated, The staff should have communicated to the nurse that Resident #1 was stiffening with transfers. That part failed. Our care plan should have been updated to include measures to prevent further skin tears for Resident #1.

Based on observation, interview and record review, the facility failed to ensure that each resident receives adequate supervision to prevent accidents for one of two residents reviewed for accidents with injuries (Resident #1). CNA B failed to ensure Resident #1 was wearing safe footwear, after identifying she was wearing slick socks when she came to the dining room. Resident #1 slipped in her socked feet and stumbled over her shoes in an attempt to follow CNA B out of her room and sustained bilateral forearm fractures. This deficient practice could affect a facility census of 28 residents on fall precautions by placing them at risk for falls with injuries to include fractures or severe adverse consequences. The Findings Include: Review of Resident #1's Face Sheet, reflected she was admitted to the facility on [DATE] to the facility's secure unit with [DIAGNOSES REDACTED]. Review of an Admission MDS for Resident #1 dated 03/01/16, reflected the following: -A BIMS score of 4 to indicating severe cognitive impairment -Limited Assistance with dressing -Independent with eating -set up help only -Walked independently throughout the secure unit -Continent of bladder and bowel. Review of a Care Plan for Resident #1 dated 03/15/16, reflected the following: Focus: Resident is at risk for falls due to psychoactive drug use Goal: Resident will be free from falls Interventions tasks- anticipate and meet resident's needs; assist resident with stand by assistance for ambulation; assure resident is wearing appropriate footwear. Observation on 04/22/16 at 5:50 PM, revealed Resident #1 being assisted out of a transportation van by two staff. Resident #1 had casts on both of her arms, starting below the wrist and extending past the elbows to the upper arms. She was escorted by staff to the secure unit with a gait belt in place. Observation of Resident #1 on 04/22/16 at 8:00 PM, revealed she was sitting in the dining area of the secure unit in a chair with both of her arms resting on pillows. Resident #1 was tearful and did not want to go to bed. Resident #1 repeatedly stated I can't use my arms. Review of hospital emergency room records dated 04/18/16 for Resident #1, revealed the following: Radiology: X-ray of the forearm two views (right) Reason for the exam- deformity of the right forearm. Findings: There is a comminuted fracture {a fracture where the bone shatters into more than 3 pieces}of the distal radius with impaction. Minimally displaced ulnar styloid avulsion. {a fracture that occurs when a small piece of bone attached to a tendon or ligament gets pulled away from the main part of the bone}. X-ray of the forearm two views (left) Reason for the exam- left forearm deformity Findings: There is a comminuted distal radial fracture which is prominently transversely oriented {a horizontal fracture} and demonstrates impaction Mildly displaced ulnar styloid {the tip end of the ulna bone} avulsion fracture. Review of a emergency room physician's History and Physical for Resident #1 dated 04/19/16, reflected Resident stated that a caregiver at the nursing home was trying to force her to eat dinner. The patient stated she fell at this time and the caregiver grabbed her arms resulting in injury. Review of a facility incident report dated 04/18/16 for Resident #1, reflected the following: Incident Description: The resident was getting up to follow the aide (CNA) and slipped and the aide grabbed her arm to keep her from falling. Immediate Action Taken: checked resident's arms there was no swelling or redness on the arms. Assisted resident to day room to eat. Resident was holding her arms so the aide started to feed her. Resident was unable to give a number to how severe the pain was. She was holding her left arm and would not let go. She cried in pain when both arms were touched. Environmental factors- resident only had her socks on and slipped. In an interview on 04/22/16 at 7:35 PM, CNA B stated she was assigned to the secure unit on 04/18/16 for the 2:00-10:00 PM shift. CNA B stated at approximately 5:45 PM, Resident #1 came to the dining room in pajamas and socked feet. CNA B stated the socks Resident #1 had on were slippery, so she told Resident #1 to go back to her room and put her shoes on because she was assisting 3 residents with their meals. CNA B went on to say she went to Resident #1's room and found her sitting on the side of her bed with her socks on, but no shoes. CNA B stated Resident #1 refused to eat dinner because she was in her pajamas and didn't want to be in the dining room in them; so she told the resident she was going back to the dining room to feed the other residents. CNA B added she started walking out of the room, when Resident #1 stated wait and jumped up. CNA B stated when Resident #1 jumped up, she stumbled over her shoes and started to fall forward; so she grabbed her by left arm and pulled her up towards her to stop the fall. CNA B stated Resident #1 begin to complain of her left arm hurting, so she sat her in a chair in her room, put her shoes on her, and went to get the nurse's attention to come to the unit. CNA B added LVN Y brought Resident #1 back to the dining room, after she was assessed and given medication for pain. CNA B stated she had to feed Resident #1, because the resident would not let go of her left arm due to pain. CNA B denied even touching Resident #1's right arm, her right arm striking anything when she fell forward, or her falling to the floor. CNA had no explanation for why Resident #1 was complaining of both arms hurting and the injuries that were found. CNA B stated because Resident #1 was capable of putting her shoes on, she didn't need to assist the resident. Observation of Resident #1 on 04/22/16 at 9:00 PM, revealed she remained in the secure unit dining room with a CNA watching TV. Resident #1 was tearful and stated again, I can't use my arms. Resident #1 stated she didn't want to go to bed and was tearful. The lower portion of her left hand that was not covered by the cast was swollen and there was light purple bruising. In an interview on 04/23/16 at 1:26 PM, when asked how she hurt her arms, Resident #1 stated a big woman wanted me to eat and hurt me. Resident #1 stated there was a scuffle on the floor. Resident #1 was tearful and stated I can't use my arms and looked at the casts on her arms. Resident #1 was unable to provide any more details of the incident. In an interview on 04/22/16 at 5:30 PM, LVN Y stated she was the charge nurse on duty on 04/18/16, when CNA B came to the door of the unit to get her attention that she was needed. LVN Y stated she found Resident #1 sitting in a personal chair in her room and initially complained of her left arm pain and was holding it close to her. LVN Y stated during her assessment of Resident #1, the resident cried out when her right forearm was touched, as well as her left. LVN Y stated there was no initial bruising or swelling; but she gave Resident #1 two tablets of Tylenol 325 mg, and took her to the dining room to eat. LVN Y stated Resident #1 would not let go of her left arm and CNA B had to feed her. LVN Y stated she telephoned the physician for orders for x-rays of Resident #1's foreman to be done the next day by a mobile radiology service. LVN Y stated she did not check on Resident #1 again prior to the end of shift, because the CNA B didn't report she was in pain and she was in bed. LVN Y also stated it didn't occur to her that Resident #1 could not get herself up after a fall, or to question CNA B about why both of her arms were hurting. In an interview on 04/23/16 at 2:44 PM, LVN W stated she worked the 10:00 PM-6:00 AM shift the night of 04/18/16, and was assigned to Resident #1. LVN W stated she was told by LVN Z that Resident #1 had a near fall, had complained of bilateral arm pain, and was scheduled to have x-rays the next day. LVN W stated she did not assess Resident #1 for swelling or bruising, because she assumed she slept all night. LVN W also stated she woke Resident #1 at 5:00 AM for her thyroid medication and placed the medication tablet in her mouth by pouring it from the paper cup and then placed a cup of water to her mouth; so she never saw her hands or arms. LVN W also stated Resident #1 had not fallen on the previous night (04/17/16) or complained of pain. In an interview on 04/23/16 at 12:46 PM, CNA C stated she worked on the secure unit for the 6:00 AM to 2:00 PM shift on 04/17/16 and 04/18/16. CNA C stated Resident #1 had no witnessed falls on her shifts; and she did not think she could get up without assistance, if she did fall. CNA C stated on the morning of 04/18/17, she had not been informed during shift change that Resident #1 had a near fall and was scheduled to have mobile x-rays. CNA C stated she went to Resident #1's room to ask her if she wanted to get up for breakfast and she stated no and closed her eyes. In an interview on 04/23/16 at 9:45 AM, CNA E stated she had worked at the facility for [AGE] years and the last time she worked with Resident #1 was on 04/16/16 on the 6:00 AM-2:00 PM shift. CNA E stated she normally worked this shift and on the secure unit since its opening last year. CNA E stated she gave Resident #1 her shower on 04/16/16, and there was no bruising or pain. CNA E stated even though Resident #1 would walk around the unit, she was unsteady at times and she did not think Resident #1 would be able to get up after a fall without assistance. CNA E also stated it was very important to Resident #1 to have her shoes on and she had never seen her out of bed without wearing them; but if she ever did, she would get her shoes and assist her in putting them on. In an interview on 04/23/16 at 11:00 AM, Resident #1's Responsible Party (RP) stated she had been told her mother had a near fall on the evening of 04/18/16 and was complaining of both of her forearms hurting. The RP added she was told Resident #1 would be getting X-rays the next day. The RP stated she came to the facility on the morning of 04/19/16, and found Resident #1 in bed with a pajama top on and a long sleeve top that were both wet. The RP stated she began to try and take the wet clothing off, when Resident #1 stated help me, help me, and she noticed both of the resident's lower arms and hands were swollen and bruised. The RP stated she became very upset and went to get the nurse on duty. In an interview on 04/24/16 at 11:57 AM, LVN Z stated when he came on duty on the morning of 04/19/16 at 6:00 AM, he was informed by the 10:00 PM-6:00 AM nurse that Resident #1 was going to have mobile service x-rays of her arms due to pain after a near fall. LVN Z stated when he made rounds at approximately 6:00 AM, Resident #1 was sleeping and he didn't want to disturb her; so he did not assess her for pain and/or swelling and bruising. LVN Z stated at approximately 9:00 AM Resident #1's RP came to get him and she was extremely upset because the resident was in pain and both of her hands were bruised and very swollen. LVN Z stated he looked briefly at Resident #1 and saw some swelling and bruising on the left wrist and light bruising on the right wrist. LVN Z added he left the room quickly to change the mobile x-ray orders to stat (as soon as possible) because Resident #1's RP was saying she suspected abuse. LVN Z stated because of the allegation, he went directly to the facility Administrator to report the allegation; rather than do a more complete assessment. LVN Z stated when the x-ray reports came back positive for fractures, the family called local police authorities, who came and took pictures, and then took Resident #1 to a local hospital for evaluation. In an interview on 04/23/16 at 6:45 PM, the DON stated CNA B had been terminated because the story she provided did not add up to the injuries sustained. The DON stated she did not question CNA B about Resident #1 not being able to get up without assistance after a fall with the injuries she had. The DON also stated CNA B should have gotten Resident #1's shoes for her and put them on to make sure she had safe footwear, rather than sending the resident to get them. The DON stated she was new to the facility and was trying to get many systems in place, but it was a big task. The DON added Resident #1 had not been reviewed for any additional fall precautions since her recent fracture diagnosis. In an interview on 04/25/16 at 11:00 AM, the DON presented an in-service on implementing a Post Analysis Tool that she had found after researching post fall analysis. The DON added Resident #1 had fall strips placed on the floor in front of her chair and in her bathroom and her bed will be in low position, when it is occupied. The DON stated Resident #1 would have to be fed, dressed by staff and toileted due to her injuries. In an interview on 04/26/16 at 12:28 PM, Resident #1's physician stated he was familiar with Resident #1's fractures. The physician, who is also the facility's Medical Director, stated CNA B's account of the event did not match the injuries sustained. The Medical Director went on to say that the type of fractures Resident #1 sustained were from impact due to a fall. The Medical Director added Resident #1 would not have been able to get up without assistance with the type of injuries she had sustained. The Medical Director also stated CNA B should have made sure Resident #1 had safe footwear on rather than telling her to put them on and should not have attempted to walk out of the room leaving her in socked feet. Review of the facility's Assessing Falls and Their Causes Policy and Procedure dated 2010 reflected the following: -General Guidelines . Falls may be due to related to underlying clinical conditions, functional decline, or environmental factors. Steps in the Procedure: 1.) . e.) Nursing staff will observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall and will document findings in the medical record. The DON provided a facility census of 28 residents on fall precautions. -

Based on interview and record review the facility failed to ensure each resident had the right to formulate an advance directive for full code when one (1) of nine (9) residents (Resident # 1) reviewed for advance directives did not receive immediate CPR. LVN A failed to immediately perform CPR when Resident # 1 was found not breathing and without a pulse. Resident # 1 was pronounced dead upon arrival to the emergency room . This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm and scope identified as pattern. This deficient practice affected Resident # 1 and placed 35 additional residents, identified as full code, at risk for delayed emergency care resulting in increased injury or death. Findings include: Review of Resident #1's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses' included Obstructive Sleep Apnea, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and [MEDICAL CONDITION]. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 11 indicating moderate cognitive impairment. The resident's height was 71 inches and weight was 297 pounds. Review of Resident #1's Care Plan dated [DATE] reflected a problem of Artery/[MEDICAL CONDITION] Approaches included, medications, laboratory tests, and diet as ordered. Vital signs as ordered. Remind resident to report chest pains, shortness of breath, heart palpitations, and abnormal pulse. The Care Plan reflected the resident was Full Code. Review of the local EMS incident log for Resident #1 reflected 911 was called on [DATE] at 4:06 AM. The ambulance arrived at the facility at 4:10 AM and departed for the local hospital at 4:55 AM. Review of Resident #1's local hospital death report reflected the resident was pronounced dead [DATE] at 5:08 AM. Review of the facility's Provider Investigation Report dated [DATE] reflected the facility investigated an allegation of neglect regarding the death of Resident #1. The neglect allegation had been lodged by CNA F alleging Resident #1 could have received more effective care from LVN A. These allegations were made based on CNA F's having heard various accounts of the incident from other staff members. In an interview on [DATE] at 2:20 PM CNA F stated on [DATE] at about 4:00 or 4:30 in the morning LVN C appeared shaken as she approached her. The CNA further stated LVN C stated (Resident #1) may have passed. CNA F further stated CNA G spoke to her after the incident and had stated He was gurgling and coughing. In an interview on [DATE] at 8:05 AM the Administrator stated The staff did not know policy and procedures for CPR prior to the incident on [DATE]. They didn't work as a team. There was some back and forth on what everyone should do. In an interview on [DATE] at 10:30 AM LVN A stated she didn't know for sure what time it was when she heard a cough down the hall. LVN A stated the entire event from the time she heard the cough until the paramedics got there was only a couple of minutes. She got up and went to see if it was Resident #1 that had coughed and she was alone when she went into the room. She saw spittle on his face, she called his name while shaking him two (2) times. She checked his pulse and there was none. LVN A stated he was on his back and his face was turned to the left. LVN A stated she ran past CNA G to the desk and dialed 911 and at the same time she hollered to the other nurse at the other nurse station and motioned for her to come hurriedly to LVN A's unit. LVN A only remembered LVN C coming by the desk one time with the crash cart and yelling at her to get off the phone and help her start CPR. LVN A stated the dispacher at 911 was telling her to calm down and breathe and tell her what her name was, where she was calling from, what was the nature of the call and many more questions. LVN A stated she told the 911 operator; (Facility Name), (Resident #1), he is a full code and needed assistance and her name was (LVN A) and that she had to do CPR. LVN A stated at that point she put the phone on the desk and ran back to the room. LVN A stated the crash cart was kept by LVN C's nurse desk at the other end of the hall. LVN A stated she and three (3) aides placed Resident #1 on the back board they retrieved from the crash cart. LVN A stated she began chest compressions immediately and also stated Resident #1 had a lot of stomach contents coming out of his mouth. LVN A stated there was a suction machine on the cart but the paramedics were there so quickly they got their suction machine out and cleared the airway and used an Ambu bag (A hand-held device used to provide positive pressure ventilation) to provide rescue breaths. LVN A stated LVN C did not attempt to assist in any manner. LVN A stated LVN C did not assist in the back board placement, direct the aides in CPR or assist in compressions or airway clearance. LVN A stated she did not believe anyone got the Ambu bag out or the suction machine. LVN A stated all of this occurred prior to the arrival of EMS. Review of CNA G's written statement dated [DATE] at 3:45 AM reflected: I checked him (Resident #1) and he was snoring, there were no signs of distress. I then left his room and went to (another resident's) room which is immediately across the hall from his. As I began to provide for (another resident) I heard this loud gasp and it came from Resident #1's room. I leave (the other resident's) room, go to (Resident #1's) room and the nurse (LVN A) is right behind me. She said she heard his gasp from the desk. We found him lying there with this thick mucus like substance running down his cheeks. The nurse checked for a pulse and tried to get a response from him by shaking and shouting (Resident #1's name) Are you all right? When she got no response she ran to the desk Call down the hall and asked (LVN C) to bring the crash cart. She (LVN A) runs back to (Resident #1) and began CPR. Review of LVN A's Nurse's Noted dated [DATE] at 3:30 AM reflected Resident snoring loudly then heard coughing/gagging sound from room. Noted spittle on left side of face. Body cool to touch and non-responsive. Called aide to dial 911. Initiated CPR. Other nurse brought crash cart. All 4 nurses placed back board under patient and continued CPR. EMT arrived and took over from nursing. Review of LVN A's written statement, undated, for the facility investigation reflected Resident coughing/gurgling sound and noted spittle on face. Felt patient skin was cool. Felt for pulse, 0 pulse. (CNA G) came. Told her to dial 911. Ran out of room. Dialed 911. Waved for (LVN C) - other nurse, brought crash cart started compressions. Then placed red board under resident. HOB lowered. It took all 4 nurses to roll patient to get board underneath him. Then a few minutes later EMT arrived and took over. In an interview on [DATE] at 3:50 PM LVN C stated she was assigned to the back nurse's station and LVN A was assigned to the front nurse's station on the 10:00 PM to 6:00 AM shift [DATE] - [DATE]. Somewhere between 4:00 AM and 4:15 AM LVN C noted LVN A was waving down the hall to her to come to the front station. LVN C further stated that when she arrived at the front station LVN A pointed towards Resident #1's room. CNA G was standing at the doorway to the resident's room. LVN C entered the room and approached the resident to check the resident. LVN C noted the resident had no pulse and was not breathing. LVN C further stated she told CNA G We need a crash cart. LVN C then ran for the crash cart and told LVN A to get off the phone and begin CPR. When LVN C returned with the crash cart from the back nurse's station, LVN A was still on the phone. LVN C repeated Get off the phone and start CPR. LVN A followed LVN C into the room and initiated CPR while LVN C returned to the front nurse's station. Where the telephone received was off the hook. LVN C picked up the phone, found 911 still on the line, and answered the operator's questions. LVN C further stated she had not been instructed by her superiors to monitor LVN A in any manner. Review of LVN C's Nurse's Note dated [DATE] at 4:15 AM reflected 4:15 AM (approx.) (LVN A) is at her desk station A on the phone looking down to my desk and waving me to come to her. I stood up and began to walk her way and she waved in a faster motion as to hurry up . She continues to talk on the phone while pointing to (Resident #1's) room then the CNA (G) (illegible word) asked me to come check him out because she had just heard him cough and then he was quiet after that. I asked her how long ago the cough was and she stated Just a minute ago or so. Not long at all. I approached (Resident #1) calling his name with no response. He was lying flat on his back in the bed with mucous drainage coming from the sides of his mouth. Eyes fixed, no palpable pulse, no audible heart rate, skin was cold, no responses to sternal rub or physical stimuli. No signs of life were present. I then asked CNA why there was no crash cart or CPR in progress. I then ran to retrieve crash cart myself. On the way back to the room (LVN A) is still standing at desk on the phone watching as I rush to the room. The CNAs around stood watching me as well. I insisted (LVN A) get off of the phone to initiate CPR or at least participate in the process. I instructed all the CNAs present to assist with getting CPR going. Resident is large and needed multiple people to position for backboard placement. Once (LVN A) and CNAs were initiating CPR I went to ensure it was 911 that was contacted. Review of LVN A's employment file reflected the LVN had no documented evidence of CPR/AED training. Further review of LVN A's employee file reflected a State Board of Nursing order dated [DATE]. The LVN had been found to have failed to initiate cardiopulmonary resuscitation when (a designated Resident number) was found unresponsive in bed. The resident had a full code status and even though 911 was called for emergent transport, CPR was not started until another nurse arrived from a different floor 6 - 10 minutes later. Respondent left the premises for six (6) minutes to pick up a family member. Emergency medical services subsequently transferred the resident to a local acute care facility, where the resident was pronounced deceased shortly after arrival. Respondent's conduct may have contributed to the resident's demise. The order further reflected the following employment requirements. : Direct Supervision: For the first year (four (4) quarters) of employment as a nurse under this order, RESPONDENT SHALL be directly supervised by a Registered Nurse, if licensed as a Registered Nurse, or by a Licensed Vocational Nurse or a Registered Nurse, if licensed as a Licensed Vocational Nurse. Direct Supervision requires another nurse, as applicable, to be working on the same unit as RESPONDENT and immediately available to provide assistance and intervention. Review of 100% of the facility's employee files reflected only 8 of 12 nurses and 8 of 33 aides had proof current CPR training. In an interview on [DATE] at 11:20 AM the RNC stated in response to Resident #1's incident, all staff employees records were reviewed to verify currency in CPR/AED training. Upon learning that several employees did not have proof of training, the Administrator determined it was necessary to begin training of all uncertified employees as soon as possible. In an interview on [DATE] at 2:30 PM the Administrator stated he was not aware that LVN A's sanctions required her to be supervised by another LVN or an RN on the same unit. If I had known about it. Yes when asked if he had considered having an LVN work the same unit as LVN A. The Administrator further stated that LVN A had initially worked with another LVN during the first week or so of LVN A's employment. After that initial phase, LVN A was assigned as shift charge nurse working either of two (2) nurse's stations on each side of the building. The Administrator further stated he had not been aware of LVN A's CPR/AED training status. Review of the facility's Policy and Procedures for Cardiopulmonary Resuscitation dated ,[DATE] reflected Depending on the underlying cause, the chances of surviving SCA (Sudden [MEDICAL CONDITION]) may be increased if CPR is initiated immediately upon collapse. The policy and procedure further reflected Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. The facility Administrator was notified on [DATE] at 11:49 AM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 4:30 PM: All clinical staff to include Registered Nurses, Licensed Vocational Nurses, Certified Nurse's Assistants, Medication Aides, and Restorative Aides are responsible for performing CPR and using AEDs. On line certifications will no longer be considered valid. Certifications will only be accepted per CMS regulations. An audit of all clinical employees' files on [DATE] verified 8 of 14 Nurses (RNs and LVNs) had documentation of current CPR/AED training. 4 LVNs have signed up for a CPR/AED class to be conducted at the facility on [DATE] at 5:30 PM by an accredited CPR/AED trainer. (See attachment A) for documentation of CPR/AED trainer. This will result in a rate of 85.7% with certification. The other 2 nurses will not be allowed to work until they provide proof of certification. The same employee file audit verified 9 of 33 Aides (CNA, MA, RA) had documentation of current CPR/AED training. 17 aides have signed up for a CPR/AED class to be conducted at the facility on [DATE] at 5:30 PM by an accredited CPR/AED trainer. One employee will send the facility a valid current CPR card by [DATE] at 8:00 PM. This will result in a rate of 81.8% with certification. The last 6 CNAs will need to provide verification of their CPR training by [DATE]. These CNAs will not work shifts unless they are supervised by staff with current CPR certifications. Those CNAs who fail to submit verifications by [DATE] will not be allowed to work. Proof of each staff member's current certification will be kept in the staff 's personnel file. Upon hire, direct care staff will be required to show evidence of CPR/AED certification. (LVN K), who works for the facility, has received CPR/AED instructor training and will be able to start conducting CPR/AED classes after [DATE] and will be responsible for conducting CPR/AED classes as required and routinely as part of orientation. Clinical Staff members hired between this date and [DATE] will be trained by an accredited trainer. The facility's Human Resources Director will develop a tickler system to ensure all CPR/AED certifications remain current and will be responsible for monitoring the certifications to ensure currency. She will be trained by the Regional Nurse Consultant by [DATE] by 8:00 PM. The facility's Director of Nursing will be responsible for ensuring each shift has at least one clinical staff member who is currently CPR/AED trained. The Assistant Director of Nursing or the Administrator will act in her absence. She will be trained by the Regional Nurse Consultant by [DATE] by 8:00 PM. (See attachment B for work schedule for [DATE] - [DATE].) An audit of all clinical employees' personnel files verified 1 LVN under restriction by the State Board of Nursing. For the one employee on stipulations, the DON, Human Resources Director and Administrator will review her stipulations and develop a plan to ensure the facility complies with the board's expectations by [DATE] at 8:00 PM. For applicants with board stipulations, The Director of Nursing, Human Resources Director, and the Administrator will review the application and documented stipulations and develop a plan before hire that ensures the facility can remain in compliance with the board's expectations. They will be trained by the Regional Nurse Consultant by [DATE] at 8:00 PM. Scheduling for employees under licensing board restrictions will be monitored by the facility's Director of Nursing and Administrator in order to be compliant with all restrictions written by these boards. The effectiveness of this process will be reviewed at least monthly by the DON and Administrator and at least quarterly by the QAA committee. The facility's Medical Director was notified of the Immediate Jeopardy on [DATE]. The investigator monitored the current Plan of Removal from [DATE] at 4:30 PM until [DATE] at 8:10 PM as follows: Observation on [DATE] at 5:30 PM reflected four (4) LVNs and 19 CNA's receiving CPR/AED training from an accredited CPR/AED Trainer Review of the accredited CPR/AED Trainer's sign-in sheets dated [DATE] at 5:30 PM reflected signatures from four (4) LVNs and 19 CNA's. In an interview on [DATE] at 4:45 PM the Human Resources Director stated she had been trained by the Regional Nurse Consultant on her responsibilities for monitoring currency of CPR/AET training for all facility employees. The Human Resources Director further stated she had received training for review of all staff with board restrictions and how to ensure the facility would be able to comply with all restrictions set by the respective boards. In interviews on [DATE] the facility's Administrator and Assistant Director of Nursing stated they had received training from the Regional Nurse Consultant on the subject of monitoring staffing schedules to ensure all shifts have a CPR/AED trained clinical employee assigned. The Administrator and ADON further stated they had received training for review of all staff with board restrictions and how to ensure the facility would be able to comply with all restrictions set by the respective boards. Review of the facility's Nurse and Aide schedules dated [DATE] - [DATE] reflected all shifts to have no less than one (1) clinical employee that has current CPR/AED training. On [DATE] at 8:10 PM the Administrator was informed the IJ was removed. However the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of removal. The Administrator provide a list of 35 residents listed as Full Code requesting CPR/AED use when needed.

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit neglect for one (1) of nine (9) residents reviewed for neglect. (Resident #1). A) The facility failed to ensure LVN A was supervised by a designated RN or LVN on the same unit, as mandated by the Texas Board of Nursing. On [DATE], LVN A failed to administer immediate CPR when Resident #1 was found unresponsive, not breathing and without a pulse. Resident # 1 was pronounced dead upon arrival to the emergency room . This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as pattern. This deficient practice could place 35 residents, identified as full code, at risk for delayed emergency care resulting in increased injury or death. Non-Immediate Jeopardy B) The facility failed to properly supervise another nurse (RN J) according to the orders set forth from the state board of nursing's employment requirements mandating RN J had no access to controlled narcotic medication for six months beginning [DATE]. The facility had provided RN J with a key to the controlled narcotic cabinet. This deficient practice placed 27 residents who received controlled narcotic medication at risk for loss of medication and adverse affects of not having their medication. Findings include: A) Review of Resident #1's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses' included Obstructive Sleep Apnea, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and [MEDICAL CONDITION]. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 11 indicating moderate cognitive impairment. The resident's height was 71 inches and weight was 297 pounds. Review of Resident #1's Care Plan dated [DATE] reflected a problem of Artery/[MEDICAL CONDITION] Approaches included, medications, laboratory tests, and diet as ordered. Vital signs as ordered. Remind resident to report chest pains, shortness of breath, heart palpitations, and abnormal pulse. The Care Plan reflected the resident was Full Code. Review of the local EMS incident log for Resident #1 reflected 911 was called on [DATE] at 4:06 AM. The ambulance arrived at the facility at 4:10 AM and departed for the local hospital at 4:55 AM. Review of Resident #1's local hospital death report reflected the resident was pronounced dead [DATE] at 5:08 AM. Review of the facility's Provider Investigation Report dated [DATE] reflected the facility investigated an allegation of neglect regarding the death of Resident #1. The neglect allegation had been lodged by CNA F alleging Resident #1 could have received more effective care from LVN A. These allegations were made based on CNA F's having heard various accounts of the incident from other staff members. In an interview on [DATE] at 2:20 PM CNA F stated on [DATE] at about 4:00 or 4:30 in the morning LVN C appeared shaken as she approached her. The CNA further stated LVN C stated (Resident #1) may have passed. CNA F further stated CNA G spoke to her after the incident and had stated He was gurgling and coughing. In an interview on [DATE] at 8:05 AM the Administrator stated The staff did not know policy and procedures for CPR prior to the incident on [DATE]. They didn't work as a team. There was some back and forth on what everyone should do. In an interview on [DATE] at 10:30 AM LVN A stated she didn't know for sure what time it was when she heard a cough down the hall. LVN A stated the entire event from the time she heard the cough until the paramedics got there was only a couple of minutes. She got up and went to see if it was Resident #1 that had coughed and she was alone when she went into the room. She saw spittle on his face, she called his name while shaking him two (2) times. She checked his pulse and there was none. LVN A stated he was on his back and his face was turned to the left. LVN A stated she ran past CNA G to the desk and dialed 911 and at the same time she hollered to the other nurse at the other nurse station and motioned for her to come hurriedly to LVN A's unit. LVN A only remembered LVN C coming by the desk one time with the crash cart and yelling at her to get off the phone and help her start CPR. LVN A stated the dispacher at 911 was telling her to calm down and breathe and tell her what her name was, where she was calling from, what was the nature of the call and many more questions. LVN A stated she told the 911 operator; (Facility Name), (Resident #1), he is a full code and needed assistance and her name was (LVN A) and that she had to do CPR. LVN A stated at that point she put the phone on the desk and ran back to the room. LVN A stated the crash cart was kept by LVN C's nurse desk at the other end of the hall. LVN A stated she and three (3) aides placed Resident #1 on the back board they retrieved from the crash cart. LVN A stated she began chest compressions immediately and stated Resident #1 had so much stomach contents coming out of his mouth. LVN A stated there was a suction machine on the cart but the paramedics were there so quickly they got their suction machine out and cleared the airway and used an Ambu bag (A hand-held device used to provide positive pressure ventilation) to provide rescue breaths. LVN A stated LVN C did not attempt to assist in any manner. LVN A stated LVN C did not assist in the back board placement, direct the aides in CPR or assist in compressions or airway clearance. LVN A stated she did not believe anyone got the Ambu bag out or the suction machine. LVN A stated all of this occurred prior to the arrival of EMS. Review of CNA G's written statement dated [DATE] at 3:45 AM reflected: I checked him (Resident #1) and he was snoring, there were no signs of distress. I then left his room and went to (another resident's) room which is immediately across the hall from his. As I began to provide for (another resident) I heard this loud gasp and it came from Resident #1's room. I leave (the other resident's) room, go to (Resident #1's) room and the nurse (LVN A) is right behind me. She said she heard his gasp from the desk. We found him lying there with this thick mucus like substance running down his cheeks. The nurse checked for a pulse and tried to get a response from him by shaking and shouting (Resident #1's name) Are you all right? When she got no response she ran to the desk Call down the hall and asked (LVN C) to bring the crash cart. She (LVN A) runs back to (Resident #1) and began CPR. Review of LVN A's Nurse's Noted dated [DATE] at 3:30 AM reflected Resident snoring loudly then heard coughing/gagging sound from room. Noted spittle on left side of face. Body cool to touch and non-responsive. Called aide to dial 911. Initiated CPR. Other nurse brought crash cart. All 4 nurses placed back board under patient and continued CPR. EMT arrived and took over from nursing. Review of LVN A's written statement, undated, for the facility investigation reflected Resident coughing/gurgling sound and noted spittle on face. Felt patient skin was cool. Felt for pulse, 0 pulse. (CNA G) came. Told her to dial 911. Ran out of room. Dialed 911. Waved for (LVN C) - other nurse, brought crash cart started compressions. Then placed red board under resident. HOB lowered. It took all 4 nurses to roll patient to get board underneath him. Then a few minutes later EMT arrived and took over. In an interview on [DATE] at 3:50 PM LVN C stated she was assigned to the back nurse's station and LVN A was assigned to the front nurse's station on the 10:00 PM to 6:00 AM shift [DATE] - [DATE]. Somewhere between 4:00 AM and 4:15 AM LVN C noted LVN A was waving down the hall to her to come to the front station. LVN C further stated that when she arrived at the front station LVN A pointed towards Resident #1's room. CNA G was standing at the doorway to the resident's room. LVN C entered the room and approached the resident to check the resident. LVN C noted the resident had no pulse and was not breathing. LVN C further stated she told CNA G We need a crash cart. LVN C then ran for the crash cart and told LVN A to get off the phone and begin CPR. When LVN C returned with the crash cart from the back nurse's station, LVN A was still on the phone. LVN C repeated Get off the phone and start CPR. LVN A followed LVN C into the room and initiated CPR while LVN C returned to the front nurse's station. Where the telephone received was off the hook. LVN C picked up the phone, found 911 still on the line, and answered the operator's questions. LVN C further stated she had not been instructed by her superiors to monitor LVN A in any manner. Review of LVN C's Nurse's Note dated [DATE] at 4:15 AM reflected 4:15 AM (approx.) (LVN A) is at her desk station A on the phone looking down to my desk and waving me to come to her. I stood up and began to walk her way and she waved in a faster motion as to hurry up . She continues to talk on the phone while pointing to (Resident #1's) room then the CNA (G) (illegible word) asked me to come check him out because she had just heard him cough and then he was quiet after that. I asked her how long ago the cough was and she stated Just a minute ago or so. Not long at all. I approached (Resident #1) calling his name with no response. He was lying flat on his back in the bed with mucous drainage coming from the sides of his mouth. Eyes fixed, no palpable pulse, no audible heart rate, skin was cold, no responses to sternal rub or physical stimuli. No signs of life were present. I then asked CNA why there was no crash cart or CPR in progress. I then ran to retrieve crash cart myself. On the way back to the room (LVN A) is still standing at desk on the phone watching as I rush to the room. The CNAs around stood watching me as well. I insisted (LVN A) get off of the phone to initiate CPR or at least participate in the process. I instructed all the CNAs present to assist with getting CPR going. Resident is large and needed multiple people to position for backboard placement. Once (LVN A) and CNAs were initiating CPR I went to ensure it was 911 that was contacted. Review of LVN A's employment file reflected the LVN had no documented evidence of CPR/AED training. Further review of LVN A's employee file reflected a State Board of Nursing order dated [DATE]. The LVN had been found to have failed to initiate cardiopulmonary resuscitation when (a designated Resident #) was found unresponsive in bed. The resident had a full code status and even though 911 was called for emergent transport, CPR was not started until another nurse arrived from a different floor 6 - 10 minutes later. Respondent left the premises for six (6) minutes to pick up a family member. Emergency medical services subsequently transferred the resident to a local acute care facility, where the resident was pronounced deceased shortly after arrival. Respondent's conduct may have contributed to the resident's demise. The order further reflected the following employment requirements. : Direct Supervision: For the first year (four (4) quarters) of employment as a nurse under this order, RESPONDENT SHALL be directly supervised by a Registered Nurse, if licensed as a Registered Nurse, or by a Licensed Vocational Nurse or a Registered Nurse, if licensed as a Licensed Vocational Nurse. Direct Supervision requires another nurse, as applicable, to be working on the same unit as RESPONDENT and immediately available to provide assistance and intervention. Review of 100% of the facility's employee files reflected only 8 of 12 nurses and 8 of 33 aides had proof current CPR training. In an interview on [DATE] at 11:20 AM the RNC stated in response to Resident #1's incident, all staff employees records were reviewed to verify currency in CPR/AED training. Upon learning that several employees did not have proof of training, the Administrator determined it was necessary to begin training of all uncertified employees as soon as possible. In an interview on [DATE] at 2:30 PM the Administrator stated he was not aware that LVN A's sanctions required her to be supervised by another LVN or an RN on the same unit. If I had known about it. Yes when asked if he had considered having an LVN work the same unit as LVN A. The Administrator further stated that LVN A had initially worked with another LVN during the first week or so of LVN A's employment. After that initial phase, LVN A was assigned as shift charge nurse working either of two (2) nurse's stations on each side of the building. The Administrator further stated he had not been aware of LVN A's CPR/AED training status. Review of the facility's Policy and Procedures for Cardiopulmonary Resuscitation dated ,[DATE] reflected Depending on the underlying cause, the chances of surviving SCA (Sudden [MEDICAL CONDITION]) may be increased if CPR is initiated immediately upon collapse. The policy and procedure further reflected Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. Review of the facility's Policy and Procedures for Abuse and Neglect - Clinical Protocol dated ,[DATE] reflected Neglect means failure to provide goods and services to necessary to avoid physical harm, mental anguish, or mental illness. The facility Administrator was notified on [DATE] at 11:49 AM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 4:30 PM: All clinical staff to include Registered Nurses, Licensed Vocational Nurses, Certified Nurse's Assistants, Medication Aides, and Restorative Aides are responsible for performing CPR and using AEDs. On line certifications will no longer be considered valid. Certifications will only be accepted per CMS regulations. An audit of all clinical employees' files on [DATE] verified 8 of 14 Nurses (RNs and LVNs) had documentation of current CPR/AED training. 4 LVNs have signed up for a CPR/AED class to be conducted at the facility on [DATE] at 5:30 PM by an accredited CPR/AED trainer. (See attachment A) for documentation of CPR/AED trainer. This will result in a rate of 85.7% with certification. The other 2 nurses will not be allowed to work until they provide proof of certification. The same employee file audit verified 9 of 33 Aides (CNA, MA, RA) had documentation of current CPR/AED training. 17 aides have signed up for a CPR/AED class to be conducted at the facility on [DATE] at 5:30 PM by an accredited CPR/AED trainer. One employee will send the facility a valid current CPR card by [DATE] at 8:00 PM. This will result in a rate of 81.8% with certification. The last 6 CNAs will need to provide verification of their CPR training by [DATE]. These CNAs will not work shifts unless they are supervised by staff with current CPR certifications. Those CNAs who fail to submit verifications by [DATE] will not be allowed to work. Proof of each staff member's current certification will be kept in the staff 's personnel file. Upon hire, direct care staff will be required to show evidence of CPR/AED certification. (LVN K), who works for the facility, has received CPR/AED instructor training and will be able to start conducting CPR/AED classes after [DATE] and will be responsible for conducting CPR/AED classes as required and routinely as part of orientation. Clinical Staff members hired between this date and [DATE] will be trained by an accredited trainer. The facility's Human Resources Director will develop a tickler system to ensure all CPR/AED certifications remain current and will be responsible for monitoring the certifications to ensure currency. She will be trained by the Regional Nurse Consultant by [DATE] by 8:00 PM. The facility's Director of Nursing will be responsible for ensuring each shift has at least one clinical staff member who is currently CPR/AED trained. The Assistant Director of Nursing or the Administrator will act in her absence. She will be trained by the Regional Nurse Consultant by [DATE] by 8:00 PM. (See attachment B for work schedule for [DATE] - [DATE].) An audit of all clinical employees' personnel files verified 1 LVN under restriction by the State Board of Nursing. For the one employee on stipulations, the DON, Human Resources Director and Administrator will review her stipulations and develop a plan to ensure the facility complies with the board's expectations by [DATE] at 8:00 PM. For applicants with board stipulations, The Director of Nursing, Human Resources Director, and the Administrator will review the application and documented stipulations and develop a plan before hire that ensures the facility can remain in compliance with the board's expectations. They will be trained by the Regional Nurse Consultant by [DATE] at 8:00 PM. Scheduling for employees under licensing board restrictions will be monitored by the facility's Director of Nursing and Administrator in order to be compliant with all restrictions written by these boards. The effectiveness of this process will be reviewed at least monthly by the DON and Administrator and at least quarterly by the QAA committee. The facility's Medical Director was notified of the Immediate Jeopardy on [DATE]. The investigator monitored the current Plan of Removal from [DATE] at 4:30 PM until [DATE] at 8:10 PM as follows: Observation on [DATE] at 5:30 PM reflected four (4) LVNs and 19 CNA's receiving CPR/AED training from an accredited CPR/AED Trainer Review of the accredited CPR/AED Trainer's sign-in sheets dated [DATE] at 5:30 PM reflected signatures from four (4) LVNs and 19 CNA's. In an interview on [DATE] at 4:45 PM the Human Resources Director stated she had been trained by the Regional Nurse Consultant on her responsibilities for monitoring currency of CPR/AET training for all facility employees. The Human Resources Director further stated she had received training for review of all staff with board restrictions and how to ensure the facility would be able to comply with all restrictions set by the respective boards. In interviews on [DATE] the facility's Administrator and Assistant Director of Nursing stated they had received training from the Regional Nurse Consultant on the subject of monitoring staffing schedules to ensure all shifts have a CPR/AED trained clinical employee assigned. The Administrator and ADON further stated they had received training for review of all staff with board restrictions and how to ensure the facility would be able to comply with all restrictions set by the respective boards. Review of the facility's Nurse and Aide schedules dated [DATE] - [DATE] reflected all shifts to have no less than one (1) clinical employee that has current CPR/AED training. On [DATE] at 8:10 PM the Administrator was informed the IJ was removed. However the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of removal. The Administrator provide a list of 35 residents listed as Full Code requesting CPR/AED use when needed. Non-Immediate Jeopardy B) Review of RN J's employment file reflected the RN had a State Board of Nursing order dated [DATE] that imposed restrictions on the RN's employment. The RN had been found to have falsely documented withdrawal of medications from the facility's dispensing system for the purpose of providing the medications for patients. The RN had, in fact, taken the medications ([MEDICATION NAME], Toradal, and [MEDICATION NAME]) for her own use. It had been additionally determined that RN J had tested positive for the consumption of Opiates, Benzodiazepines, Tricyclic and Antidepressants and had been under the influence of these narcotics while on duty caring for patients. Terms and Conditions of Employment for employment at the current facility, dated [DATE] reflected Nurse will not have access to controlled medications or other abusable medications during first six (6) months of work. Access includes counting or administering controlled or usable medications, witnessing wastage, pharmacy receipt of controlled or abusable medications, or ability to access storage areas for controlled or usable medications. In an interview on [DATE] at 2:21 PM RN J stated she had begun employment at the facility in late September of 2015 and had notified the facility of her restricted status at the time of her interview. The RN further stated she provided a copy of the board's findings at the same time. RN J further stated she had been aware that she was restricted from access to controlled medications but she had not been aware that having a key to the medication narcotic cabinet constituted access to controlled narcotics. RN J stated there was currently [MEDICATION NAME] locked in the cabinet she had access to. The RN further stated that she had been informed on that day that she would not be allowed to keep keys to the medication carts or medication room. RN J further stated she had been sanctioned by the board after admitting to diversion of narcotics for her own personal use. In an interview on [DATE] at 1:20 PM The Regional Nurse Consultant stated RN J did have access to controlled narcotics in that she had carried a key to a medication cart that included a narcotic's compartment. RN J also had a key to the narcotics compartment. The RNC further stated RN J had just been informed that she would no longer have access to the medication carts. The RNC stated she did not know why the RN had been allowed to carry the keys. The Administrator provide a list of 27 residents who received controlled narcotic medication.

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit neglect for one (1) of nine (9) residents reviewed for neglect. (Resident #1). A) The facility failed to ensure LVN A was supervised by a designated RN or LVN on the same unit, as mandated by the Texas Board of Nursing. On [DATE], LVN A failed to administer immediate CPR when Resident #1 was found unresponsive, not breathing and without a pulse. Resident # 1 was pronounced dead upon arrival to the emergency room . This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as pattern. This deficient practice could place 35 residents, identified as full code, at risk for delayed emergency care resulting in increased injury or death. Non-Immediate Jeopardy B) The facility failed to properly supervise another nurse (RN J) according to the orders set forth from the state board of nursing's employment requirements mandating RN J had no access to controlled narcotic medication for six months beginning [DATE]. The facility had provided RN J with a key to the controlled narcotic cabinet. This deficient practice placed 27 residents who received controlled narcotic medication at risk for loss of medication and adverse affects of not having their medication. Findings include: Review of the facility's Policy and Procedures for Cardiopulmonary Resuscitation dated ,[DATE] reflected Depending on the underlying cause, the chances of surviving SCA (Sudden [MEDICAL CONDITION]) may be increased if CPR is initiated immediately upon collapse. The policy and procedure further reflected Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. Review of the facility's Policy and Procedures for Abuse and Neglect - Clinical Protocol dated ,[DATE] reflected Neglect means failure to provide goods and services to necessary to avoid physical harm, mental anguish, or mental illness. A) Review of Resident #1's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses' included Obstructive Sleep Apnea, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and [MEDICAL CONDITION]. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 11 indicating moderate cognitive impairment. The resident's height was 71 inches and weight was 297 pounds. Review of Resident #1's Care Plan dated [DATE] reflected a problem of Artery/[MEDICAL CONDITION] Approaches included, medications, laboratory tests, and diet as ordered. Vital signs as ordered. Remind resident to report chest pains, shortness of breath, heart palpitations, and abnormal pulse. The Care Plan reflected the resident was Full Code. Review of the local EMS incident log for Resident #1 reflected 911 was called on [DATE] at 4:06 AM. The ambulance arrived at the facility at 4:10 AM and departed for the local hospital at 4:55 AM. Review of Resident #1's local hospital death report reflected the resident was pronounced dead [DATE] at 5:08 AM. Review of the facility's Provider Investigation Report dated [DATE] reflected the facility investigated an allegation of neglect regarding the death of Resident #1. The neglect allegation had been lodged by CNA F alleging Resident #1 could have received more effective care from LVN A. These allegations were made based on CNA F's having heard various accounts of the incident from other staff members. In an interview on [DATE] at 2:20 PM CNA F stated on [DATE] at about 4:00 or 4:30 in the morning LVN C appeared shaken as she approached her. The CNA further stated LVN C stated (Resident #1) may have passed. CNA F further stated CNA G spoke to her after the incident and had stated He was gurgling and coughing. In an interview on [DATE] at 8:05 AM the Administrator stated The staff did not know policy and procedures for CPR prior to the incident on [DATE]. They didn't work as a team. There was some back and forth on what everyone should do. In an interview on [DATE] at 10:30 AM LVN A stated she didn't know for sure what time it was when she heard a cough down the hall. LVN A stated the entire event from the time she heard the cough until the paramedics got there was only a couple of minutes. She got up and went to see if it was Resident #1 that had coughed and she was alone when she went into the room. She saw spittle on his face, she called his name while shaking him two (2) times. She checked his pulse and there was none. LVN A stated he was on his back and his face was turned to the left. LVN A stated she ran past CNA G to the desk and dialed 911 and at the same time she hollered to the other nurse at the other nurse station and motioned for her to come hurriedly to LVN A's unit. LVN A only remembered LVN C coming by the desk one time with the crash cart and yelling at her to get off the phone and help her start CPR. LVN A stated the dispacher at 911 was telling her to calm down and breathe and tell her what her name was, where she was calling from, what was the nature of the call and many more questions. LVN A stated she told the 911 operator; (Facility Name), (Resident #1), he is a full code and needed assistance and her name was (LVN A) and that she had to do CPR. LVN A stated at that point she put the phone on the desk and ran back to the room. LVN A stated the crash cart was kept by LVN C's nurse desk at the other end of the hall. LVN A stated she and three (3) aides placed Resident #1 on the back board they retrieved from the crash cart. LVN A stated she began chest compressions immediately and stated Resident #1 had so much stomach contents coming out of his mouth. LVN A stated there was a suction machine on the cart but the paramedics were there so quickly they got their suction machine out and cleared the airway and used an Ambu bag (A hand-held device used to provide positive pressure ventilation) to provide rescue breaths. LVN A stated LVN C did not attempt to assist in any manner. LVN A stated LVN C did not assist in the back board placement, direct the aides in CPR or assist in compressions or airway clearance. LVN A stated she did not believe anyone got the Ambu bag out or the suction machine. LVN A stated all of this occurred prior to the arrival of EMS. Review of CNA G's written statement dated [DATE] at 3:45 AM reflected: I checked him (Resident #1) and he was snoring, there were no signs of distress. I then left his room and went to (another resident's) room which is immediately across the hall from his. As I began to provide for (another resident) I heard this loud gasp and it came from Resident #1's room. I leave (the other resident's) room, go to (Resident #1's) room and the nurse (LVN A) is right behind me. She said she heard his gasp from the desk. We found him lying there with this thick mucus like substance running down his cheeks. The nurse checked for a pulse and tried to get a response from him by shaking and shouting (Resident #1's name) Are you all right? When she got no response she ran to the desk Call down the hall and asked (LVN C) to bring the crash cart. She (LVN A) runs back to (Resident #1) and began CPR. Review of LVN A's Nurse's Noted dated [DATE] at 3:30 AM reflected Resident snoring loudly then heard coughing/gagging sound from room. Noted spittle on left side of face. Body cool to touch and non-responsive. Called aide to dial 911. Initiated CPR. Other nurse brought crash cart. All 4 nurses placed back board under patient and continued CPR. EMT arrived and took over from nursing. Review of LVN A's written statement, undated, for the facility investigation reflected Resident coughing/gurgling sound and noted spittle on face. Felt patient skin was cool. Felt for pulse, 0 pulse. (CNA G) came. Told her to dial 911. Ran out of room. Dialed 911. Waved for (LVN C) - other nurse, brought crash cart started compressions. Then placed red board under resident. HOB lowered. It took all 4 nurses to roll patient to get board underneath him. Then a few minutes later EMT arrived and took over. In an interview on [DATE] at 3:50 PM LVN C stated she was assigned to the back nurse's station and LVN A was assigned to the front nurse's station on the 10:00 PM to 6:00 AM shift [DATE] - [DATE]. Somewhere between 4:00 AM and 4:15 AM LVN C noted LVN A was waving down the hall to her to come to the front station. LVN C further stated that when she arrived at the front station LVN A pointed towards Resident #1's room. CNA G was standing at the doorway to the resident's room. LVN C entered the room and approached the resident to check the resident. LVN C noted the resident had no pulse and was not breathing. LVN C further stated she told CNA G We need a crash cart. LVN C then ran for the crash cart and told LVN A to get off the phone and begin CPR. When LVN C returned with the crash cart from the back nurse's station, LVN A was still on the phone. LVN C repeated Get off the phone and start CPR. LVN A followed LVN C into the room and initiated CPR while LVN C returned to the front nurse's station. Where the telephone received was off the hook. LVN C picked up the phone, found 911 still on the line, and answered the operator's questions. LVN C further stated she had not been instructed by her superiors to monitor LVN A in any manner. Review of LVN C's Nurse's Note dated [DATE] at 4:15 AM reflected 4:15 AM (approx.) (LVN A) is at her desk station A on the phone looking down to my desk and waving me to come to her. I stood up and began to walk her way and she waved in a faster motion as to hurry up . She continues to talk on the phone while pointing to (Resident #1's) room then the CNA (G) (illegible word) asked me to come check him out because she had just heard him cough and then he was quiet after that. I asked her how long ago the cough was and she stated Just a minute ago or so. Not long at all. I approached (Resident #1) calling his name with no response. He was lying flat on his back in the bed with mucous drainage coming from the sides of his mouth. Eyes fixed, no palpable pulse, no audible heart rate, skin was cold, no responses to sternal rub or physical stimuli. No signs of life were present. I then asked CNA why there was no crash cart or CPR in progress. I then ran to retrieve crash cart myself. On the way back to the room (LVN A) is still standing at desk on the phone watching as I rush to the room. The CNAs around stood watching me as well. I insisted (LVN A) get off of the phone to initiate CPR or at least participate in the process. I instructed all the CNAs present to assist with getting CPR going. Resident is large and needed multiple people to position for backboard placement. Once (LVN A) and CNAs were initiating CPR I went to ensure it was 911 that was contacted. Review of LVN A's employment file reflected the LVN had no documented evidence of CPR/AED training. Further review of LVN A's employee file reflected a State Board of Nursing order dated [DATE]. The LVN had been found to have failed to initiate cardiopulmonary resuscitation when (a designated Resident #) was found unresponsive in bed. The resident had a full code status and even though 911 was called for emergent transport, CPR was not started until another nurse arrived from a different floor 6 - 10 minutes later. Respondent left the premises for six (6) minutes to pick up a family member. Emergency medical services subsequently transferred the resident to a local acute care facility, where the resident was pronounced deceased shortly after arrival. Respondent's conduct may have contributed to the resident's demise. The order further reflected the following employment requirements. : Direct Supervision: For the first year (four (4) quarters) of employment as a nurse under this order, RESPONDENT SHALL be directly supervised by a Registered Nurse, if licensed as a Registered Nurse, or by a Licensed Vocational Nurse or a Registered Nurse, if licensed as a Licensed Vocational Nurse. Direct Supervision requires another nurse, as applicable, to be working on the same unit as RESPONDENT and immediately available to provide assistance and intervention. Review of 100% of the facility's employee files reflected only 8 of 12 nurses and 8 of 33 aides had proof current CPR training. In an interview on [DATE] at 11:20 AM the RNC stated in response to Resident #1's incident, all staff employees records were reviewed to verify currency in CPR/AED training. Upon learning that several employees did not have proof of training, the Administrator determined it was necessary to begin training of all uncertified employees as soon as possible. In an interview on [DATE] at 2:30 PM the Administrator stated he was not aware that LVN A's sanctions required her to be supervised by another LVN or an RN on the same unit. If I had known about it. Yes when asked if he had considered having an LVN work the same unit as LVN A. The Administrator further stated that LVN A had initially worked with another LVN during the first week or so of LVN A's employment. After that initial phase, LVN A was assigned as shift charge nurse working either of two (2) nurse's stations on each side of the building. The Administrator further stated he had not been aware of LVN A's CPR/AED training status. The facility Administrator was notified on [DATE] at 11:49 AM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 4:30 PM: All clinical staff to include Registered Nurses, Licensed Vocational Nurses, Certified Nurse's Assistants, Medication Aides, and Restorative Aides are responsible for performing CPR and using AEDs. On line certifications will no longer be considered valid. Certifications will only be accepted per CMS regulations. An audit of all clinical employees' files on [DATE] verified 8 of 14 Nurses (RNs and LVNs) had documentation of current CPR/AED training. 4 LVNs have signed up for a CPR/AED class to be conducted at the facility on [DATE] at 5:30 PM by an accredited CPR/AED trainer. (See attachment A) for documentation of CPR/AED trainer. This will result in a rate of 85.7% with certification. The other 2 nurses will not be allowed to work until they provide proof of certification. The same employee file audit verified 9 of 33 Aides (CNA, MA, RA) had documentation of current CPR/AED training. 17 aides have signed up for a CPR/AED class to be conducted at the facility on [DATE] at 5:30 PM by an accredited CPR/AED trainer. One employee will send the facility a valid current CPR card by [DATE] at 8:00 PM. This will result in a rate of 81.8% with certification. The last 6 CNAs will need to provide verification of their CPR training by [DATE]. These CNAs will not work shifts unless they are supervised by staff with current CPR certifications. Those CNAs who fail to submit verifications by [DATE] will not be allowed to work. Proof of each staff member's current certification will be kept in the staff 's personnel file. Upon hire, direct care staff will be required to show evidence of CPR/AED certification. (LVN K), who works for the facility, has received CPR/AED instructor training and will be able to start conducting CPR/AED classes after [DATE] and will be responsible for conducting CPR/AED classes as required and routinely as part of orientation. Clinical Staff members hired between this date and [DATE] will be trained by an accredited trainer. The facility's Human Resources Director will develop a tickler system to ensure all CPR/AED certifications remain current and will be responsible for monitoring the certifications to ensure currency. She will be trained by the Regional Nurse Consultant by [DATE] by 8:00 PM. The facility's Director of Nursing will be responsible for ensuring each shift has at least one clinical staff member who is currently CPR/AED trained. The Assistant Director of Nursing or the Administrator will act in her absence. She will be trained by the Regional Nurse Consultant by [DATE] by 8:00 PM. (See attachment B for work schedule for [DATE] - [DATE].) An audit of all clinical employees' personnel files verified 1 LVN under restriction by the State Board of Nursing. For the one employee on stipulations, the DON, Human Resources Director and Administrator will review her stipulations and develop a plan to ensure the facility complies with the board's expectations by [DATE] at 8:00 PM. For applicants with board stipulations, The Director of Nursing, Human Resources Director, and the Administrator will review the application and documented stipulations and develop a plan before hire that ensures the facility can remain in compliance with the board's expectations. They will be trained by the Regional Nurse Consultant by [DATE] at 8:00 PM. Scheduling for employees under licensing board restrictions will be monitored by the facility's Director of Nursing and Administrator in order to be compliant with all restrictions written by these boards. The effectiveness of this process will be reviewed at least monthly by the DON and Administrator and at least quarterly by the QAA committee. The facility's Medical Director was notified of the Immediate Jeopardy on [DATE]. The investigator monitored the current Plan of Removal from [DATE] at 4:30 PM until [DATE] at 8:10 PM as follows: Observation on [DATE] at 5:30 PM reflected four (4) LVNs and 19 CNA's receiving CPR/AED training from an accredited CPR/AED Trainer Review of the accredited CPR/AED Trainer's sign-in sheets dated [DATE] at 5:30 PM reflected signatures from four (4) LVNs and 19 CNA's. In an interview on [DATE] at 4:45 PM the Human Resources Director stated she had been trained by the Regional Nurse Consultant on her responsibilities for monitoring currency of CPR/AET training for all facility employees. The Human Resources Director further stated she had received training for review of all staff with board restrictions and how to ensure the facility would be able to comply with all restrictions set by the respective boards. In interviews on [DATE] the facility's Administrator and Assistant Director of Nursing stated they had received training from the Regional Nurse Consultant on the subject of monitoring staffing schedules to ensure all shifts have a CPR/AED trained clinical employee assigned. The Administrator and ADON further stated they had received training for review of all staff with board restrictions and how to ensure the facility would be able to comply with all restrictions set by the respective boards. Review of the facility's Nurse and Aide schedules dated [DATE] - [DATE] reflected all shifts to have no less than one (1) clinical employee that has current CPR/AED training. On [DATE] at 8:10 PM the Administrator was informed the IJ was removed. However the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of removal. The Administrator provide a list of 35 residents listed as Full Code requesting CPR/AED use when needed. Non-Immediate Jeopardy B) Review of RN J's employment file reflected the RN had a State Board of Nursing order dated [DATE] that imposed restrictions on the RN's employment. The RN had been found to have falsely documented withdrawal of medications from the facility's dispensing system for the purpose of providing the medications for patients. The RN had, in fact, taken the medications ([MEDICATION NAME], Toradal, and [MEDICATION NAME]) for her own use. It had been additionally determined that RN J had tested positive for the consumption of Opiates, Benzodiazepines, Tricyclic and Antidepressants and had been under the influence of these narcotics while on duty caring for patients. Terms and Conditions of Employment for employment at the current facility, dated [DATE] reflected Nurse will not have access to controlled medications or other abusable medications during first six (6) months of work. Access includes counting or administering controlled or usable medications, witnessing wastage, pharmacy receipt of controlled or abusable medications, or ability to access storage areas for controlled or usable medications. In an interview on [DATE] at 2:21 PM RN J stated she had begun employment at the facility in late September of 2015 and had notified the facility of her restricted status at the time of her interview. The RN further stated she provided a copy of the board's findings at the same time. RN J further stated she had been aware that she was restricted from access to controlled medications but she had not been aware that having a key to the medication narcotic cabinet constituted access to controlled narcotics. RN J stated there was currently [MEDICATION NAME] locked in the cabinet she had access to. The RN further stated that she had been informed on that day that she would not be allowed to keep keys to the medication carts or medication room. RN J further stated she had been sanctioned by the board after admitting to diversion of narcotics for her own personal use. In an interview on [DATE] at 1:20 PM The Regional Nurse Consultant stated RN J did have access to controlled narcotics in that she had carried a key to a medication cart that included a narcotic's compartment. RN J also had a key to the narcotics compartment. The RNC further stated RN J had just been informed that she would no longer have access to the medication carts. The RNC stated she did not know why the RN had been allowed to carry the keys. The Administrator provide a list of 27 residents who received controlled narcotic medication.

Based on interview and record review the Administrator failed to administer the facility in a manner that enabled it to use it's resources effectively and efficiently to attain and maintain the highest practible physical, mental, and psychosocial well-being of each resident for one (1) of one (1) facility when: The Administrator failed to ensure LVN A was supervised by an RN or LVN on the same unit, as mandated by the Texas Board of Nursing. A) On [DATE] LVN A failed to initiate immediate CPR when Resident # 1 was found unresponsive, not breathing and without a pulse. Resident # 1 was pronounced dead upon arrival to the emergency room . This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as pattern. This deficient practice could place 35 residents, identified as full code, at risk for delayed emergency care resulting in increased injury or death. Non-Immediate Jeopardy B) The Administrator also failed to ensure RN J was properly supervise as mandated by the Texas Board of Nursing. RN J was was provided a key to the controlled narcotic cabinet when her restrictions mandated she was to have no access to controlled narcotic medication for six months beginning [DATE]. This deficient practice placed 27 residents who received controlled narcotic medication at risk for loss of medication and adverse affects of not having their medication. Findings include: A) Review of Resident #1's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses' included Obstructive Sleep Apnea, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and [MEDICAL CONDITION]. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 11 indicating moderate cognitive impairment. The resident's height was 71 inches and weight was 297 pounds. Review of Resident #1's Care Plan dated [DATE] reflected a problem of Artery/[MEDICAL CONDITION] Approaches included, medications, laboratory tests, and diet as ordered. Vital signs as ordered. Remind resident to report chest pains, shortness of breath, heart palpitations, and abnormal pulse. The Care Plan reflected the resident was Full Code. Review of the local EMS incident log for Resident #1 reflected 911 was called on [DATE] at 4:06 AM. The ambulance arrived at the facility at 4:10 AM and departed for the local hospital at 4:55 AM. Review of Resident #1's local hospital death report reflected the resident was pronounced dead [DATE] at 5:08 AM. Review of the facility's Provider Investigation Report dated [DATE] reflected the facility investigated an allegation of neglect regarding the death of Resident #1. The neglect allegation had been lodged by CNA F alleging Resident #1 could have received more effective care from LVN A. These allegations were made based on CNA F's having heard various accounts of the incident from other staff members. In an interview on [DATE] at 2:20 PM CNA F stated on [DATE] at about 4:00 or 4:30 in the morning LVN C appeared shaken as she approached her. The CNA further stated LVN C stated (Resident #1) may have passed. CNA F further stated CNA G spoke to her after the incident and had stated He was gurgling and coughing. In an interview on [DATE] at 8:05 AM the Administrator stated The staff did not know policy and procedures for CPR prior to the incident on [DATE]. They didn't work as a team. There was some back and forth on what everyone should do. In an interview on [DATE] at 10:30 AM LVN A stated she didn't know for sure what time it was when she heard a cough down the hall. LVN A stated the entire event from the time she heard the cough until the paramedics got there was only a couple of minutes. She got up and went to see if it was Resident #1 that had coughed and she was alone when she went into the room. She saw spittle on his face, she called his name while shaking him two (2) times. She checked his pulse and there was none. LVN A stated he was on his back and his face was turned to the left. LVN A stated she ran past CNA G to the desk and dialed 911 and at the same time she hollered to the other nurse at the other nurse station and motioned for her to come hurriedly to LVN A's unit. LVN A only remembered LVN C coming by the desk one time with the crash cart and yelling at her to get off the phone and help her start CPR. LVN A stated the dispacher at 911 was telling her to calm down and breathe and tell her what her name was, where she was calling from, what was the nature of the call and many more questions. LVN A stated she told the 911 operator; (Facility Name), (Resident #1), he is a full code and needed assistance and her name was (LVN A) and that she had to do CPR. LVN A stated at that point she put the phone on the desk and ran back to the room. LVN A stated the crash cart was kept by LVN C's nurse desk at the other end of the hall. LVN A stated she and three (3) aides placed Resident #1 on the back board they retrieved from the crash cart. LVN A stated she began chest compressions immediately and stated Resident #1 had so much stomach contents coming out of his mouth. LVN A stated there was a suction machine on the cart but the paramedics were there so quickly they got their suction machine out and cleared the airway and used an Ambu bag (A hand-held device used to provide positive pressure ventilation) to provide rescue breaths. LVN A stated LVN C did not attempt to assist in any manner. LVN A stated LVN C did not assist in the back board placement, direct the aides in CPR or assist in compressions or airway clearance. LVN A stated she did not believe anyone got the Ambu bag out or the suction machine. LVN A stated all of this occurred prior to the arrival of EMS. Review of CNA G's written statement dated [DATE] at 3:45 AM reflected: I checked him (Resident #1) and he was snoring, there were no signs of distress. I then left his room and went to (another resident's) room which is immediately across the hall from his. As I began to provide for (another resident) I heard this loud gasp and it came from Resident #1's room. I leave (the other resident's) room, go to (Resident #1's) room and the nurse (LVN A) is right behind me. She said she heard his gasp from the desk. We found him lying there with this thick mucus like substance running down his cheeks. The nurse checked for a pulse and tried to get a response from him by shaking and shouting (Resident #1's name) Are you all right? When she got no response she ran to the desk Call down the hall and asked (LVN C) to bring the crash cart. She (LVN A) runs back to (Resident #1) and began CPR. Review of LVN A's Nurse's Noted dated [DATE] at 3:30 AM reflected Resident snoring loudly then heard coughing/gagging sound from room. Noted spittle on left side of face. Body cool to touch and non-responsive. Called aide to dial 911. Initiated CPR. Other nurse brought crash cart. All 4 nurses placed back board under patient and continued CPR. EMT arrived and took over from nursing. Review of LVN A's written statement, undated, for the facility investigation reflected Resident coughing/gurgling sound and noted spittle on face. Felt patient skin was cool. Felt for pulse, 0 pulse. (CNA G) came. Told her to dial 911. Ran out of room. Dialed 911. Waved for (LVN C) - other nurse, brought crash cart started compressions. Then placed red board under resident. HOB lowered. It took all 4 nurses to roll patient to get board underneath him. Then a few minutes later EMT arrived and took over. In an interview on [DATE] at 3:50 PM LVN C stated she was assigned to the back nurse's station and LVN A was assigned to the front nurse's station on the 10:00 PM to 6:00 AM shift [DATE] - [DATE]. Somewhere between 4:00 AM and 4:15 AM LVN C noted LVN A was waving down the hall to her to come to the front station. LVN C further stated that when she arrived at the front station LVN A pointed towards Resident #1's room. CNA G was standing at the doorway to the resident's room. LVN C entered the room and approached the resident to check the resident. LVN C noted the resident had no pulse and was not breathing. LVN C further stated she told CNA G We need a crash cart. LVN C then ran for the crash cart and told LVN A to get off the phone and begin CPR. When LVN C returned with the crash cart from the back nurse's station, LVN A was still on the phone. LVN C repeated Get off the phone and start CPR. LVN A followed LVN C into the room and initiated CPR while LVN C returned to the front nurse's station. Where the telephone received was off the hook. LVN C picked up the phone, found 911 still on the line, and answered the operator's questions. LVN C further stated she had not been instructed by her superiors to monitor LVN A in any manner. Review of LVN C's Nurse's Note dated [DATE] at 4:15 AM reflected 4:15 AM (approx.) (LVN A) is at her desk station A on the phone looking down to my desk and waving me to come to her. I stood up and began to walk her way and she waved in a faster motion as to hurry up . She continues to talk on the phone while pointing to (Resident #1's) room then the CNA (G) (illegible word) asked me to come check him out because she had just heard him cough and then he was quiet after that. I asked her how long ago the cough was and she stated Just a minute ago or so. Not long at all. I approached (Resident #1) calling his name with no response. He was lying flat on his back in the bed with mucous drainage coming from the sides of his mouth. Eyes fixed, no palpable pulse, no audible heart rate, skin was cold, no responses to sternal rub or physical stimuli. No signs of life were present. I then asked CNA why there was no crash cart or CPR in progress. I then ran to retrieve crash cart myself. On the way back to the room (LVN A) is still standing at desk on the phone watching as I rush to the room. The CNAs around stood watching me as well. I insisted (LVN A) get off of the phone to initiate CPR or at least participate in the process. I instructed all the CNAs present to assist with getting CPR going. Resident is large and needed multiple people to position for backboard placement. Once (LVN A) and CNAs were initiating CPR I went to ensure it was 911 that was contacted. Review of LVN A's employment file reflected the LVN had no documented evidence of CPR/AED training. Further review of LVN A's employee file reflected a State Board of Nursing order dated [DATE]. The LVN had been found to have failed to initiate cardiopulmonary resuscitation when (a designated Resident #) was found unresponsive in bed. The resident had a full code status and even though 911 was called for emergent transport, CPR was not started until another nurse arrived from a different floor 6 - 10 minutes later. Respondent left the premises for six (6) minutes to pick up a family member. Emergency medical services subsequently transferred the resident to a local acute care facility, where the resident was pronounced deceased shortly after arrival. Respondent's conduct may have contributed to the resident's demise. The order further reflected the following employment requirements. : Direct Supervision: For the first year (four (4) quarters) of employment as a nurse under this order, RESPONDENT SHALL be directly supervised by a Registered Nurse, if licensed as a Registered Nurse, or by a Licensed Vocational Nurse or a Registered Nurse, if licensed as a Licensed Vocational Nurse. Direct Supervision requires another nurse, as applicable, to be working on the same unit as RESPONDENT and immediately available to provide assistance and intervention. Review of 100% of the facility's employee files reflected only 8 of 12 nurses and 8 of 33 aides had proof current CPR training. In an interview on [DATE] at 11:20 AM the RNC stated in response to Resident #1's incident, all staff employees records were reviewed to verify currency in CPR/AED training. Upon learning that several employees did not have proof of training, the Administrator determined it was necessary to begin training of all uncertified employees as soon as possible. In an interview on [DATE] at 2:30 PM the Administrator stated he was not aware that LVN A's sanctions required her to be supervised by another LVN or an RN on the same unit. If I had known about it. Yes when asked if he had considered having an LVN work the same unit as LVN A. The Administrator further stated that LVN A had initially worked with another LVN during the first week or so of LVN A's employment. After that initial phase, LVN A was assigned as shift charge nurse working either of two (2) nurse's stations on each side of the building. The Administrator further stated he had not been aware of LVN A's CPR/AED training status. Review of the facility's Policy and Procedures for Cardiopulmonary Resuscitation dated ,[DATE] reflected Depending on the underlying cause, the chances of surviving SCA (Sudden [MEDICAL CONDITION]) may be increased if CPR is initiated immediately upon collapse. The policy and procedure further reflected Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. Review of the facility's Policy and Procedures for Abuse and Neglect - Clinical Protocol dated ,[DATE] reflected Neglect means failure to provide goods and services to necessary to avoid physical harm, mental anguish, or mental illness. The facility Administrator was notified on [DATE] at 11:49 AM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 4:30 PM: All clinical staff to include Registered Nurses, Licensed Vocational Nurses, Certified Nurse's Assistants, Medication Aides, and Restorative Aides are responsible for performing CPR and using AEDs. On line certifications will no longer be considered valid. Certifications will only be accepted per CMS regulations. An audit of all clinical employees' files on [DATE] verified 8 of 14 Nurses (RNs and LVNs) had documentation of current CPR/AED training. 4 LVNs have signed up for a CPR/AED class to be conducted at the facility on [DATE] at 5:30 PM by an accredited CPR/AED trainer. (See attachment A) for documentation of CPR/AED trainer. This will result in a rate of 85.7% with certification. The other 2 nurses will not be allowed to work until they provide proof of certification. The same employee file audit verified 9 of 33 Aides (CNA, MA, RA) had documentation of current CPR/AED training. 17 aides have signed up for a CPR/AED class to be conducted at the facility on [DATE] at 5:30 PM by an accredited CPR/AED trainer. One employee will send the facility a valid current CPR card by [DATE] at 8:00 PM. This will result in a rate of 81.8% with certification. The last 6 CNAs will need to provide verification of their CPR training by [DATE]. These CNAs will not work shifts unless they are supervised by staff with current CPR certifications. Those CNAs who fail to submit verifications by [DATE] will not be allowed to work. Proof of each staff member's current certification will be kept in the staff 's personnel file. Upon hire, direct care staff will be required to show evidence of CPR/AED certification. (LVN K), who works for the facility, has received CPR/AED instructor training and will be able to start conducting CPR/AED classes after [DATE] and will be responsible for conducting CPR/AED classes as required and routinely as part of orientation. Clinical Staff members hired between this date and [DATE] will be trained by an accredited trainer. The facility's Human Resources Director will develop a tickler system to ensure all CPR/AED certifications remain current and will be responsible for monitoring the certifications to ensure currency. She will be trained by the Regional Nurse Consultant by [DATE] by 8:00 PM. The facility's Director of Nursing will be responsible for ensuring each shift has at least one clinical staff member who is currently CPR/AED trained. The Assistant Director of Nursing or the Administrator will act in her absence. She will be trained by the Regional Nurse Consultant by [DATE] by 8:00 PM. (See attachment B for work schedule for [DATE] - [DATE].) An audit of all clinical employees' personnel files verified 1 LVN under restriction by the State Board of Nursing. For the one employee on stipulations, the DON, Human Resources Director and Administrator will review her stipulations and develop a plan to ensure the facility complies with the board's expectations by [DATE] at 8:00 PM. For applicants with board stipulations, The Director of Nursing, Human Resources Director, and the Administrator will review the application and documented stipulations and develop a plan before hire that ensures the facility can remain in compliance with the board's expectations. They will be trained by the Regional Nurse Consultant by [DATE] at 8:00 PM. Scheduling for employees under licensing board restrictions will be monitored by the facility's Director of Nursing and Administrator in order to be compliant with all restrictions written by these boards. The effectiveness of this process will be reviewed at least monthly by the DON and Administrator and at least quarterly by the QAA committee. The facility's Medical Director was notified of the Immediate Jeopardy on [DATE]. The investigator monitored the current Plan of Removal from [DATE] at 4:30 PM until [DATE] at 8:10 PM as follows: Observation on [DATE] at 5:30 PM reflected four (4) LVNs and 19 CNA's receiving CPR/AED training from an accredited CPR/AED Trainer Review of the accredited CPR/AED Trainer's sign-in sheets dated [DATE] at 5:30 PM reflected signatures from four (4) LVNs and 19 CNA's. In an interview on [DATE] at 4:45 PM the Human Resources Director stated she had been trained by the Regional Nurse Consultant on her responsibilities for monitoring currency of CPR/AET training for all facility employees. The Human Resources Director further stated she had received training for review of all staff with board restrictions and how to ensure the facility would be able to comply with all restrictions set by the respective boards. In interviews on [DATE] the facility's Administrator and Assistant Director of Nursing stated they had received training from the Regional Nurse Consultant on the subject of monitoring staffing schedules to ensure all shifts have a CPR/AED trained clinical employee assigned. The Administrator and ADON further stated they had received training for review of all staff with board restrictions and how to ensure the facility would be able to comply with all restrictions set by the respective boards. Review of the facility's Nurse and Aide schedules dated [DATE] - [DATE] reflected all shifts to have no less than one (1) clinical employee that has current CPR/AED training. On [DATE] at 8:10 PM the Administrator was informed the IJ was removed. However the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of removal. The Administrator provide a list of 35 residents listed as Full Code requesting CPR/AED use when needed. Non-Immediate Jeopardy B) Review of RN J's employment file reflected the RN had a State Board of Nursing order dated [DATE] that imposed restrictions on the RN's employment. The RN had been found to have falsely documented withdrawal of medications from the facility's dispensing system for the purpose of providing the medications for patients. The RN had, in fact, taken the medications ([MEDICATION NAME], Toradal, and [MEDICATION NAME]) for her own use. It had been additionally determined that RN J had tested positive for the consumption of Opiates, Benzodiazepines, Tricyclic and Antidepressants and had been under the influence of these narcotics while on duty caring for patients. Terms and Conditions of Employment for employment at the current facility, dated [DATE] reflected Nurse will not have access to controlled medications or other abusable medications during first six (6) months of work. Access includes counting or administering controlled or usable medications, witnessing wastage, pharmacy receipt of controlled or abusable medications, or ability to access storage areas for controlled or usable medications. In an interview on [DATE] at 2:21 PM RN J stated she had begun employment at the facility in late September of 2015 and had notified the facility of her restricted status at the time of her interview. The RN further stated she provided a copy of the board's findings at the same time. RN J further stated she had been aware that she was restricted from access to controlled medications but she had not been aware that having a key to the medication narcotic cabinet constituted access to controlled narcotics. RN J stated there was currently [MEDICATION NAME] locked in the cabinet she had access to. The RN further stated that she had been informed on that day that she would not be allowed to keep keys to the medication carts or medication room. RN J further stated she had been sanctioned by the board after admitting to diversion of narcotics for her own personal use. In an interview on [DATE] at 1:20 PM The Regional Nurse Consultant stated RN J did have access to controlled narcotics in that she had carried a key to a medication cart that included a narcotic's compartment. RN J also had a key to the narcotics compartment. The RNC further stated RN J had just been informed that she would no longer have access to the medication carts. The RNC stated she did not know why the RN had been allowed to carry the keys. The Administrator provide a list of 27 residents who received controlled narcotic medication.

Based on observation, interview and record review the facility failed to implement policies and procedures for 4 of 6 residents reviewed for pressure ulcers (Residents #1,#3, #7 and #17). A. The facility failed to prevent Resident #7 from the developing 18 pressure ulcers. Resident # 7 was diagnosed with [REDACTED]. The facility failed to provide pressure reducing devices and skin assessments to identify pressure ulcers for Resident #7. Resident # 7 was taken to the hospital for dehydration and evaluation of his pressure ulcers. B. The facility failed to prevent a pressure ulcer on Resident #1's coccyx from advancing from a Stage 1 to a Stage 2. Resident #1 was left up in a reclining wheelchair for long periods of time without a pressure relieving devices. Resident #1 did not have a physician ordered treatment dressing on his coccyx on 12/07/11 at 5:00 PM. The last documented treatment was on 12/03/11, or more than 72 hours prior to the next treatment. There was no documentation for assessment and treatment of [REDACTED]. C. The facility failed to identify, assess and treat facility acquired pressure ulcers for Residents #3 and #17. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 12/08/11 at 12:15 PM. While the IJ was lifted on 12/09/11 at 2:00 PM, the facility remained out of compliance at a scope of pattern and severity level of actual harm that is not IJ because all measures for prevention and treatment of [REDACTED]. This deficient practice contributed to the development of new pressure ulcers and the worsening of existing pressure ulcers for Residents #1, #3, #7 and #17. These failures could place the additional 2 residents identified at risk for developing new pressure ulcers, that could lead to additional medical complications. Findings include: A. Review of Resident # 7's Admission Face Sheet reflected a [AGE] year old male admitted to facility on 12/09/09. Review of physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. A physician order [REDACTED]. Review of Resident #7's most current quarterly Minimum Data Set (MDS) assessment, dated 11/12/11, reflected that Resident #7 was at risk for pressure ulcers. Review of the Care Plan, dated 8/31/10, reflected Resident #7 had potential for developing skin breakdown related to incontinence. Further review of the Care Plan, updated 11/01/11, reflected Resident #7 had a Stage 2 pressure ulcer on the right buttock. Approaches included barrier cream with each incontinent care and a pressure reducing device for his bed. Review of the Hospital Clinical Pathology Report, dated 11/23/11 reflected Resident #7 was positive [MEDICAL CONDITION] in his left elbow. Review of Interdisciplinary Progress Notes from 11/23/11 to 12/05/11 reflected that Resident #7 remained on contact isolation [MEDICAL CONDITION] infection. Observation on 12/06/11 at 11:30 AM revealed Resident # 7 lying in bed with his elbows bent and his arms pulled close to his sides. His hands were turned downwards towards his chest. There were no positioning devices, pillows or wedges in his bed or in his room to provide for pressure relief. Resident #7 did not have heel protectors on his feet and there were not any located in his room. The pressure relieving bed device was in the off position. Observation on 12/7/11 at 8:00 AM revealed Resident #7 ' s door closed with a Contact Isolation sign in place. Upon entering Resident #7 was observed to be lying on his left side with his right arm pulled tight to his ribs and his hands closed pulled tight against his chest. There were no hand rolls in his hands. There were no pillows or wedges in his bed or in his room to provide for pressure relief. Resident #7 did not have heel protectors on his feet and there were not any in his room. The pressure reducing bed device was in the off position. In an interview at 12/07/11 8:00 AM, LVN N stated, "Resident #7 had been in isolation for a week or more and she had been taking care of him on and off since he had been at the facility." LVN N stated that she used to put rolled up wash-cloths in his hands but, "It looks like they've not been doing it because his hands are a lot more curved." In an interview on 12/07/11 at 2:30 PM LVN M stated Resident #7 would receive assistance to get up for all meals but he has not been up since he has been in isolation and that he ate in bed with assistance from staff. LVN M further stated that she checks on him when she makes her rounds but does not check his skin. Observation on 12/07/11 at 8:50 AM revealed a red circle approximately. 5 centimeters (cm) x 5 cm on Resident #7 ' s left stomach area where his shirt was pulled up. Resident ' s lips were chapped and his tongue and mouth were also dry. The Director of Nurses (DON) came into the resident's room and pulled his shirt down. There was a cup of water on the bed-side table but Resident #7 was unable to reach it. The DON held the cup of water to Resident #7 ' s mouth until he finished drinking. In an interview on 12/07/11 at 8:50 AM, the DON stated the red mark on Resident ' s left stomach area was from him resting his elbow on his stomach and that she had just noticed it. The DON then asked CNA T to prop his left arm on a pillow. However, no other skin areas were addressed at this time. Observation on 12/07/11 at 9:50 AM revealed Resident #7 lying with left foot resting on right lower shin with his knees together. He did not have heel protectors on and his pressure reducing bed was in the off position. Resident #7 ' s arms are pulled tight to his sides and his hands were curled in, resting on his chest. The pressure reducing bed is in the off position. LVN N rolled her treatment cart into his room. LVNs T and L did not don an isolation gown or a mask during wound care procedure that lasted 2.5 hours. LVN L was assisting by holding Resident #7 ' s arm out and holding his hand. Resident #7 was able to bend his right elbow and open his right hand with assistance from LVN L while LVN N provided wound care to his pressure ulcer on right elbow and right chest. Interview on 12/07/11 at 9:50 AM LVN N stated that she was going to perform wound care on Resident #7's left and right elbows only. During an observation on 12/07/11 at 9:50 AM of the (2) two known pressure ulcers (Stage 2 right elbow and healing Stage 1 healing on left elbow) revealed Resident #7 to have additional, unidentified pressure ulcers as follows: 1. LVN N removed the bandage on Resident #7's right inner elbow to expose a Stage 4 pressure ulcer that was infected [MEDICAL CONDITION]. The pressure ulcer measured approximately 6 cm x 6 cm in diameter with the right side having black eschar and the left side exposing a tendon. LVN N tried to wipe Resident #7's tendon that was exposed with a yellow covering, but the yellow covering would not come off. The middle of the pressure ulcer appeared to be approximately 2.5 cm-3 cm deep. LVN N cleansed the wound and applied a gauze dressing. (This was one of the two pressure ulcers that facility had identified as a Stage 2 before the skin assessment). 2. Resident #7 could not bend his left elbow or open his left hand without grimacing, moaning, or pulling away from LVN N. LVN N removed the bandage on Resident #7's left elbow and revealed a healing Stage 1 wound that was red, unblanchable and measured approximately 4 cm x 4 cm. (This was one of the two pressure ulcers that facility had identified as a Stage 1 before the skin assessment). 3. Resident #7 had a Stage 1 pressure ulcer on his right front lower shin where his left foot had been resting, measuring approximately 7 cm x 3 cm with redness that was unblanchable (stayed red) when LVN N pressed the area with her finger. 4. Both of Resident #7's inner knees had Stage 1 unblanchable pressure ulcers the size of silver dollars. 5. Resident 7's left trochanter (hip bone) had an inflamed area approximately 3.4 cm x 2.5 cm with the center Stage 2 (opened area) approximately 2 cm x 1.3 cm. 6. Resident #7 had a Stage 2 (skin was opened) pressure ulcer on his left side chest, below his rib and measured approximately 2.5 cm x 1.3 cm. 7. Resident #7 had a Stage 1, unblanchable pressure ulcer on his medial chest/rib that measured 1 cm x 2 cm. 8. As a result of laying on his left arm, Resident #7 had a Stage 1 pressure ulcer that measured approximately .75 cm raised blister on his left deltoid (shoulder) approximately 5 cm x 5 cm in diameter. 9. Resident #7 ' s had a Stage 1, unblanchable pressure ulcers on his inner right thigh, measuring 9.2 cm x .4 cm. 10. Resident #7 had an unblanchable Stage 1 on his right outer chest rib area measuring 3 cm x 3 cm developed from his right elbow resting on his chest. 11. LVN N and LVN L turned Resident #7 over to expose his buttocks and discovered 2 Stage 2 pressure ulcers with red inflamed skin that extended across the buttocks. Each side of the buttocks had areas that measured approximately 5 cm x 5 cm in diameter surrounded by redness and open skin. 12. Resident #7's right heel had an unstageable pressure ulcer due to an intact, clear colored, fluid filled, blister that measured 6 cm x 6 cm. 13. Resident #7's left heel had an unstageable pressure ulcer due to an intact, clear colored, fluid filled blister that was red, blue, and black on the outside that measured 4 cm x 5 cm. Interview on 12/07/11 at 11:00 LVN N stated she couldn ' t believe that Resident #7 had so many pressure ulcers. Review of Interdisciplinary Progress Notes dated 12/07/11 titled Wounds reflected, Stage 1: 1) Right front lower shin pressure redness 2) Left and Right inner knees pressure redness 3) Left trochanter 3.4 cm x 2.5 cm whole redness included with Stage 2 over trochanter 2 cm x 1.3 cm 4) Left chest below rib/abdominal side 2.5 cm x 1.3 cm 5) Left medial rib/abdominal 2 cm x 2 cm 6) Left deltoid raised, warm redness 7) Left elbow healing wound, but still red 8) Thigh 9.2 cm x .4 cm 9) Right outer chest/rib redness 3 cm x 3 cm Stage 2: 10) Right buttock medial 11) Left buttock medial 12) Left trochanter 2 cm x 1.3 cm 13) Right foot medial first joint off great toe Unstageable: 14) Right heel fluid filled 6 cm x 6 cm 15) Left heel outer red/blue-black 4 cm x 5 cm Stage 4: 16) Right inner [MEDICAL CONDITION] positive In an interview on 12/08/11 at 10:40 AM the Nurse Practitioner (NP) stated, [MEDICAL CONDITION] is something that if occluded (covered and not exposed to air) that there is no reason to keep isolated. Some residents would deteriorate so badly if they couldn ' t go out of the room. In an interview on 12/07/11 at 1:00 PM DON stated that she had talked to Resident 7's wife and let her know that she and the Physician had decided to send her husband to the hospital because of poor skin turgor, dehydration and pressure ulcers. Review of Hospital Emergency Records reflected Resident #7 was admitted to the hospital on [DATE] at 6:30 PM. Hospital triage notes listed as Complaint: Sores on Feet; Chief Complaint: Lethargy." He has multiple bed sores from inactivity; Dry mucus membranes; Contractures of both upper extremities; I have completed a completed comprehensive skin exam and found, patient has multiple decubitus ulcers from being bedridden with right elbow previously cultured [MEDICAL CONDITION]." Further review of Emergency Records reflected [DIAGNOSES REDACTED]. Review of Hospital Physical Therapy Department Records, dated 12/08/11, reflected Resident #7's " right medial (inner) elbow appears to be painful. Demonstrates grimacing and guarding." Observations on 12/7/2011 at 2:30 PM at a local hospital revealed Resident #7 in an isolation room lying on his right side in a fetal position with positioning pillows between his legs, under his shoulder, under both arms, cushioned heel protectors on his feet and covered with two blankets. A foley catheter was in place and was draining brown urine into the collection bag. Resident #7 ' s visible wounds were covered. The charge nurse attending to Resident #7 was awaiting Physical Therapy to complete their assessment. Further observation revealed Resident #7 was sleeping and appeared content. B. Review of Resident #1's Face Sheet reflected he was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1 was at risk for pressure ulcers and Skin Ulcer Treatments reflected application of nonsurgical dressing and application of ointments/medications. Review of Resident #1's Braden Scale score dated 11/03/11 reflected a total score of 14 (indicating moderate risk for pressure ulcers for a total score of 13-14). Review of Resident #1's Care Plan for Decubitus dated 11/15/11 reflected "Stage 2 to Coccyx " on description, updated on 11/29/11 reflected " (no) open/skin closed, (Stage) I (decubitus) (continue) same (treatment), " and updated again on 12/02/11 reflected " small opening 0.3 x 0.2 cm, (Stage) II (decubitus) (continue) [MEDICATION NAME]. " The approaches included " 1. Notify physician of decubitus location with measurements, stage, and drainage; 2. Notify family of change in resident ' s condition; 3. Assess for signs of infection; 4. Treat decubitus as ordered; 5. Eliminate risk factors, i.e. dry moist skin, immobility. Use spenco mattress to (decrease) pressure. 6. Observe for unusual symptoms. Record and report to physician. 7. Turn resident every 2 hours and (as needed). 8. Notify physician if ulcer does not respond to treatment. 9. Measure site each week and report if increasing, chart measurement, color, drainage, etc. " Observation on 12/06/11 at 10:45 AM revealed Resident #1 was lying on his back in his reclining wheelchair. Resident #1 did not have any type of pressure relieving device or pillow in his reclining wheelchair and his bed did not have an air mattress. The resident was not interviewable. During an interview on 12/06/11 at 10:45 AM, LVN K stated Resident #1 had multiple skin tears, but failed to mention the resident had a Stage 2 pressure ulcer. During an interview on 12/06/11 at 3:15 PM, the Director of Nursing (DON) stated Resident #1 had a Stage 1 pressure ulcer. Observation on 12/06/11 from 3:35 PM- 5:45 PM revealed Resident #1 sitting in a reclining wheelchair in the living room. The resident was leaning forward and back attempting to sit up in the reclined chair. Resident #1 did not have a pressure relieving device in the wheelchair. Resident #1 sat in the in the same position in his reclining wheelchair for the entire time from 3:35 PM to at least 5:45 PM. During an interview on 12/07/11 at 8:00 AM, the DON stated Resident #1 had a Stage 1 pressure ulcer to his coccyx when he returned from his stay at the hospital on [DATE]. During an interview on 12/07/11 at 5:35 PM, the DON stated, "Resident #1 returned from the hospital on [DATE] with a Stage 1 pressure ulcer to his coccyx but it healed, and now it has opened today and is a Stage 2 ulcer. " The DON stated Resident #1 does not have an air mattress. Observation on 12/07/11 at 5:00 PM revealed Certified Nurse Aide (CNA) Q and R changing Resident #1's brief. An opened red Stage II pressure ulcer approximately the size of a dime was observed on the resident's coccyx. The pressure ulcer did not have a dressing and/or treatment covering it. CNA Q called Registered Nurse (RN) B in to look at the pressure ulcer. During an interview on 12/07/11 at 5:10 PM, RN B stated, "Resident #1 should have a [MEDICATION NAME] (occlusive [MEDICATION NAME]) dressing and stated the pressure ulcer had been a Stage 1 and was now a stage 2." RN B confirmed the [MEDICATION NAME] dressing was not present and should have been. During an interview on 12/08/11 at 3:30 PM RN B stated she did not document the new status of Resident #1's wound on 12/07/11. RN B stated the wound had already been documented on 12/02/11. During an interview 12/08/11 at 9:41 AM, the DON stated Resident #1's pressure ulcer on his coccyx " opened back up yesterday." The DON stated the nurse should have documented the pressure ulcer reopening on the wound treatment progress notes. The DON confirmed RN B did not document on Resident #1's pressure ulcer. The DON stated Resident #1 is supposed to be turned every 2 hours to prevent worsening of the pressure ulcer. The DON stated she does not have a process of ensuring the CNA's are turning Resident #1 every 2 hours. The DON confirmed Resident #1 did not have any type of cushion in his wheelchair. The DON stated they have Spenco cushions (padded cushion designed for Non-ambulatory patients of all ages who have a low to moderate risk of getting pressure sores) in the hall closet, but they are not gel or pressure relieving. During an interview on 12/08/11 at 10:40 AM the Nurse Practitioner (NP) stated " (Resident #1) should have a good pad in the chair especially since they are aware of (the pressure ulcer)." The NP stated, "I'm surprised that the facility did not have a pressure relieving pad in Resident #1's chair." Review of Resident #1's Treatment Record dated 12/01/11-12/31/11 reflected a treatment originally dated 11/15/11 for " coccyx apply [MEDICATION NAME] every 72 hours and as needed per protocol." The last signature that reflected when this treatment was administered was on 12/03/11. There was not a signature for the treatment until 12/07/11 after the surveyor observed the pressure ulcer without the [MEDICATION NAME] dressing (at least 96 hours later or 4 days after the treatment on 12/03/11). Review of Resident #1's Nurse's Wound Treatment progress notes dated 11/10/11-12/08/11 reflected no documentation on the pressure ulcer except on 12/02/11 a check mark next to pressure ulcer, Stage I. The description reflected " coccyx redness irregular round shape." A note next to M.D. (Medical Doctor) notified reflected " aware upon readmission." Initial measurements reflected " 10 (cm) x 10 (cm) closed." Initial treatment reflected " [MEDICATION NAME] (every) 72 hours." Review of Resident #1's Nurse's Wound Treatment progress notes dated 11/10/11-12/08/11 reflected no documentation on the pressure ulcer except on 12/02/11. The progress note reflected " Stage II to Coccyx, 4 cm x 1.2 cm x .1 cm." This note was signed by LVN K. This information did not match the " Pressure Ulcer Scale for Healing" or "PUSH tool 3.0" documentation that was done on the same day. Review of Resident #1's "Pressure Ulcer Scale for Healing" or "PUSH tool 3.0" dated 11/15/11 reflected an entry on 11/15/11 as an 8 for sub-score for length x width in cm 2 (8.1-12.0 cm2), a 0 for exudate amount (none 0, light 1, moderate 2, heavy 3) and 0 for tissue type (0 closed, 1 [MEDICATION NAME] tissue, 2 granulation tissue, 3 slough, 4 necrotic tissue). The next entry on 11/29/11 reflected a 7 for length x width, 0 for exudate amount and 0 for tissue type. The final entry dated 12/02/11 reflected 7 for length x width, 0 for exudate and 0 for tissue type. There were no other entries. The 12/02/11 entry did not indicate the pressure ulcer was a Stage II as the nurse had documented on the progress notes. C. Review of Resident #3's Admission Summary reflected a [AGE] year old male who was admitted to facility on 9/01/11. Review of Resident #3's physician's orders [REDACTED]. During an observation 12/7/11 at 5:17 PM Resident #3 was slouched down in his wheel chair with his left arm stuck down inside of the chair. during an interview at this time, Resident #3 stated that he had a sore on his elbow because it rubs the chair all day and that that it hurts. Resident #3 stated, " Help me. " Observation on 12/7/11 at 5:30 revealed LVN M examined Resident #3's arm and discovered a Stage 1 pressure sore on left arm approximately 5 cm x 4 cm inch circle with 2 small blisters in the middle. During an interview on 12/07/11 at 5:30 LVN M stated, Resident #3's sore, reddened, blistered arm was a pressure ulcer and that she would inform the Physician. D. A review of Resident #17's history and physical dated 8/19/11 reflected an [AGE] year old male with [DIAGNOSES REDACTED]. He is alert to person only and admitted to facility on 02/21/01 . Observation on 12/8/11 at 12:30 PM revealed CNA S performing incontinent care on Resident # 17, wiping from anal area into his opened wound on his coccyx. The wound was a Stage 2 pressure ulcer. Resident #17's cocyx had a reddened area approximately 5 cm x 5 cm and his skin was opened with a scant amount blood present.. There was no dressing on the wound and no dressing was applied at this time. Interview on 12/8/11 at 4:50 PM LVN L stated that Resident #17 hasn't had any skin issues lately and that his bottom may get red, but they put [MEDICATION NAME] on it. Review of the facility's policy and procedure dated 03/08/2002, titled "Abuse Prohibition Policy and Procedure" reflected the "Policy: It is the policy of the facility to provide a safe environment free of abuse, neglect, mistreatment, exploitation and misappropriation of resident property. " Review of a second facility policy, titled " Abuse Prevention Program " included a subsection titled " Reporting Abuse to Facility Management " which reflected that Neglect was defined as the " failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. " In addition, another subsection of the policy titled " Recognizing Signs and Symptoms of Abuse/Neglect " reflected inadequate provision of care as one of the signs of actual physical neglect. Review of the facility's policy and procedure dated 10/14/2010, titled "Wound Program" reflects the purpose is "To provide consistent observation of the presence of or absence of skin conditions, the treatment of [REDACTED]." A head-to-toe skin assessment is done by a licensed nurse on admission, return from a hospital stay, weekly and as needed...measure all wounds,discolorations,scars." In the Procedure portion of this policy it reflects: A.) "On Admission". 2. Enter all measurements of discolorations and scars on the Progress Notes (Nurses notes) form in the Wound Book. 3. Enter all wound measurements on the Documentation of Wounds form. 4. Make 2 copies of the form. Turn one into the DON and place the second one in the Nurses Notes section in the resident's chart. 5. Initiate the PUSH Tool if a pressure ulcer is present and place in the wound book. B.) "New Observed Wounds" 1. Measure wounds... 2. Complete forms Documentation of Wounds and Alleged Incident/Accident Report... 3. Follow the wound protocol for all wound treatments..." C.) "Daily Treatments/Skin Assessments" 1. The wound nurse assigned to do the wound treatments will look at each previously observed wound. The ordered treatment will be performed..." 2. Skin assessments will be assigned weekly..." 3. Wounds that have not shown any improvement after 14 days of treatment, will be evaluated. The physician will be contacted for a change of treatment." E.) "Steps in Wound Prevention" 1. Apply skin barrier cream to the perineal/buttocks area(s) following incontinent care. 2. Reposition a minimum of 2 hours for those prone to skin breakdown. 3. Use additional appliances as needed: spenco mattresses for chair and /or bed, air mattress, specialty mattress, heel protectors, padded Wheelchair, pillows,etc. ...." On 12/08/11 at 12:15 PM, the Administrator and DON were informed of an Immediate Jeopardy related lack of care and services provided for Pressure Ulcers. On 12/08/11 at 7:20 PM, The Administrator presented the surveyors with a written plan of removal, which included the following: As of notification on December 8th at approximately 12:30 PM that the facility is receiving an IJ for Pressure Ulcers, the staff began immediately to prepare a plan of removal. On December 8, 2011, we will do the following: 1. We will reassess all residents with current known wounds and evaluate their current treatment. 2. High risk residents will have a skin assessment done. 20 residents have been identified as high risk by one or more of the following: Braden Scale; Inability to move self; Poor intake and Incontinence. 3. We will assess high risk residents for the need of pressure reducing items and initiate. We will use pillows, Spenco mattresses (bed and chairs), and air mattresses. Additional supplies such as pressure releasing cushions will be ordered on Friday, 12/09/2011. 4. Staff will be in serviced on wound care program including identifying, caring, and prevention of wounds. Infection control procedures will be in serviced (as noted above) 5. CNAs will document on ADL (Activities of Daily Living)flow sheets the turning and repositioning of residents with pressure ulcers and those at high risk for pressure ulcers. 6. QA (Quality Assurance) Committee will be involved in the evaluation and monitoring of the wound program. Each shift nurse will document in the treatment book the appropriateness of positioning and pressure release items being used on the above residents. DON will monitor the above steps for the next 48 hours. Based on observations and interviews on 12/08/11 and 11/09/11 of staff being in-serviced on the Wound Program, including: assessment, treatment, healing, reassessment, prevention and documentation the Surveyor informed the Executive Director, Administrator and DON on 12/09/11 at 2:00 PM that the Immediacy no longer existed. However, the deficient practice remained at the level of Actual Harm at a Pattern that is not Immediate Jeopardy because the facility administrative staff had not had time to develop, implement and monitor all corrective actions outlined in their plan of removal. The facility CMS 672 reflected only (1) one resident with a facility acquired pressure ulcer Stage II or higher. Review of facility ' s Roster/Sample Matrix provided on 12/06/11 reflected 3 residents with pressure sores. The DON provided information indicating 9 residents had facility acquired pressure ulcers.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures to prevent neglect for 4 of 6 residents reviewed for pressure ulcers (#1, #3, #7, #17). A. The facility failed to identify, assess, treat, and provide interventions and pressure relieving devices which resulted in the resident developing 18 pressure ulcers. Resident # 7 was taken to the hospital on [DATE] for dehydration and evaluation of his pressure ulcers. B. The facility failed to accurately assess, treat and provide interventions and pressure relieving devices for the pressure ulcer on Resident #1's coccyx. C. The facility failed to identify, assess and treat facility acquired pressure ulcers for Residents #3 and #17. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 12/08/11 at 12:15 PM. While the IJ was lifted on 12/09/11 at 2:00 PM, the facility remained out of compliance at a scope of pattern and severity level of actual harm that is not IJ because all measures for prevention and treatment of [REDACTED]. This deficient practice contributed to the development of new pressure ulcers and the worsening of existing pressure ulcers for Residents #1, #3, #7 and #17. These failures could place the additional 2 residents identified at risk for developing new pressure ulcers, that could lead to additional medical complications. Findings include: Review of the facility's policy and procedure dated 03/08/2002, titled "Abuse Prohibition Policy and Procedure" reflected the "Policy: It is the policy of the facility to provide a safe environment free of abuse, neglect, mistreatment, exploitation and misappropriation of resident property. " Review of a second facility policy, titled " Abuse Prevention Program " included a subsection titled " Reporting Abuse to Facility Management " which reflected that Neglect was defined as the " failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. " In addition, another subsection of the policy titled " Recognizing Signs and Symptoms of Abuse/Neglect " reflected inadequate provision of care as one of the signs of actual physical neglect. Review of the facility's policy and procedure dated 10/14/2010, titled "Wound Program" reflects the purpose is "To provide consistent observation of the presence of or absence of skin conditions, the treatment of [REDACTED]." A head-to-toe skin assessment is done by a licensed nurse on admission, return from a hospital stay, weekly and as needed...measure all wounds,discolorations,scars." In the Procedure portion of this policy it reflects: A.) "On Admission". 2. Enter all measurements of discolorations and scars on the Progress Notes (Nurses notes) form in the Wound Book. 3. Enter all wound measurements on the Documentation of Wounds form. 4. Make 2 copies of the form. Turn one into the DON and place the second one in the Nurses Notes section in the resident's chart. 5. Initiate the PUSH Tool if a pressure ulcer is present and place in the wound book. B.) "New Observed Wounds" 1. Measure wounds... 2. Complete forms Documentation of Wounds and Alleged Incident/Accident Report... 3. Follow the wound protocol for all wound treatments..." C.) "Daily Treatments/Skin Assessments" 1. The wound nurse assigned to do the wound treatments will look at each previously observed wound. The ordered treatment will be performed..." 2. Skin assessments will be assigned weekly..." 3. Wounds that have not shown any improvement after 14 days of treatment, will be evaluated. The physician will be contacted for a change of treatment." E.) "Steps in Wound Prevention" 1. Apply skin barrier cream to the perineal/buttocks area(s) following incontinent care. 2. Reposition a minimum of 2 hours for those prone to skin breakdown. 3. Use additional appliances as needed: spenco mattresses for chair and /or bed, air mattress, specialty mattress, heel protectors, padded Wheelchair, pillows,etc. ...." A. Review of Resident # 7's Admission Face Sheet reflected a [AGE] year old male admitted to facility on 12/09/09. Review of physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. A physician order [REDACTED]. Review of Resident #7's most current quarterly Minimum Data Set (MDS) assessment, dated 11/12/11, reflected that Resident #7 was at risk for pressure ulcers. Review of the Care Plan, dated 8/31/10, reflected Resident #7 had potential for developing skin breakdown related to incontinence. Further review of the Care Plan, updated 11/01/11, reflected Resident #7 had a Stage 2 pressure ulcer on the right buttock. Approaches included barrier cream with each incontinent care and a pressure reducing device for his bed. Review of the Hospital Clinical Pathology Report, dated 11/23/11 reflected Resident #7 was positive [MEDICAL CONDITION] in his left elbow. Review of Interdisciplinary Progress Notes from 11/23/11 to 12/05/11 reflected that Resident #7 remained on contact isolation [MEDICAL CONDITION] infection. Observation on 12/06/11 at 11:30 AM revealed Resident # 7 lying in bed with his elbows bent and his arms pulled close to his sides. His hands were turned downwards towards his chest. There were no positioning devices, pillows or wedges in his bed or in his room to provide for pressure relief. Resident #7 did not have heel protectors on his feet and there were not any located in his room. The pressure relieving bed device was in the off position. Observation on 12/7/11 at 8:00 AM revealed Resident #7 ' s door closed with a Contact Isolation sign in place. Upon entering Resident #7 was observed to be lying on his left side with his right arm pulled tight to his ribs and his hands closed pulled tight against his chest. There were no hand rolls in his hands. There were no pillows or wedges in his bed or in his room to provide for pressure relief. Resident #7 did not have heel protectors on his feet and there were not any in his room. The pressure reducing bed device was in the off position. In an interview at 12/07/11 8:00 AM, LVN N stated, "Resident #7 had been in isolation for a week or more and she had been taking care of him on and off since he had been at the facility." LVN N stated that she used to put rolled up wash-cloths in his hands but, "It looks like they've not been doing it because his hands are a lot more curved." In an interview on 12/07/11 at 2:30 PM LVN M stated Resident #7 would receive assistance to get up for all meals but he has not been up since he has been in isolation and that he ate in bed with assistance from staff. LVN M further stated that she checks on him when she makes her rounds but does not check his skin. Observation on 12/07/11 at 8:50 AM revealed a red circle approximately. 5 centimeters (cm) x 5 cm on Resident #7 ' s left stomach area where his shirt was pulled up. Resident ' s lips were chapped and his tongue and mouth were also dry. The Director of Nurses (DON) came into the resident's room and pulled his shirt down. There was a cup of water on the bed-side table but Resident #7 was unable to reach it. The DON held the cup of water to Resident #7 ' s mouth until he finished drinking. In an interview on 12/07/11 at 8:50 AM, the DON stated the red mark on Resident ' s left stomach area was from him resting his elbow on his stomach and that she had just noticed it. The DON then asked CNA T to prop his left arm on a pillow. However, no other skin areas were addressed at this time. Observation on 12/07/11 at 9:50 AM revealed Resident #7 lying with left foot resting on right lower shin with his knees together. He did not have heel protectors on and his pressure reducing bed was in the off position. Resident #7 ' s arms are pulled tight to his sides and his hands were curled in, resting on his chest. The pressure reducing bed is in the off position. LVN N rolled her treatment cart into his room. LVNs T and L did not don an isolation gown or a mask during wound care procedure that lasted 2.5 hours. LVN L was assisting by holding Resident #7 ' s arm out and holding his hand. Resident #7 was able to bend his right elbow and open his right hand with assistance from LVN L while LVN N provided wound care to his pressure ulcer on right elbow and right chest. Interview on 12/07/11 at 9:50 AM LVN N stated that she was going to perform wound care on Resident #7's left and right elbows only. During an observation on 12/07/11 at 9:50 AM of the (2) two known pressure ulcers (Stage 2 right elbow and healing Stage 1 healing on left elbow) revealed Resident #7 to have additional, unidentified pressure ulcers as follows: 1. LVN N removed the bandage on Resident #7's right inner elbow to expose a Stage 4 pressure ulcer that was infected [MEDICAL CONDITION]. The pressure ulcer measured approximately 6 cm x 6 cm in diameter with the right side having black eschar and the left side exposing a tendon. LVN N tried to wipe Resident #7's tendon that was exposed with a yellow covering, but the yellow covering would not come off. The middle of the pressure ulcer appeared to be approximately 2.5 cm-3 cm deep. LVN N cleansed the wound and applied a gauze dressing. (This was one of the two pressure ulcers that facility had identified as a Stage 2 before the skin assessment). 2. Resident #7 could not bend his left elbow or open his left hand without grimacing, moaning, or pulling away from LVN N. LVN N removed the bandage on Resident #7's left elbow and revealed a healing Stage 1 wound that was red, unblanchable and measured approximately 4 cm x 4 cm. (This was one of the two pressure ulcers that facility had identified as a Stage 1 before the skin assessment). 3. Resident #7 had a Stage 1 pressure ulcer on his right front lower shin where his left foot had been resting, measuring approximately 7 cm x 3 cm with redness that was unblanchable (stayed red) when LVN N pressed the area with her finger. 4. Both of Resident #7's inner knees had Stage 1 unblanchable pressure ulcers the size of silver dollars. 5. Resident 7's left trochanter (hip bone) had an inflamed area approximately 3.4 cm x 2.5 cm with the center Stage 2 (opened area) approximately 2 cm x 1.3 cm. 6. Resident #7 had a Stage 2 (skin was opened) pressure ulcer on his left side chest, below his rib and measured approximately 2.5 cm x 1.3 cm. 7. Resident #7 had a Stage 1, unblanchable pressure ulcer on his medial chest/rib that measured 1 cm x 2 cm. 8. As a result of laying on his left arm, Resident #7 had a Stage 1 pressure ulcer that measured approximately .75 cm raised blister on his left deltoid (shoulder) approximately 5 cm x 5 cm in diameter. 9. Resident #7 ' s had a Stage 1, unblanchable pressure ulcers on his inner right thigh, measuring 9.2 cm x .4 cm. 10. Resident #7 had an unblanchable Stage 1 on his right outer chest rib area measuring 3 cm x 3 cm developed from his right elbow resting on his chest. 11. LVN N and LVN L turned Resident #7 over to expose his buttocks and discovered 2 Stage 2 pressure ulcers with red inflamed skin that extended across the buttocks. Each side of the buttocks had areas that measured approximately 5 cm x 5 cm in diameter surrounded by redness and open skin. 12. Resident #7's right heel had an unstageable pressure ulcer due to an intact, clear colored, fluid filled, blister that measured 6 cm x 6 cm. 13. Resident #7's left heel had an unstageable pressure ulcer due to an intact, clear colored, fluid filled blister that was red, blue, and black on the outside that measured 4 cm x 5 cm. Interview on 12/07/11 at 11:00 LVN N stated she couldn ' t believe that Resident #7 had so many pressure ulcers. Review of Interdisciplinary Progress Notes dated 12/07/11 titled Wounds reflected, Stage 1: 1) Right front lower shin pressure redness 2) Left and Right inner knees pressure redness 3) Left trochanter 3.4 cm x 2.5 cm whole redness included with Stage 2 over trochanter 2 cm x 1.3 cm 4) Left chest below rib/abdominal side 2.5 cm x 1.3 cm 5) Left medial rib/abdominal 2 cm x 2 cm 6) Left deltoid raised, warm redness 7) Left elbow healing wound, but still red 8) Thigh 9.2 cm x .4 cm 9) Right outer chest/rib redness 3 cm x 3 cm Stage 2: 10) Right buttock medial 11) Left buttock medial 12) Left trochanter 2 cm x 1.3 cm 13) Right foot medial first joint off great toe Unstageable: 14) Right heel fluid filled 6 cm x 6 cm 15) Left heel outer red/blue-black 4 cm x 5 cm Stage 4: 16) Right inner [MEDICAL CONDITION] positive In an interview on 12/08/11 at 10:40 AM the Nurse Practitioner (NP) stated, [MEDICAL CONDITION] is something that if occluded (covered and not exposed to air) that there is no reason to keep isolated. Some residents would deteriorate so badly if they couldn ' t go out of the room. In an interview on 12/07/11 at 1:00 PM DON stated that she had talked to Resident 7's wife and let her know that she and the Physician had decided to send her husband to the hospital because of poor skin turgor, dehydration and pressure ulcers. Review of Hospital Emergency Records reflected Resident #7 was admitted to the hospital on [DATE] at 6:30 PM. Hospital triage notes listed as Complaint: Sores on Feet; Chief Complaint: Lethargy." He has multiple bed sores from inactivity; Dry mucus membranes; Contractures of both upper extremities; I have completed a completed comprehensive skin exam and found, patient has multiple decubitus ulcers from being bedridden with right elbow previously cultured [MEDICAL CONDITION]." Further review of Emergency Records reflected [DIAGNOSES REDACTED]. Review of Hospital Physical Therapy Department Records, dated 12/08/11, reflected Resident #7's " right medial (inner) elbow appears to be painful. Demonstrates grimacing and guarding." Observations on 12/7/2011 at 2:30 PM at a local hospital revealed Resident #7 in an isolation room lying on his right side in a fetal position with positioning pillows between his legs, under his shoulder, under both arms, cushioned heel protectors on his feet and covered with two blankets. A foley catheter was in place and was draining brown urine into the collection bag. Resident #7 ' s visible wounds were covered. The charge nurse attending to Resident #7 was awaiting Physical Therapy to complete their assessment. Further observation revealed Resident #7 was sleeping and appeared content. B. Review of Resident #1's Face Sheet reflected he was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1 was at risk for pressure ulcers and Skin Ulcer Treatments reflected application of nonsurgical dressing and application of ointments/medications. Review of Resident #1's Braden Scale score dated 11/03/11 reflected a total score of 14 (indicating moderate risk for pressure ulcers for a total score of 13-14). Review of Resident #1's Care Plan for Decubitus dated 11/15/11 reflected "Stage 2 to Coccyx " on description, updated on 11/29/11 reflected " (no) open/skin closed, (Stage) I (decubitus) (continue) same (treatment), " and updated again on 12/02/11 reflected " small opening 0.3 x 0.2 cm, (Stage) II (decubitus) (continue) [MEDICATION NAME]. " The approaches included " 1. Notify physician of decubitus location with measurements, stage, and drainage; 2. Notify family of change in resident ' s condition; 3. Assess for signs of infection; 4. Treat decubitus as ordered; 5. Eliminate risk factors, i.e. dry moist skin, immobility. Use spenco mattress to (decrease) pressure. 6. Observe for unusual symptoms. Record and report to physician. 7. Turn resident every 2 hours and (as needed). 8. Notify physician if ulcer does not respond to treatment. 9. Measure site each week and report if increasing, chart measurement, color, drainage, etc. " Observation on 12/06/11 at 10:45 AM revealed Resident #1 was lying on his back in his reclining wheelchair. Resident #1 did not have any type of pressure relieving device or pillow in his reclining wheelchair and his bed did not have an air mattress. The resident was not interviewable. During an interview on 12/06/11 at 10:45 AM, LVN K stated Resident #1 had multiple skin tears, but failed to mention the resident had a Stage 2 pressure ulcer. During an interview on 12/06/11 at 3:15 PM, the Director of Nursing (DON) stated Resident #1 had a Stage 1 pressure ulcer. Observation on 12/06/11 from 3:35 PM- 5:45 PM revealed Resident #1 sitting in a reclining wheelchair in the living room. The resident was leaning forward and back attempting to sit up in the reclined chair. Resident #1 did not have a pressure relieving device in the wheelchair. Resident #1 sat in the in the same position in his reclining wheelchair for the entire time from 3:35 PM to at least 5:45 PM. During an interview on 12/07/11 at 8:00 AM, the DON stated Resident #1 had a Stage 1 pressure ulcer to his coccyx when he returned from his stay at the hospital on [DATE]. During an interview on 12/07/11 at 5:35 PM, the DON stated, "Resident #1 returned from the hospital on [DATE] with a Stage 1 pressure ulcer to his coccyx but it healed, and now it has opened today and is a Stage 2 ulcer. " The DON stated Resident #1 does not have an air mattress. Observation on 12/07/11 at 5:00 PM revealed Certified Nurse Aide (CNA) Q and R changing Resident #1's brief. An opened red Stage II pressure ulcer approximately the size of a dime was observed on the resident's coccyx. The pressure ulcer did not have a dressing and/or treatment covering it. CNA Q called Registered Nurse (RN) B in to look at the pressure ulcer. During an interview on 12/07/11 at 5:10 PM, RN B stated, "Resident #1 should have a [MEDICATION NAME] (occlusive [MEDICATION NAME]) dressing and stated the pressure ulcer had been a Stage 1 and was now a stage 2." RN B confirmed the [MEDICATION NAME] dressing was not present and should have been. During an interview on 12/08/11 at 3:30 PM RN B stated she did not document the new status of Resident #1's wound on 12/07/11. RN B stated the wound had already been documented on 12/02/11. During an interview 12/08/11 at 9:41 AM, the DON stated Resident #1's pressure ulcer on his coccyx " opened back up yesterday." The DON stated the nurse should have documented the pressure ulcer reopening on the wound treatment progress notes. The DON confirmed RN B did not document on Resident #1's pressure ulcer. The DON stated Resident #1 is supposed to be turned every 2 hours to prevent worsening of the pressure ulcer. The DON stated she does not have a process of ensuring the CNA's are turning Resident #1 every 2 hours. The DON confirmed Resident #1 did not have any type of cushion in his wheelchair. The DON stated they have Spenco cushions (padded cushion designed for Non-ambulatory patients of all ages who have a low to moderate risk of getting pressure sores) in the hall closet, but they are not gel or pressure relieving. During an interview on 12/08/11 at 10:40 AM the Nurse Practitioner (NP) stated " (Resident #1) should have a good pad in the chair especially since they are aware of (the pressure ulcer)." The NP stated, "I'm surprised that the facility did not have a pressure relieving pad in Resident #1's chair." Review of Resident #1's Treatment Record dated 12/01/11-12/31/11 reflected a treatment originally dated 11/15/11 for " coccyx apply [MEDICATION NAME] every 72 hours and as needed per protocol." The last signature that reflected when this treatment was administered was on 12/03/11. There was not a signature for the treatment until 12/07/11 after the surveyor observed the pressure ulcer without the [MEDICATION NAME] dressing (at least 96 hours later or 4 days after the treatment on 12/03/11). Review of Resident #1's " Documentation of Wounds " record dated 11/15/11 reflected a check mark next to pressure ulcer, Stage I. The description reflected " coccyx redness irregular round shape." A note next to M.D. (Medical Doctor) notified reflected " aware upon readmission." Initial measurements reflected " 10 (cm) x 10 (cm) closed." Initial treatment reflected " [MEDICATION NAME] (every) 72 hours." Review of Resident #1's Nurse's Wound Treatment progress notes dated 11/10/11-12/08/11 reflected no documentation on the pressure ulcer except on 12/02/11. The progress note reflected " Stage II to Coccyx, 4 cm x 1.2 cm x .1 cm." This note was signed by LVN K. This information did not match the " Pressure Ulcer Scale for Healing" or "PUSH tool 3.0" documentation that was done on the same day. Review of Resident #1's "Pressure Ulcer Scale for Healing" or "PUSH tool 3.0" dated 11/15/11 reflected an entry on 11/15/11 as an 8 for sub-score for length x width in cm 2 (8.1-12.0 cm2), a 0 for exudate amount (none 0, light 1, moderate 2, heavy 3) and 0 for tissue type (0 closed, 1 [MEDICATION NAME] tissue, 2 granulation tissue, 3 slough, 4 necrotic tissue). The next entry on 11/29/11 reflected a 7 for length x width, 0 for exudate amount and 0 for tissue type. The final entry dated 12/02/11 reflected 7 for length x width, 0 for exudate and 0 for tissue type. There were no other entries. The 12/02/11 entry did not indicate the pressure ulcer was a Stage II as the nurse had documented on the progress notes. C. Review of Resident #3's Admission Summary reflected a [AGE] year old male who was admitted to facility on 9/01/11. Review of Resident #3's physician's orders [REDACTED]. During an observation 12/7/11 at 5:17 PM Resident #3 was slouched down in his wheel chair with his left arm stuck down inside of the chair. during an interview at this time, Resident #3 stated that he had a sore on his elbow because it rubs the chair all day and that that it hurts. Resident #3 stated, " Help me. " Observation on 12/7/11 at 5:30 revealed LVN M examined Resident #3's arm and discovered a Stage 1 pressure sore on left arm approximately 5x4 inch circle with 2 small blisters in the middle. During an interview on 12/07/11 at 5:30 LVN M stated, Resident #3's sore, reddened, blistered arm was a pressure ulcer and that she would inform the Physician. D. A review of Resident #17's history and physical dated 8/19/11 reflected an [AGE] year old male with [DIAGNOSES REDACTED]. He is alert to person only and admitted to facility on 02/21/01 . Observation on 12/8/11 at 12:30 PM revealed CNA S performing incontinent care on Resident # 17, wiping from anal area into his opened wound on his coccyx. The wound was a Stage 2 pressure ulcer. Resident #17's cocyx had a reddened area approximately 5 cm x 5 cm and his skin was opened with a scant amount blood present.. There was no dressing on the wound and no dressing was applied at this time. Interview on 12/8/11 at 4:50 PM LVN L stated that Resident #17 hasn't had any skin issues lately and that his bottom may get red, but they put [MEDICATION NAME] on it. On 12/08/11 at 12:15 PM, the Administrator and DON were informed of an Immediate Jeopardy related lack of care and services provided for Pressure Ulcers. On 12/08/11 at 7:20 PM, The Administrator presented the surveyors with a written plan of removal, which included the following: As of notification on December 8th at approximately 12:30 PM that the facility is receiving an IJ for Pressure Ulcers, the staff began immediately to prepare a plan of removal. On December 8, 2011, we will do the following: 1. We will reassess all residents with current known wounds and evaluate their current treatment. 2. High risk residents will have a skin assessment done. 20 residents have been identified as high risk by one or more of the following: Braden Scale; Inability to move self; Poor intake and Incontinence. 3. We will assess high risk residents for the need of pressure reducing items and initiate. We will use pillows, Spenco mattresses (bed and chairs), and air mattresses. Additional supplies such as pressure releasing cushions will be ordered on Friday, 12/09/2011. 4. Staff will be in serviced on wound care program including identifying, caring, and prevention of wounds. Infection control procedures will be in serviced (as noted above) 5. CNAs will document on ADL (Activities of Daily Living)flow sheets the turning and repositioning of residents with pressure ulcers and those at high risk for pressure ulcers. 6. QA (Quality Assurance) Committee will be involved in the evaluation and monitoring of the wound program. Each shift nurse will document in the treatment book the appropriateness of positioning and pressure release items being used on the above residents. DON will monitor the above steps for the next 48 hours. Based on observations and interviews on 12/08/11 and 11/09/11 of staff being in-serviced on the Wound Program, including: assessment, treatment, healing, reassessment, prevention and documentation the Surveyor informed the Executive Director, Administrator and DON on 12/09/11 at 2:00 PM that the Immediacy no longer existed. However, the deficient practice remained at the level of Actual Harm at a Pattern that is not Immediate Jeopardy because the facility administrative staff had not had time to develop, implement and monitor all corrective actions outlined in their plan of removal. The facility CMS 672 reflected only (1) one resident with a facility acquired pressure ulcer Stage II or higher. Review of facility ' s Roster/Sample Matrix provided on 12/06/11 reflected 3 residents with pressure sores. The DON provided information indicating 9 residents had facility acquired pressure ulcers.

Based on observation, interview and record review the facility failed to ensure that 4 of 6 residents reviewed for pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing (Residents #1,#3, #7 and #17). A. The facility failed to identify, assess, treat, and provide interventions and pressure relieving devices which resulted in the resident developing 18 pressure ulcers. Resident # 7 was taken to the hospital on [DATE] for dehydration and evaluation of his pressure ulcers. B. The facility failed to accurately assess, treat, and provide interventions and pressure relieving devices for the pressure ulcer on Resident #1's coccyx. C. The facility failed to identify, assess and treat facility acquired pressure ulcers for Residents #3 and #17. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 12/08/11 at 12:15 PM. While the IJ was lifted on 12/09/11 at 2:00 PM, the facility remained out of compliance at a scope of pattern and severity level of actual harm that is not IJ because all measures for prevention and treatment of [REDACTED]. This deficient practice contributed to the development of new pressure ulcers and the worsening of existing pressure ulcers for Residents #1, #3, #7 and #17, with the potential to place an additional 2 residents at risk for developing new pressure ulcers. The findings include: A.) Review of Resident #7's Admission Face Sheet reflected a [AGE] year old male admitted to facility on 12/09/09. Review of physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. A physician order [REDACTED]. Resident #7's most current quarterly Minimum Data Set (MDS) assessment, dated 11/12/11, reflected that Resident #7 was at risk for pressure ulcers. Review of the Care Plan, dated 8/31/10, reflected Resident #7 had potential for developing skin breakdown related to incontinence. Further review of the Care Plan, updated 11/01/11, reflected Resident #7 had a Stage 2 pressure ulcer on the right buttock. Approaches included barrier cream with each incontinent care and a pressure reducing device for his bed. Review of the Hospital Clinical Pathology Report, dated 11/23/11 reflected Resident #7 was positive [MEDICAL CONDITION] in his left elbow. Review of Interdisciplinary Progress Notes from 11/23/11 to 12/05/11 reflected that Resident #7 remained on contact isolation [MEDICAL CONDITION] infection. on 12/06/11 at 11:30 AM revealed Resident # 7 lying in bed with his elbows bent and his arms pulled close to his sides. His hands were turned downwards towards his chest. There were no positioning devices, pillows or wedges in his bed or in his room to provide for pressure relief. Resident #7 did not have heel protectors on his feet and there were not any located in his room. The pressure relieving bed device was in the off position. Observation on 12/7/11 at 8:00 AM revealed Resident #7 ' s door closed with a Contact Isolation sign in place. Upon entering Resident #7 was observed to be lying on his left side with his right arm pulled tight to his ribs and his hands closed pulled tight against his chest. There were no hand rolls in his hands. There were no pillows or wedges in his bed or in his room to provide for pressure relief. Resident #7 did not have heel protectors on his feet and there were not any in his room. The pressure reducing bed device was in the off position. In an interview at 12/07/11 8:00 AM, LVN N stated, "Resident #7 had been in isolation for a week or more and she had been taking care of him on and off since he had been at the facility." LVN N stated that she used to put rolled up wash-cloths in his hands but, "It looks like they've not been doing it because his hands are a lot more curved." In an interview on 12/07/11 at 2:30 PM LVN M stated Resident #7 would receive assistance to get up for all meals but he has not been up since he has been in isolation and that he ate in bed with assistance from staff. LVN M further stated that she checks on him when she makes her rounds but does not check his skin. Observation on 12/07/11 at 8:50 AM revealed a red circle 5 centimeters (cm) x 5 cm on Resident #7 ' s left stomach area where his shirt was pulled up. Resident ' s lips were chapped and his tongue and mouth were also dry. The Director of Nurses (DON) came into the resident's room and pulled his shirt down. There was a cup of water on the bed-side table but Resident #7 was unable to reach it. The DON held the cup of water to Resident #7 ' s mouth until he finished drinking. An interview on 12/07/11 at 8:50 AM, the DON stated the red mark on Resident ' s left stomach area was from him resting his elbow on his stomach and that she had just noticed it. The DON then asked CNA T to prop his left arm on a pillow. However, no other skin areas were addressed at this time. Observation on 12/07/11 at 9:50 AM revealed Resident #7 lying with left foot resting on right lower shin with his knees together. He did not have heel protectors on and his pressure reducing bed was in the off position. Resident #7 ' s arms are pulled tight to his sides and his hands were curled in, resting on his chest. The pressure reducing bed is in the off position. LVN N rolled her treatment cart into his room. LVNs T and L did not don an isolation gown or a mask during wound care procedure that lasted 2.5 hours. LVN L was assisting by holding Resident #7 ' s arm out and holding his hand. Resident #7 was able to bend his right elbow and open his right hand with assistance from LVN L while LVN N provided wound care to his pressure ulcer on right elbow and right chest. Interview on 12/07/11 at 9:50 AM LVN N stated that she was going to perform wound care on Resident #7's left and right elbows only. During an observation on 12/07/11 at 9:50 AM of the (2) two known pressure ulcers (Stage 2 right elbow and healing Stage1 healing on left elbow) revealed Resident #7 to have additional, unidentified pressure ulcers as follows: 1. LVN N removed the bandage on Resident #7's right inner elbow to expose a Stage 4 pressure ulcer that was infected [MEDICAL CONDITION]. The pressure ulcer measured approximately 6 cm x 6 cm in diameter with the right side having black eschar and the left side exposing a tendon. LVN N tried to wipe Resident #7's tendon that was exposed with a yellow covering, but the yellow covering would not come off. The middle of the pressure ulcer appeared to be approximately 2.5 cm-3 cm deep. LVN N cleansed the wound and applied a gauze dressing. (This was one of the two pressure ulcers that facility had identified as a Stage 2 before the skin assessment). 2. Resident #7 could not bend his left elbow or open his left hand without grimacing, moaning, or pulling away from LVN N. LVN N removed the bandage on Resident #7's left elbow and revealed a healing Stage 1 wound that was red, unblanchable and measured approximately 4 cm x 4cm. (This was one of the two pressure ulcers that facility had identified as a Stage 1 before the skin assessment). 3. There was a Stage 1 pressure ulcer on his right front lower shin where his left foot had been resting, measuring approximately 7 cm x 3 cm with redness that was unblanchable (stayed red) when LVN N pressed the area with her finger. 4. Both inner knees had Stage 1 unblanchable pressure ulcers the size of silver dollars. 5. The left trochanter (hip bone) had an inflamed area approximately 3.4 cm x 2.5 cm with the center Stage 2 (opened area) approximately 2 cm x1.3 cm. 6. There was a Stage 2 (skin was opened) pressure ulcer on his left side chest, below his rib and measured approximately 2.5 cmx 1.3 cm. 7. There was a Stage 1, unblanchable pressure ulcer on his medial chest/rib that measured 1 cm x 2 cm. 8. As a result of laying on his left arm there was a Stage 1 pressure ulcer that measured approximately .75 cm raised blister on his left deltoid (shoulder) approximately 5 cm x 5 cm in diameter. 9. There was a Stage 1, unblanchable pressure ulcers on his inner right thigh, measuring 9.2 cm x .4 cm. 10. A unblanchable Stage 1 on the resident's right rib area measuring 3 cm x 3cm that developed from his right elbow placing pressure on his chest. 11. LVN N and LVN L turned Resident #7 over to expose his buttocks and discovered Stage 2 pressure ulcers with red inflamed skin that extended down the buttocks. Each side of the buttocks had a red area that measured 5 cm x 5 cm in diameter surrounded by redness and open skin. 12. An unstageable pressure ulcer due to an intact, clear colored, fluid filled, blister that measured 6 cm x 6 cm was observed on the right heel. 13. An unstageable pressure ulcer due to an intact, clear colored, fluid filled blister that was red, blue, and black on the outside of the right heel that measured 4 cm x 5 cm. Interview on 12/07/11 at 11:00 LVN N stated she couldn ' t believe that Resident #7 had so many pressure ulcers. Review of Interdisciplinary Progress Notes dated 12/07/11 titled Wounds reflected, Stage 1: 1) Right front lower shin pressure redness 2) Left and Right inner knees pressure redness 3) Left trochanter 3.4 cm x 2.5 cm whole redness included with Stage 2 over trochanter 2 cm x 1.3 cm 4) Left chest below rib/abdominal side 2.5 cm x 1.3 cm 5) Left medial rib/abdominal 2 cm x 2 cm 6) Left deltoid raised, warm redness 7) Left elbow healing wound, but still red 8) Thigh 9.2 cm x .4 cm 9) Right outer chest/rib redness 3 cm x 3 cm Stage 2: 10) Right buttock medial 11) Left buttock medial 12) Left trochanter 2 cm x 1.3 cm 13) Right foot medial first joint off great toe Unstageable: 14) Right heel fluid filled 6 cm x 6 cm 15) Left heel outer red/blue-black 4 cm x 5 cm Stage 4: 16) Right inner [MEDICAL CONDITION] positive In an interview on 12/08/11 at 10:40 AM the Nurse Practitioner (NP) stated, [MEDICAL CONDITION] is something that if occluded (covered and not exposed to air) that there is no reason to keep isolated. Some residents would deteriorate so badly if they couldn ' t go out of the room. In an interview on 12/07/11 at 1:00 PM DON stated that she had talked to Resident 7's wife and let her know that she and the Physician had decided to send her husband to the hospital because of poor skin turgor, dehydration and pressure ulcers. of Hospital Emergency Records reflected Resident #7 was admitted to the hospital on [DATE] at 6:30 PM. Hospital triage notes listed as Complaint: Sores on Feet; Chief Complaint: Lethargy." He has multiple bed sores from inactivity; Dry mucus membranes; Contractures of both upper extremities; I have completed a completed comprehensive skin exam and found, patient has multiple decubitus ulcers from being bedridden with right elbow previously cultured [MEDICAL CONDITION]." Further review of Emergency Records reflected [DIAGNOSES REDACTED]. Review of Hospital Physical Therapy Department Records, dated 12/08/11, reflected Resident #7's " right medial (inner) elbow appears to be painful. Demonstrates grimacing and guarding." )Observations on 12/7/2011 at 2:30 PM at a local hospital revealed Resident #7 in an isolation room lying on his right side in a fetal position with positioning pillows between his legs, under his shoulder, under both arms, cushioned heel protectors on his feet and covered with two blankets. A Foley catheter was in place and was draining brown urine into the collection bag. Resident #7 ' s visible wounds were covered. The charge nurse attending to Resident #7 was awaiting Physical Therapy to complete their assessment. Further observation revealed Resident #7 was sleeping and appeared content. B.) Review of Resident #1's Face Sheet reflected he was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1 was at risk for pressure ulcers and Skin Ulcer Treatments reflected application of nonsurgical dressing and application of ointments/medications. Review of Resident #1's Braden Scale score dated 11/03/11 reflected a total score of 14 (indicating moderate risk for pressure ulcers for a total score of 13-14). Review of Resident #1's Care Plan for Decubitus dated 11/15/11 reflected "Stage 2 to Coccyx " on description, updated on 11/29/11 reflected " (no) open/skin closed, (Stage) I (decubitus) (continue) same (treatment), " and updated again on 12/02/11 reflected " small opening 0.3 x 0.2 cm, (Stage) II (decubitus) (continue) [MEDICATION NAME]. " The approaches included " 1. Notify physician of decubitus location with measurements, stage, and drainage; 2. Notify family of change in resident ' s condition; 3. Assess for signs of infection; 4. Treat decubitus as ordered; 5. Eliminate risk factors, i.e. dry moist skin, immobility. Use spenco mattress to (decrease) pressure. 6. Observe for unusual symptoms. Record and report to physician. 7. Turn resident every 2 hours and (as needed). 8. Notify physician if ulcer does not respond to treatment. 9. Measure site each week and report if increasing, chart measurement, color, drainage, etc. " Observation on 12/06/11 at 10:45 AM revealed Resident #1 was lying on his back in his reclining wheelchair. Resident #1 did not have any type of pressure relieving device or pillow in his reclining wheelchair and his bed did not have an air mattress. The resident was not interviewable. During an interview on 12/06/11 at 10:45 AM, LVN K stated Resident #1 had multiple skin tears, but failed to mention the resident had a Stage 2 pressure ulcer. During an interview on 12/06/11 at 3:15 PM, the Director of Nursing (DON) stated Resident #1 had a Stage 1 pressure ulcer. Observation on 12/06/11 from 3:35 PM- 5:45 PM revealed Resident #1 sitting in a reclining wheelchair in the living room. The resident was leaning forward and back attempting to sit up in the reclined chair. Resident #1 did not have a pressure relieving device in the wheelchair. Resident #1 sat in the in the same position in his reclining wheelchair for the entire time from 3:35 PM to at least 5:45 PM. During an interview on 12/07/11 at 8:00 AM, the DON stated Resident #1 had a Stage 1 pressure ulcer to his coccyx when he returned from his stay at the hospital on [DATE]. During an interview on 12/07/11 at 5:35 PM, the DON stated, "Resident #1 returned from the hospital on [DATE] with a Stage 1 pressure ulcer to his coccyx but it healed, and now it has opened today and is a Stage 2 ulcer. " The DON stated Resident #1 does not have an air mattress. Observation on 12/07/11 at 5:00 PM revealed Certified Nurse Aide (CNA) Q and R changing Resident #1's brief. An opened red Stage II pressure ulcer approximately the size of a dime was observed on the resident's coccyx. The pressure ulcer did not have a dressing and/or treatment covering it. CNA Q called Registered Nurse (RN) B in to look at the pressure ulcer. During an interview on 12/07/11 at 5:10 PM, RN B stated, "Resident #1 should have a [MEDICATION NAME] (occlusive [MEDICATION NAME]) dressing and stated the pressure ulcer had been a Stage 1 and was now a stage 2." RN B confirmed the [MEDICATION NAME] dressing was not present and should have been. During an interview on 12/08/11 at 3:30 PM RN B stated she did not document the new status of Resident #1's wound on 12/07/11. RN B stated the wound had already been documented on 12/02/11. During an interview 12/08/11 at 9:41 AM, the DON stated Resident #1's pressure ulcer on his coccyx " opened back up yesterday." The DON stated the nurse should have documented the pressure ulcer reopening on the wound treatment progress notes. The DON confirmed RN B did not document on Resident #1's pressure ulcer. The DON stated Resident #1 is supposed to be turned every 2 hours to prevent worsening of the pressure ulcer. The DON stated she does not have a process of ensuring the CNA's are turning Resident #1 every 2 hours. The DON confirmed Resident #1 did not have any type of cushion in his wheelchair. The DON stated they have Spenco cushions (padded cushion designed for Non-ambulatory patients of all ages who have a low to moderate risk of getting pressure sores) in the hall closet, but they are not gel or pressure relieving. During an interview on 12/08/11 at 10:40 AM the Nurse Practitioner (NP) stated " (Resident #1) should have a good pad in the chair especially since they are aware of (the pressure ulcer)." The NP stated, "I'm surprised that the facility did not have a pressure relieving pad in Resident #1's chair." Review of Resident #1's Treatment Record dated 12/01/11-12/31/11 reflected a treatment originally dated 11/15/11 for " coccyx apply [MEDICATION NAME] every 72 hours and as needed per protocol." The last signature that reflected when this treatment was administered was on 12/03/11. There was not a signature for the treatment until 12/07/11 after the surveyor observed the pressure ulcer without the [MEDICATION NAME] dressing (at least 96 hours later or 4 days after the treatment on 12/03/11). Review of Resident #1's " Documentation of Wounds " record dated 11/15/11 reflected a check mark next to pressure ulcer, Stage I. The description reflected " coccyx redness irregular round shape." A note next to M.D. (Medical Doctor) notified reflected " aware upon readmission." Initial measurements reflected " 10 (cm) x 10 (cm) closed." Initial treatment reflected " [MEDICATION NAME] (every) 72 hours." Review of Resident #1's Nurse's Wound Treatment progress notes dated 11/10/11-12/08/11 reflected no documentation on the pressure ulcer except on 12/02/11. The progress note reflected " Stage II to Coccyx, 4 cm x 1.2 cm x .1 cm." This note was signed by LVN K. This information did not match the " Pressure Ulcer Scale for Healing" or "PUSH tool 3.0" documentation that was done on the same day. Review of Resident #1's "Pressure Ulcer Scale for Healing" or "PUSH tool 3.0" dated 11/15/11 reflected an entry on 11/15/11 as an 8 for sub-score for length x width in cm 2 (8.1-12.0 cm2), a 0 for exudate amount (none 0, light 1, moderate 2, heavy 3) and 0 for tissue type (0 closed, 1 [MEDICATION NAME] tissue, 2 granulation tissue, 3 slough, 4 necrotic tissue). The next entry on 11/29/11 reflected a 7 for length x width, 0 for exudate amount and 0 for tissue type. The final entry dated 12/02/11 reflected 7 for length x width, 0 for exudate and 0 for tissue type. There were no other entries. The 12/02/11 entry did not indicate the pressure ulcer was a Stage II as the nurse had documented on the progress notes. C. Review of Resident #3's Admission Summary reflected a [AGE] year old male who was admitted to facility on 9/01/11. Review of Resident #3's physician's orders [REDACTED]. During an observation 12/7/11 at 5:17 PM Resident #3 was slouched down in his wheel chair with his left arm stuck down inside of the chair. during an interview at this time, Resident #3 stated that he had a sore on his elbow because it rubs the chair all day and that that it hurts. Resident #3 stated, " Help me. " Observation on 12/7/11 at 5:30 revealed LVN M examined Resident #3's arm and discovered a Stage 1 pressure sore on left arm approximately 5x4 inch circle with 2 small blisters in the middle. During an interview on 12/07/11 at 5:30 LVN M stated, Resident #3's sore, reddened, blistered arm was a pressure ulcer and that she would inform the Physician. D. A review of Resident #17's history and physical dated 8/19/11 reflected an [AGE] year old male with [DIAGNOSES REDACTED]. He is alert to person only and admitted to facility on 02/21/01 . Observation on 12/8/11 at 12:30 PM revealed CNA S performing incontinent care on Resident # 17, wiping from anal area into his opened wound on his coccyx. The wound was a Stage 2 pressure ulcer. Resident #17's coccyx had a reddened area approximately 5 cm x 5 cm and his skin was opened with a scant amount blood present.. There was no dressing on the wound and no dressing was applied at this time. Interview on 12/8/11 at 4:50 PM LVN L stated that Resident #17 hasn't had any skin issues lately and that his bottom may get red, but they put [MEDICATION NAME] on it. Review of the facility's policy and procedure dated 10/14/2010, titled "Wound Program" reflects the purpose is "To provide consistent observation of the presence of or absence of skin conditions, the treatment of [REDACTED]." A head-to-toe skin assessment is done by a licensed nurse on admission, return from a hospital stay, weekly and as needed...measure all wounds,discolorations,scars." In the Procedure portion of this policy it reflects: A.) "On Admission". 2. Enter all measurements of discolorations and scars on the Progress Notes (Nurses notes) form in the Wound Book. 3. Enter all wound measurements on the Documentation of Wounds form. 4. Make 2 copies of the form. Turn one into the DON and place the second one in the Nurses Notes section in the resident's chart. 5. Initiate the PUSH Tool if a pressure ulcer is present and place in the wound book. B.) "New Observed Wounds" 1. Measure wounds... 2. Complete forms Documentation of Wounds and Alleged Incident/Accident Report... 3. Follow the wound protocol for all wound treatments..." C.) "Daily Treatments/Skin Assessments" 1. The wound nurse assigned to do the wound treatments will look at each previously observed wound. The ordered treatment will be performed..." 2. Skin assessments will be assigned weekly..." 3. Wounds that have not shown any improvement after 14 days of treatment, will be evaluated. The physician will be contacted for a change of treatment." E.) "Steps in Wound Prevention" 1. Apply skin barrier cream to the perineal/buttocks area(s) following incontinent care. 2. Reposition a minimum of 2 hours for those prone to skin breakdown. 3. Use additional appliances as needed: spenco mattresses for chair and /or bed, air mattress, specialty mattress, heel protectors, padded Wheelchair, pillows,etc. ...." On 12/08/11 at 12:15 PM, the Administrator and DON were informed of an Immediate Jeopardy related to the lack of care and services provided for Pressure Ulcers. On 12/08/11 at 7:20 PM, The Administrator presented the surveyors with a written plan of removal, which included the following: As of notification on December 8th at approximately 12:30 PM that the facility is receiving an IJ for Pressure Ulcers, the staff began immediately to prepare a plan of removal. On December 8, 2011, we will do the following: 1. We will reassess all residents with current known wounds and evaluate their current treatment. 2. High risk residents will have a skin assessment done. 20 residents have been identified as high risk by one or more of the following: Braden Scale; Inability to move self; Poor intake and Incontinence. 3. We will assess high risk residents for the need of pressure reducing items and initiate. We will use pillows, Spenco mattresses (bed and chairs), and air mattresses. Additional supplies such as pressure releasing cushions will be ordered on Friday, 12/09/2011. 4. Staff will be in serviced on wound care program including identifying, caring, and prevention of wounds. Infection control procedures will be in serviced (as noted above) 5. CNAs will document on ADL (Activities of Daily Living)flow sheets the turning and repositioning of residents with pressure ulcers and those at high risk for pressure ulcers. 6. QA (Quality Assurance) Committee will be involved in the evaluation and monitoring of the wound program. Each shift nurse will document in the treatment book the appropriateness of positioning and pressure release items being used on the above residents. DON will monitor the above steps for the next 48 hours. Based on observations and interviews on 12/08/11 and 11/09/11 of staff being in-serviced on the Wound Program, including: assessment, treatment, healing, reassessment, prevention and documentation the Surveyor informed the Executive Director, Administrator and DON on 12/09/11 at 2:00 PM that the Immediacy no longer existed. However, the deficient practice remained at the level of Actual Harm at a Pattern that is not Immediate Jeopardy because the facility administrative staff had not had time to develop, implement and monitor all corrective actions outlined in their plan of removal. The facility CMS 672 reflected only (1) one resident with a facility acquired pressure ulcer Stage II or higher. Review of facility ' s Roster/Sample Matrix provided on 12/06/11 reflected 3 residents with pressure sores. The DON provided information indicating 9 residents had facility acquired pressure ulcers.