Every finding on record at Lakeside Nursing and Rehabilitation Center

Based on interviews and record reviews the facility failed to ensure, in accordance with accepted professional standards and practices, complete, accurately documented, readily accessible, and systemically organized medical records for each Resident, for 1 of 4 residents (Resident # 2) reviewed for accurate records. The facility failed to obtain an order Resident #2's physician for the use of the abductor wedge. This failure could place residents at risk for receiving care interventions without physicians' orders. The findings included: A record review of Resident #2's admission record dated 6/3/2026 revealed an admission date of 8/16/2022 and readmitted on [DATE] with diagnoses which included generalized muscle weakness. A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed that resident #2 was a [AGE] year-old female admitted for LTC with ADL. Resident #2 was assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #2's hospital records dated 5/17/2026 revealed the Orthopedic Surgeon performed a surgical repair for Resident #2's left hip and ordered for Resident #2 not to rotate her left leg, cross her legs, or flex her hip, orthopedic surgery operative note . post operative plan: the patient will be weightbearing as tolerated to the injured lower extremity. They will be under posterior hip precautions (no internal rotation past neutral, no hip flexion beyond 90 degrees, and no crossing legs) for the first 6 weeks. We will see the patient back in clinic in 2 weeks for a wound check. left hip replacement, abductor pillow in place. A record review of Resident #2's physician's orders dated 6/3/2026 revealed no orders for Resident #2's abduction-wedge. A record review of Resident #2's facility therapy department in-service titled Safe positioning in bed dated 5/20/2026 revealed, maintain posterior hip precautions - no hip flexion, no crossing legs, no internal rotation, log rolling; move trunk, hips, and shoulders, as one unit for all turns, use of abduction pillow at all times in supine, abduction knee separator in sitting, . avoid pulling on upper extremities or pelvis. During an interview an observation on 6/3/2026 at 2:40 PM revealed Resident #2 was seated in her wheelchair visiting with her Representative. Resident #2 wore an abductor-wedge in between her legs. The Representative stated she believed the facility received the order from the surgeon and knew how to use the abduction web wedge. During an interview and observation on 6/3/2026 at 3:10 PM revealed CNA B attended Resident #2's at her bedside CNA B demonstrated Resident #2's wedge as she laid in bed CNA B stated she had received training from the physical therapy department on applying the wedge and removing the wedge. During an interview on 6/3/2026 at 3:20 PM LVN C stated she was the charge nurse for Resident #2 and stated Resident #2 had a need for an abductor wedge between her legs because Resident #2 has been recovering from a left hip fracture with surgical repair. LVN C stated Resident #2 should not rotate or flex her left leg and the intervention from the therapy department was for Resident #2 to wear the abductor wedge in between her legs. LVN C stated she reviewed Resident #2's medical record and recognized Resident #2 had no physicians' orders detailing the care and use of the abductor wedge. LVN C stated the potential negative outcome could be Resident #2 received an abductor wedge without an order or care plans for the abductor-wedge. During an interview on 6/3/2026 at 4:10 PM the Therapy Director stated Resident #2 was admitted from the hospital on 5/19/2026 after a surgical repair to her left hip and an abductor wedge between her legs was applied at the hospital and was wearing the abductor wedge between her legs. The Therapy Director stated the abductor wedge was used to keep Resident #2's left leg in a straight alinement to the hip socket and restricted Resident #2 from twisting her left leg and prevented Resident #2 from crossing her legs. The Therapy Director stated the potential for harm could be if the wedge was not used Resident #2 could possibly twist her leg, cross her legs, or flex the hip joint which could cause damage to the surgical repair of the hip. The therapy director stated upon admission Resident #2 was assessed by the therapy department as having a need for the abductor wedge and developed and implemented an in-service education for all the nursing staff and began training specific for Resident #2. The Therapy director stated all staff have received the training. The Therapy Director stated she was a member of the IDT team and had met with the IDT team to discuss Resident #2's admission and needs for therapy services which included the use of the abductor wedge. The Therapy Director stated the potential negative outcome could be Resident #2 could be receiving therapies without physician orders. During an interview on 6/3/2026 at 4:45 PM the DON stated she would have to review the details surrounding the abductor-wedge and had no comment at the time. During an interview on 6/4/2026 at 4:45 PM the Administrator stated the expectation was for Residents #2's abduction wedge, which was assessed by the therapy department and the staff was educated, and Resident #2 should have had a physician order for the abductor-wedge. A record review of the facility's undated Medical Records policy revealed, It is the policy of this facility to ensure every resident has an accurate record. The resident record will contain: . the resident Service plan, physician orders, .

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Residents #2) reviewed for comprehensive care plans in that: The facility failed to care plan Resident #2's abductor wedge that was needed for her after hospitalization care. This failure could place residents at risk for not receiving care interventions.The findings included A record review of Resident #2's admission record dated 6/3/2026 revealed an admission date of 8/16/2022 and readmission on [DATE] with diagnoses which included generalized muscle weakness. A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old female admitted for LTC with ADL. Resident #2 was assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #2's care plan dated 6/3/2026 revealed no focuses, goals, nor interventions for Resident #2's need for an abduction wedge for her legs. A record review of Resident #2's nursing progress notes for the period 5/15/2026 through 6/5/2026 revealed the following:*On 5/15/2026 Resident #2 was assessed with pain when applying weight to her left leg, NP A received a report and prescribed x-ray images for the left hip which was diagnosed as a left hip fracture on 5/16/2026.*On 5/16/2026 Resident #2 was ordered to be transferred to the hospital for evaluation and treatment and was admitted for after hospital care on 5/19/2026. A record review of Resident #2's hospital records dated 5/17/2026 revealed the Orthopedic Surgeon performed a surgical repair for Resident #2's left hip and ordered for Resident #2 not to rotate her left leg, cross her legs, or flex her hip, orthopedic surgery operative note . post operative plan: the patient will be weightbearing as tolerated to the injured lower extremity. They will be under posterior hip precautions (no internal rotation past neutral, no hip flexion beyond 90 degrees, and no crossing legs) for the first 6 weeks. We will see the patient back in clinic in 2 weeks for a wound check. left hip replacement, abductor pillow in place. A record review of Resident #2's facility therapy department in-service titled Safe positioning in bed dated 5/20/2026 revealed, maintain posterior hip precautions - no hip flexion, no crossing legs, no internal rotation, log rolling; move trunk, hips, and shoulders, as one unit for all turns, use of abduction pillow at all times in supine, abduction knee separator in sitting, . avoid pulling on upper extremities or pelvis. During an interview an observation on 6/3/2026 at 2:40 PM revealed Resident #2 was seated in her wheelchair visiting with her Representative. Resident #2 wore an abductor-wedge in between her legs. Resident #2's Representative stated she participated in a care plan meeting, however the discussion in the meeting never reviewed the details of Resident #2's need for an abduction wedge in between her legs. Resident #2's Representative stated Resident #2 was given the wedge after her surgery at the hospital and was admitted to the facility with the same wedge. Resident #2 Representative stated she believed the facility received the order from the surgeon and knew how to use the abduction web wedge. During an interview and observation on 6/3/2026 at 3:10 PM revealed CNA B attended Resident #2's at her bedside CNA B demonstrated Resident #2's wedge as she laid in bed CNA B stated she had received training from the physical therapy department on applying the wedge and removing the wedge. During an interview on 6/3/2026 at 3:20 PM LVN C stated she was the charge nurse for Resident #2 and stated Resident #2 had a need for an abductor wedge between her legs because Resident #2 has been recovering from a left hip fracture with surgical repair. LVN C stated Resident #2 should not rotate or flex her left leg and the intervention from the therapy department was for Resident #2 to wear the abductor wedge in between her legs. LVN C stated she reviewed Resident #2's medical record and recognized Resident #2 had no care plan interventions detailing the care and use of the abductor wedge. LVN C stated the potential negative outcome could possibly be she received an abductor wedge without an order. During an interview on 6/3/2026 at 4:10 PM the Therapy Director stated Resident #2 was admitted from the hospital on 5/19/2026 after a surgical repair to her left hip and an abductor wedge between her legs was applied at the hospital and was wearing the abductor wedge between her legs. The Therapy Director stated the abductor wedge was used to keep Resident #2's left leg in a straight alinement to the hip socket and restricted Resident #2 from twisting her left leg and prevented Resident #2 from crossing her legs. The Therapy Director stated the potential for harm could be if the wedge was not used Resident #2 could possibly twist her leg, cross her legs, or flex the hip joint which could cause damage to the surgical repair of the hip. The therapy director stated upon admission Resident #2 was assessed by the therapy department as having a need for the abductor wedge and developed and implemented an in-service education for all the nursing staff and began training specific for Resident #2. The Therapy director stated all staff have received the training. The Therapy Director stated she was a member of the IDT team and had met with the IDT team to discuss Resident #2's admission and needs for therapy services which included the use of the abductor wedge. The Therapy Director stated she also attended the care plan meeting on 5/27/2026 and had reviewed Resident #2's care plan and she had not recognized Resident #2 did not have care plan interventions for which reflected the in-service education for the staff. The Therapy Director stated the potential negative outcome could be Resident #2 could be receiving therapies without a care plan. During an interview on 6/3/2026 at 4:45 PM the DON stated she would have to review the details surrounding the abductor-wedge and had no comment at the time. During an interview on 6/4/2026 at 4:45 PM the Administrator stated the expectation was for Residents #2's abduction wedge, which was assessed by the therapy department and the staff was educated, should have been reflected on the care plan. A record review of the facility's undated Care and Treatments policy revealed, it is the policy of this facility that the interdisciplinary team shall develop and complete a comprehensive person-centered care plan for each resident that includes measurable objectives End time frames to meet a residence medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement A baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective in person centered care that meet professional standards of quality care.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. 1 container of an orange juice cup was sitting on top of a box of orange juice and was partially opened. 2. A box of graham cracker tart shells was open and the individual shells were not covered. 3. A box of vanilla ice cream cups was open, not dated and contained cups that had opened and spilled out into the cardboard box. 4. A box of strawberries in the freezer was open and the plastic wrap around the strawberries was torn, exposing the strawberries to the air. 5. An individually wrapped glazed donut was in a plastic baggie with smeared marks at the top where the Date and Contents line was located. 6. An undated and unlabeled bag of red juice was located under the juice dispenser and was not connected to the dispenser. 7. The facility failed to store a mop in the proper position in the utility closet. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness. The findings were: 1. Observation on 07/28/25 at 9:12 am in the kitchen revealed a small container of orange juice sitting on top of a cardboard box of orange juice that had the cardboard lid partially opened and juice had leaked out onto the side of the container. 2. Observation on 07/28/25 at 9:12 am in the kitchen revealed a box of graham cracker crust tart shells that was open, not dated and exposed to the air.3. Observation on 07/28/25 at 9:12 am in the kitchen freezer revealed a box of vanilla ice cream cups that was open, not dated and contained cups that had opened and spilled out into the cardboard box. This appeared to indicate that at some point the containers were not kept frozen and melted so that the contents spilled out. 4. Observation on 07/28/25 at 9:12 am in the kitchen, revealed a box of strawberries in the freezer that was open and the plastic wrap around the strawberries was torn, exposing the strawberries to the air.5. Observation on 07/28/25 at 9:12 am in the kitchen, revealed a baggie of an individually wrapped glazed donut with illegible ink smears on the label part of the bag for date and contents.6. Observation on 07/28/25 at 9:12 am in the kitchen, revealed an undated and unlabeled open bag of red juice located under the juice dispenser laying on a shelf that was not connected to the dispenser. A kitchen employee grabbed the container off the shelf when she noted surveyor was looking at it and said she was going to take it to the trash. 7. Observation of the utility closet in the kitchen on 07/29/25 at 10:00 am revealed a mop stored head-side down in the drain compartment of a mop- bucket. The mop was not in use at the time of the observation. The Dietary Manager was asked if that is where the mop is usually stored he said, ‘No, it should be hung up. He then proceeded to try and hang the handle of the mop on a wall mounted mop and broom holder. The holder would not hold the handle so he just took the mop head off, put it in a plastic bag and had one of his employees take it to the laundry. On 07/31/25 at 1:00 pm, a follow-up observation of the closet revealed a mop with the mop head up leaning against the wall of the closet. When asked if this was the proper way to store the mop, the Dietary Manager stated that it should probably be stored with mop head down which was also incorrect. Record review of an undated Policy/Procedure for Dietary Services revealed It is the policy of this facility that the facility shall have an organized food service, appropriately planning, equipped, and staffed to prepare and serve the number of meals created in the kitchen. Under the Procedures, #7 stated All cleaning equipment must be stored in designated area when not in use. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 6-501.16 Drying Mops. After use, mops shall be placed in a position that allows them to air-dry without soiling walls, equipment, or supplies.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #89) reviewed for privacy, in that: The facility failed on 7/30/2025 when CNA A and RA B did not completely close Resident #89's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #89's face sheet, dated 07/30/2025, revealed an admission date of 12/09/2023 and, a readmission date of 10/03/2024, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood),Dysphagia (Difficulty swallowing), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood). Record review of Resident #89's Quarterly MDS assessment, dated 04/25/2025, revealed the resident had a BIMS score of 09, indicating she was moderately cognitively impaired. Resident #89 was always incontinent of bladder and frequently incontinent of bowel and, required total assistance with her ADLs. Record review of Resident #89's care plan, dated 12/20/2023, revealed a problem of has bowel and bladder incontinence r/t Activity Intolerance, Dementia, Disease Process, Impaired Mobility, w/c bound, and Overactive Bladder., with an intervention of TOILET USE: The resident requires extensive assist from (2) staff for toileting. Observation on 07/30/2025 at 10:20 a.m. revealed CNA A and RA B did not completely close the privacy curtains while they provided incontinent care for Resident #89, exposing the resident who could be seen if somebody entered the room. Further observation revealed Resident #89's roommate was in the room. The privacy curtain was folded on itself on one end and was too short to be completely closed. During an interview with CNA A and RA B on 07/30/2025 at 11:11 a.m., when CNA A stated the privacy curtains was not completely closed while they provided care for Resident #89 but it should have been to protect the resident privacy. Neither CNA had noticed the privacy curtain was too short to completely close and were going to notify Maintenance. They stated they received resident rights training within the last year. During an interview with the DON on 07/30/2025 at 3:55 p.m., when DON stated privacy must be provided during nursing care and Resident #89's privacy curtains should have been closed completely. DON stated the staff had received training on resident rights within the year and the training was provided by the ADONs and herself. The DON stated they also check the staff skills annually and as needed. Review of Facility's policy, titled Resident Rights, undated, revealed They also will have the right to privacy, maintain privacy curtains for dressing and when providing care.

Based on interview and record review the facility failed to ensure the resident Minimum Data Set (MDS) assessment accurately reflected the resident's status for 2 (Resident #48 and Resident #84) of 5 residents reviewed for accuracy of assessments. 1.The facility failed to ensure Resident #48 was coded on his annual MDS assessment dated [DATE] as receiving an antipsychotic medication. 2.The facility failed to ensure Resident #84 was coded on his quarterly MDS assessment dated [DATE] as receiving an antipsychotic medication. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1.Review of Resident #48's admission sheet with an original admission date of 8/31/24 and a re-admission date of 7/16/25, showed a [AGE] year-old male resident with diagnoses including Dementia, Depression, Anxiety, Post Traumatic Stress Disorder, Cholecystitis (inflammation of the gallbladder, often caused by gallstones), Parkinson's Disease (a movement disorder of the nervous system), and Hypertension (high blood pressure). Review of Resident #48's order summary included an order for Nuplazid (Pimavanserin) 34 MG dated 8/30/24, with directions to give 34 MG one time a day for hallucinations. Nuplazid is an atypical antipsychotic indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis. Review of Resident #48's annual MDS assessment dated [DATE] documented the resident with a BIMS of 11, indicating moderate cognitive impairment. Further review of the assessment showed in Section N - Medications, N0415. High-Risk Drug Classes: Use and Indication 1. Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days A. Antipsychotic, a blank box under the Is taking column for antipsychotic medication. Review of Resident #48's care plan with a revision date of 9/2/24, documented the resident is on antipsychotic medication use r/t hallucinations with interventions/tasks including Document episodes of behavior; Document non-pharmacological interventions; Pimavanserin as ordered per Medical Doctor (MD); and Quarterly Abnormal Involuntary Movement Scale (AIMS) assessment to be completed. 2.Review of Resident #84's admission sheet with an original admission date of 1/17/23 and a re-admission date of 10/3/23, showed a [AGE] year-old male with diagnoses including Type 2 Diabetes Mellitus, Hypertension, Anxiety, Bipolar Disorder, and Benign Prostatic Hyperplasia (enlarged prostate). Review of Resident #84's order summary included an order for Latuda (Lurasidone) 40 MG dated 4/10/25, with directions to give 1 tablet by mouth one time a day for Bipolar. Latuda is an atypical antipsychotic indicated for the treatment of schizophrenia and bipolar depression. Review of Resident #84's quarterly MDS assessment dated [DATE] documented the resident with a BIMS of 14, indicating intact cognition. Further review of the assessment showed in Section N - Medications, N0415. High-Risk Drug Classes: Use and Indication 1. Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days A. Antipsychotic, a blank box under the Is taking column for antipsychotic medication. Review of Resident #84's care plan with a revision date of 5/20/24, documented the resident receives Lurasidone Psychotropic medication r/t Bipolar disorder with interventions/tasks including Administer medications (Latuda) as ordered. Monitor/document for side effects and effectiveness. During an interview with the MDS Coordinator on 7/30/25 at 2:24 PM, the MDS Coordinator stated she opens the MDS assessment in the scheduled time frame and the interdisciplinary team reviews the medical record and completes their portion of the assessment. The MDS Coordinator stated when the assessment was complete, a registered nurse with Resource Utilization Group (RUG) training will sign the assessment. The MDS Coordinator stated after the assessment has been signed, she will lock and transmit it. The MDS Coordinator stated it was important for the MDS to be accurate, because they use the assessment for quality measures, to perform the care of the patient, and to revise the care plan. During an interview with the DON on 7/30/25 at 4:00 PM, the DON stated her expectation for the MDS assessments is that they are accurate, and if they are inaccurate, her expectation was that they be fixed. During an interview with the DON on 7/31/25 at 9:08 AM, the DON stated they use the Resident Assessment Instrument (RAI) Manual as a reference for the MDS assessments. Review of the RAI Manual (Resident Assessment Instrument) dated October 2024, documented in section N0450: Antipsychotic Medication Review Coding Tips and Special Populations, Any medication that has a pharmacological classification or therapeutic category of antipsychotic medication must be recorded in this section, regardless of why the medication is being used.Review of the facility policy titled Resident Assessment, undated, documented It is the policy of this facility to complete a comprehensive assessment of the resident's needs which are based on the State's specific Resident Assessment Instrument (RAI) and the facility's interdepartmental assessment forms.

Based on observation, interviews, and record reviews, 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 disease and infection for 1 of 6 residents (Resident #86) reviewed for infection control, in that: While providing colostomy care for Resident #86, LVN C failed to use proper infection control. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #86's face sheet, dated 07/30/2025, revealed an admission date of 02/05/2025, and a readmission date of 05/01/2025, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus(high level of sugar in the blood),Dysphagia (Difficulty swallowing), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), Hypothyroidism (under active thyroid), Hypertension (high blood pressure), Ileostomy status(opening in the abdominal wall allowing for elimination of feces). Record review of Resident #86's Significant Change MDS, dated [DATE], revealed the resident had a BIMS score of 15 indicating no cognitive impairment. Resident #86 required total assistance with her ADLs, was always incontinent of bladder and, had a ostomy. Review of Resident #86's care plan, dated 02/06/2025, revealed a problem of Has an alteration in gastro-intestinal status r/t Diverticulitis withperforation and Ileostomy status. and an intervention of Provide ileostomy care and change bag as needed. Observation on 07/30/2025 at 12:05 p.m. revealed while providing Ileostomy (opening in the abdomen allowing waste to exit the body) care for Resident #86, LVN C, use sanitizer between change of gloves after removing the collection bag and after cleaning the stoma, however LVN C did not sanitize between her fingers. During an interview with LVN C, on 07/30/2025 at 12:25 p.m., she stated she did not realize she did not correctly sanitize her hands but confirmed she should sanitize between her fingers to prevent cross contamination and put the resident at risk for infection. She confirmed receiving infection control training within the year. During an interview with the DON on 07/30/2025 at 3:55 p.m., she stated staff had to sanitize between their fingers while sanitizing to prevent risk of infection for the residents. She confirmed training was provided for the staff at least annually and their skills were check at least annually Review of facility policy, titled Hand Hygiene, dated 10/2022, revealed Using alcohol-based hand rubs. Apply generous amount of product to palm of hands and rub hands together. Cover all surfaces of hands and fingers until hands are dry.

Based on record review and interview, the facility failed to ensure the right to receive written notice of a room change before the change was made for 2 of 2 resident (Resident #41 & Resident #80) reviewed for resident room changes. The facility did not provide evidence that Resident #41 and Resident #80 was given a written notice of a room change before the resident was moved. This deficient practice could affect residents in the facility that are moved without required notification. The findings included: Record review of Resident #41's comprehensive MDS assessment, dated 06/14/2024 reflected a [AGE] year-old female admitted on [DATE] a primary diagnosis of Other encephalopathy (damage or disease that affects the brain) and assessed to have severe cognitive impairment. Record review of Resident #41's face sheet, dated 06/21/2024 listed Resident #41's RP as Resident #41's primary contact. Record review of Resident #80's quarterly MDS assessment, dated 06/03/2024, reflected a [AGE] year-old female admitted on [DATE] with a primary diagnosis of Acute and chronic respiratory failure with hypoxia (not getting enough oxygen into your blood) and was assessed to not have cognitive impairment. Record review of Resident #80's progress notes, dated 05/20/2024 at 11:27 AM, authored by ADON C, reflected Spoke w/ resident about room change. Resident acknowledged understanding and agreed. Interview on 06/18/2024 at 11:40 AM, Resident #41's RP stated she was the primary responsible party for Resident #41 and stated in the last month (May 2024) the facility moved both Resident #41 and her roommate, Resident #80 from room [ROOM NUMBER] to their current room at the end of the hall. Resident #41's RP stated she was not notified of this room change prior to when the change was made and was later notified this communication was made to Resident #41's other family who was not listed as the RP. Resident #41's RP stated had she been notified of the room change then it would have been rejected outright. Resident #41's RP stated she became aware of Resident #41's room change when she visited and could not find Resident #41. Resident #41's RP stated she never received a written notification of the room change and was informed after the room change was made by the DON that the change was made to accommodate a different resident in a different room who would be better equipped in room [ROOM NUMBER] due to its proximity to the nurse's station and a recent fall incident. Interview on 06/18/2024 at 11:54 PM, Resident #80 stated she was requested to move to her current room from room [ROOM NUMBER] approximately 1 month ago (May 2024) to which she initially declined as the DON stated Resident #41 was not going to be transferring with her. Resident #80 stated after her initial declination to move rooms, the DON then returned to request her to move to room [ROOM NUMBER] but then stated Resident #41 was going with her. Resident #80 stated at no point was she provided a written notification of the room change. Resident #80 stated she was requested to move to her current room to accommodate a different resident who recently experienced a fall and was requiring more direct nursing care based on the proximity of room [ROOM NUMBER] to the nurse's station. Interview on 06/20/2024 at 9:52 AM, ADON C stated she was the assigned ADON for Resident #80 and Resident #41's hall. ADON C stated she completed the notification of the room change to Resident #80 and Resident #41 verbally, during which neither disagreed. ADON C stated she did not provide a written notification as she was not instructed to, and only made the room change notification to Resident #80 and Resident #41 based on the instruction provided that day from the DON. ADON C stated she was not familiar with why Resident #80 and Resident #41 were being moved and was only told by the DON of the need to move them. Interview on 06/20/2024 at 10:07 AM, the SW stated she was not part of the room change for Resident #80 and Resident #41. The SW stated the facility protocol during room changes was to verbally request the room change, and if the resident was to refuse, then a 5-day written notification was to be issued, however this was never needed to be utilized as a resident had never refused before. The SW confirmed the staff who made the verbal notification to Resident #80 and Resident #41 was ADON C. Interview on 06/20/2024 at 10:40 AM, the DON stated she and the ADM were both present when the notification of the room change was made to Resident #41 and Resident #80 and stated Resident #80 did not disagree and that was evidenced by the fact that the room change was inevitably made. The DON stated there was no record of the DON and ADM being present for the verbal notification and stated written notifications of room changes were not part of facility protocol as they were only used when a resident was to disagree to the room change. The DON stated the SW would primarily be the one to provide the written notification of the room change but during the room change with Resident #41 and Resident #80 a verbal notification was instead made by herself and the ADM. Interview on 06/20/2024 at 10:54 AM, the ADM stated he did not have record of a written notification of the room change for Resident #41 and Resident #80 due to both residents not objecting to the room change and the room change was made the same day when both he and the DON made a verbal request for Resident #41 and Resident #80 to move from #101. The ADM stated he did not see a potential concern with not providing a written notification because he did not see a potential abusive scenario where a resident would be moved without their consent. The ADM stated his facility protocol regarding room changes was only to issue written 5-day notifications was when a resident was to disagree and stated Resident #80 never disagreed to the room change and further stated Resident #41's RP never complained of the room change to any staff at any time. A request for a facility policy was requested at this time. Facility policy specific to room changes was not provided prior to exit. A request was made to the ADM on 06/20/2024 at 10:54 AM.

Based on observations, interviews, and record review, the facility failed to prepare puree food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed for puree preparation. The facility failed to follow the puree diet recipe for Pureed Buttered [NAME] Bread for 06/20/24 lunch. This failure could affect residents on puree diet at risk of receiving inadequate diet that could affect their health. Findings included: Record Review of Week At a Glance week 2 revealed Pureed Buttered [NAME] Bread to be served for pureed diets. Record Review of recipe Pureed Buttered [NAME] Bread, Copyright 2024, reflected Ingredients: white sliced bread, melted margarine, and milk and instructions to add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. During an observation, interview, and record review on 06/20/24 at 10:11 AM, [NAME] F prepared Pureed Buttered [NAME] Bread not according to the recipe. The recipe was not present while [NAME] F was preparing this recipe. Observation revealed [NAME] F did not add margarine or milk during this preparation. [NAME] F revealed she added chicken broth and water to the pureed white bread menu item. She further revealed the product was not a mashed potato consistency because the foods became hardened when on the steam table due to the liquids evaporating by the time foods were served. During an observation and interview on 06/20/24 at 11:48 AM, the CDM revealed they did not use the Pureed Buttered [NAME] Bread that was made during the pureed foods observation. The CDM further revealed the Pureed Bread that was going to be served for 06/20/24 lunch had ingredients to include bread, margarine, and broth. The CDM stated he would contact the RD to see if broth was okay to use instead of the milk. During an interview on 06/20/24 at 02:06 PM, the CDM revealed the RD stated it was okay to use broth or a liquid with nutritive value instead of milk in pureed recipes due to some residents having an allergy to milk. He further revealed the kitchen did not use the prepared pureed bread that was observed by this surveyor for 06/20/24 lunch. A policy for following recipes was requested from the DON on 06/21/24 at 10:27 AM. There was not a policy available.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for, 1 of 4 medication carts observed, in that: The Nurse Medication Cart in the 300 hall contained eleven loose medication pills. This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications. The findings were: Observation on 06/19/2024 at 9:57 a.m. of the 300 Hall Nurse Medication Cart revealed there were eleven loose medication pills inside one of the drawers. During an interview with Nurse E on 06/19/2024 at 9:57 a.m., Nurse E confirmed there were eleven loose medication pills inside a drawer of the Nurse Medication Cart. During an interview with the DON on 06/19/2024 @ 10:27 a.m., she stated medication carts should not have loose medications. They were the responsibility of the nurse that accepted responsibility for the cart, also the medications carts were supposed to be checked bi-weekly by the ADON's and any loose medications were to be identified, followed by a medication count then cross-checked by residents, then disposed of per facility policy. Record review of the facility policy titled Medication Access and Storage revealed, Policy Statement: Medication storage areas are kept clean, well lit, and free of clutter.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #28) reviewed for pharmacy services. Resident #28 was provided a medication, Prilosec, outside of the ordered time range. This failure could place residents at risk of not receiving the therapeutic effects of their prescribed medications. The findings included: Record review of Resident #28's face sheet, dated 6/20/24, reflected a [AGE] year-old female with an initial admitted [DATE] and diagnoses including: Acute Pancreatitis ( condition where the pancreas becomes inflamed (swollen) over a short period of time, Cirrhosis of the Liver ( a type of liver damage where healthy cells are replaced by scar tissue) and Hepatic Failure ( loss of liver function ). Record review of Resident # 28's Quarterly MDS assessment, dated 1/3/24, revealed Resident # 28 was assessed with a BIMS score of 15 which indicated intact cognition. Record review of resident #28's Care Plan dated 8/12/23 revealed the resident had GERD (Gastroesophageal Reflux Disease) with interventions give the resident their medications as ordered. Record review of Resident # 28's Physician orders for June 2023 revealed that Resident # 28 was prescribed Prilosec 20 mg daily at 0630 for GERD (Gastroesophageal Reflux Disease). Record review of medication administration history for Resident # 28, dated 6/20/24, revealed that Prilosec was administered on 6/20/24 at 810 a.m. Observation on 6/20/24 at 915 a.m. revealed that Resident # 28's medication order for Prilosec 20 mg on the electronic medication administration record was red, indicating that the medication was not given as ordered. Interview with CMA A on 6/20/24 at 8:05 am, revealed that medication Prilosec 20 mg for Resident # 28 was scheduled at 6:30 a.m. but adminstered at 810 a.m because , Resident # 28 does not like to take medication before eating breakfast. Interview with Resident # 28 on 6/20/24 at 10:00 a.m. revealed she has told all nurses that she does not want any medications before breakfast. During an interview on 06/20/2024 at 10:45 AM, the DON stated that the expectation for certified medication assistants was to administer medications per physician orders and notify the charge nurse of any deviation. The DON stated if a nurse makes a medication error, such as providing medications out of a one-hour window when scheduled, they should inform the DON, physician, and RP. The DON stated the risk of the resident receiving medications outside of physician orders could cause possible side effects. She stated her ADONs currently monitor this task at random, and she oversees this task. A record review of the facility's Policy Medication Administration , dated May 2007, revealed, Any irregularly in pouring or administrating must be reported to the physician .

Based on interviews and record reviews, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality for 1 (Residents #451) of 8 residents reviewed for baseline care plans. Resident #451's baseline care plan, dated 06/18/24, did not reflect any interventions for focus of at risk for falls. This deficient practice could affect residents admitted to the facility and result in missed or inadequate care. The findings included: Record Review of Resident #451's Admission Record, dated 06/18/24, reflected a [AGE] year-old male admitted [DATE] with diagnoses to include fracture of left femur, difficulty in walking, abnormalities of gait and mobility, cognitive communication deficit, and need for assistance with personal care. Record Review of Resident #451's Admission MDS assessment, dated 06/12/24, reflected a BIMS score of 13 out of 15, indicating cognitively intact. His MDS assessment further reflected all questions pertaining falls in section J were not answered. Record Review of Resident #451's care plan, dated 06/18/2024, revealed no interventions for problem At risk for falls r/t (SPECIFY), initiated 06/09/2024, and for problem Has acute/chronic pain r/t, initiated 06/09/2024. Record Review of Resident #451's Fall Risk Evaluation, dated 06/08/24, Resident had 1-2 falls in the last 3 months with a medium risk for falls. Record Review of Resident #451's hospital records, dated 06/05/24, revealed resident was admitted for left femur fracture and left hip contusion following a fall from a previous group home. During an interview on 06/20/24 at 05:00 PM the DON revealed any new admission will have fall interventions in place and staff knew to do this. The DON would not confirm there were no fall interventions on Resident #451's care plan when showed the electronic copy of Resident #451's care plan. Interview and observation of Resident #451 on 06/18/24 at 04:29 PM revealed some fall interventions in place to include: call light within reach, bed in lowest position, room was free from clutter. Resident #451 revealed he has not fallen while in the facility and the staff checked in on him regularly. Record Review of the facility's policy Fall Management System, undated, reflected, Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. Record Review of the facility's policy Care Planning, undated, reflected nothing about the baseline care plans. A policy for baseline care plans was requested from the DON on 06/21/24 at 10:27 AM and on 06/22/24 at 10:17 AM. There was not a policy available.

Based on interview and record review, the facility failed to demonstrate their response and rationale regarding the resident's council's grievances after group meetings concerning issues of resident care and life in the facility and provide a private space for residents' monthly council meetings for 1 of 1 resident council, in that: The facility failed to demonstrate their response and rationale for such response to the resident council's grievances. The facility failed to provide the resident council with a private space for their monthly meetings. This failure could place residents that participate in a resident council at risk of not having the right to their concerns and grievances followed through with. The findings included: During confidential interviews on 06/19/24 at 02:02 PM, residents stated grievances were not always followed up on and they were concerned the grievances they wrote were not being addressed. They stated they felt they could not make grievances without being reprimanded by staff. They expressed they were not aware they could have resident council meetings without staff. During an interview 06/20/24 on 03:01 PM, the AD revealed she has had meetings for resident council with staff members. She further revealed it was the president's preference to have AD present at all meetings, but other residents did not request the AD to be present at all meetings. She further revealed the resident council meeting was held in the dining room or the conference room. During an interview on 06/21/24 at 10:30 AM, the Activities Director revealed they have had resident council meetings in the dining room due to growing numbers of resident council members. The AD further revealed she put signs up for staff to not walk by the resident council meeting, but it did not stop staff from walking by. She pointed out the nurse's station was near the dining room, and they could not control nurses being present at the nurse's station while the resident council meeting was going on. During an interview on 06/21/24 at 10:56 AM, the ombudsman revealed staff members have always been present at the resident council meetings and she did not know if residents were aware they could have resident council meetings without staff members. She suggested that the AD put signs up to let staff members know to not walk into the dining room to provide privacy to the resident council meeting. She further revealed the facility's grievance system was broken and needed work. She had received complaints from residents about grievances not going anywhere and not being addressed. During an interview on 06/21/24 11:18 AM, the AD revealed sometimes old business and old grievances that have been resolved were not discussed. She further revealed she asked residents if they wanted to discuss old grievances being resolved and some residents in the resident council said no. She revealed it may be important to discuss when grievances had been resolved so residents knew grievances had been addressed. She assumed residents would speak up if they wanted to hear the grievance solutions and did not consider the residents may stay quiet and still want to hear the solutions. Attempts to interview the resident council president were not successful as she was at medical appointments per facility staff. Record review of the facility's Grievance Log for the last 6 months revealed April 2024 was the only one that had Resident Council for 4 out of 6 grievances, reported on 04/17/24 and resolved 04/17/24 with resolution noted to be satisfactory. Record review of the facility's Complaint/Grievance Follow-up Report for these 4 grievances, dated 04/17/24, revealed the person notified of resolution for these complaints was the [resident council president]. Record review of the facility's policy titled Grievances, revised 12.2023, reflected, It is the policy of this facility to establish a grievance process that allows the resident(s) a way to execute their right to voice concerns or grievances to the facility or other agency/entity without fear of discrimination or reprisal. And The Grievance Official or designee responds to the individual expressing the concern within (3) three working days of the initial concerns to acknowledge receipt and describe steps taken toward resolution. There were no policies about resident council.

Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the residents for 1 of 3 residents (Resident # 15) reviewed for call light. The facility failed to ensure. Resident # 15's call light was within reach. This failure could place residents at risk of achieving independent functioning, dignity, and wellbeing. Findings include: Record review of Resident 15's face sheet dated 6/18/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident # 15 had diagoses which included: Guillain-Barre syndrome, (is a rare neurological disorder that occurs when the body's immune system attacks the peripheral nervous system), Paraplegia (is a specific pattern in which you can't deliberately control or move your muscles) and Pulmonary hypertension (condition that occurs when blood pressure in the lungs is higher than normal). Record review of Resident # 15's Quarterly MDS, dated [DATE], reflected a BIMS score of 13, which indicated cognition was intact. Record review of Resident # 15 Quarterly MDS, dated [DATE], reflected under section G, 0130, option # 1 which stated, the patient required assistance X 2. Record review of Resident # 15 care plan dated 1/11/23, revised 5/4/24 revealed that Resident # 15 had an alteration in muscle function related to Guillain [NAME] Syndrome, intervention Be sure call light is with in reach. Observation on 6/18/24 at 10:15 a.m. revealed the call light was not visible for Resident # 15. Resident #15's call light was located inside the nightstand drawer. In an interview with Resident # 15 on 6/18/24 at 10:35 a.m., he stated, I don't like to bother the CNA's . During an interview on 6/18/24, at 10:18 am, LVN B stated that she was the assigned nurse for Resident #15 and mentioned that the call light was located inside the nightstand drawer. She noted that the lack of accessibility of a call light could possibly have a negative impact if Resident # 15 required assistance. During an interview with the DON on June 21, 2024, at 9:05 a.m., she expressed that it was her expectation for call lights to be within arm's length of all residents. She emphasized that the absence of a call light could result in a fall if a resident required assistance. The DON was unaware that Resident #15's call light was not visible. She mentioned that her ADON's were responsible for ensuring that all residents' call lights were within reach, and she monitors this randomly. Record review of the facility's policy titled Call Light/Bell , undated, reflected Place call light with in residents reach.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 32 residents (Resident #50) reviewed for safe comfortable environment. The facility failed to ensure Resident #50's room was free of two cracks in the floor, running the length of the room. This deficient practice could place residents at risk of falling due to a tripping hazard created from the floor crack. The findings included: Observation and interview on 06/18/2024 at 12:13 PM, Resident #50's room was revealed to contain two cracks, each measuring approximately 1.5 millimeters in width or slightly larger than the thickness of pencil lead and measuring approximately 12 feet long of one crack and the other measuring approximately 8 feet long. Resident #50 stated she has had this crack in her room for as long as she had been in the room and did not prefer to have the crack in the floor. Resident #50 stated she has expressed the concern to her nursing staff but could not identify individual staff and stated she had not seen maintenance in her room since she had been in this room. Resident #50 stated she has never tripped on the crack and did not believe the crack had grown. Resident #50 stated the crack went underneath her roommate's bed as well but was only visible on her side of the room in front of her bed. Record review of Resident #50's comprehensive MDS assessment, dated 06/14/2024, reflected an [AGE] year-old female admitted on [DATE] with a primary diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (A group of thinking and social symptoms that interferes with daily functioning), and was assessed to have severe cognitive impairment. Interview on 06/20/2024 at 9:30 AM, LVN D stated she has worked at the facility for a few weeks as a medication aide and has never observed the crack in Resident #50's room. Interview on 06/20/2024 at 9:36 AM, LVN E stated she was the charge nurse for Resident #50's hall and had never seen a crack in Resident #50's room at any time. Interview on 06/20/2024 at 9:52 AM, ADON C stated she was the ADON assigned to Resident #50's hall and had never observed a crack in the room and stated if any staff member had observed it, it was facility protocol to submit a work order request in their digital work order logbook. Interview on 06/20/2024 at 10:07 AM, the SW stated she had never received a concern from Resident #50 regarding broken flooring but also that she had never observed it in her room during her routine visits to Resident #50. Observation and interview on 06/20/2024 at 10:33 AM, the MS stated he has not received work orders related to Resident #50's room related to floor repair or cracks in the floor. The MS stated he last visited Resident #50's room on 04/12/2024 for a telephone repair and during that visit he did not observe any floor cracks. The MS stated any staff who visit the room could submit a work order. During observation of the crack in Resident #50's room, the MS stated the floor crack was significant and required it to be submitted as an outside vendor request. Observation and interview on 06/20/2024 at 11:42 AM, the ADM stated he was not familiar with any cracks in Resident #50's room and stated he had not received any concerns from Resident #50 related to the state of the bedroom floor. During observation of Resident #50's floor, he stated this was the first time he had observed it before and stated he believed the crack in the floor to not have been observed previously as the bed was potentially rotated in a position that obscured the full length of the crack. The ADM stated even in a 90-degree rotation of the bed, he did not believe staff would have noticed the crack even as the crack was observed to extend past where the bed had covered or would have covered in a 90 degree rotation. The ADM stated the risk of the broken floor to be a potential tripping hazard along with a potential infection control concern as water or contaminates could be harbored in the crack. Policy specific to physical environment and building upkeep was requested at this time. Facility policy specific to physical environment and building upkeep was not provided prior to exit. A request was made to the ADM on 06/20/2024 at 11:42 AM.

Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program for 1 of 1 dining room for pests, in that: An unknown number of gnats were surrounding the beverage station (to include cranberry juice, water, coffee, mugs, and glasses) in the dining room for 06/18/24 lunch. This deficient practice could place residents at risk of residing in an environment with pests. Findings included: Observation on 06/18/24 at 11:59 AM revealed an unknown number of flying black living things, surrounding mugs and glasses that were upside down and present in the beverage station. It was further revealed the residents were getting their beverages from this station for 06/18/24 lunch. Observation and interview 06/18/24 12:09 PM with the Activities Director revealed there were bugs around the beverage station. She stated she would get the maintenance director or the dietary department to clean the beverage area. Observation on 06/18/24 at 12:16 PM revealed 8 residents received mugs or glasses from the beverage station that had these black flying bugs around their respective glass and mugs. These glasses and mugs were observed to not be sent to the kitchen for cleaning. Interview on 06/18/24 at 12:16 PM with the Activities Director revealed kitchen was bringing out cleaned mugs and glasses. Interview and observation on 06/18/24 at 12:16 PM with the Housekeeping Supervisor revealed the pest control company came to the facility earlier in the day to clean the area where containers of liquids were available to residents. The Housekeeping Supervisor was observed waving a towel as to try to hit these bugs away from this area. Interview on 06/18/24 at 12:17 PM, Resident #24 and Resident #24's POA revealed there were gnats around the dining room a lot and unaware of why. They expressed dislike when gnats were surrounding them when they were in the dining room. Interview on 06/20/24 at 09:29 AM, the CDM revealed housekeeping oversaw making sure the beverage station was cleaned. Housekeeping were supposed to let them know when anything kitchen related like cups need to be cleaned. He further revealed the kitchen washed all the glasses and mugs from the drink station on 06/18/24. Interview on 06/21/24 at 10:54 AM, the Maintenance Director revealed there were problems with gnats in the dining room and the pest control company targeted this area along with other areas in the facility. Record Review of [Pest Control Company] service log reflected service date of 06/18/24 for general type of pest to service locations to include the dining area. This was confirmed by the Maintenance Director. Record Review of the facility's policy on section: Physical Environment with a subject of Maintains Effective Pest Control Program, undated, reflected An effective pest control program is defined as measures to eradicate and contain common household pests .

Based on interview and record review the facility failed to ensure the resident's right to be free from abuse for 3 of 5 residents (Resident #1, #2 and #3) reviewed for abuse: CNA A, as part of a CNA chat group, took a video recording of Resident #1, naked, in the shower having a bowel movement, with a close-up view of her exposed bottom with feces on it and he shared it with the chat group. CNA B, as part of a CNA chat group, took a digital picture of Resident #2, naked, in the shower with her back toward the camera and not aware of the photo and she shared it with the chat group. CNA C as part of a CNA chat group, took a photo of Resident #3 after he had fallen on the floor without pants on, and shared it with the chat group. The noncompliance was identified as PNC. The IJ began on February 5th and ended on February 6th 2024. The facility had corrected the noncompliance before the survey began. This deficient practice could affect residents who require assistance with ADL's and result in emotional abuse and exploitation. The findings included: 1. Record review of Resident #1's electronic face sheet dated 02/14/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: weakness (lacking strength), contracture of muscle, left hand (tissues tighten or shorten causing a deformity, pain, and loss of function), cognitive communication deficit (difficulty with thinking and how someone uses language) and hemiplegia (paralysis of one side of body), and hemiparesis (one sided weakness) following unspecified cerebrovascular disease ( a group of conditions that affect blood flow and the blood vessels of the brain) affecting left non-dominant side. Record review of Resident #1's quarterly MDS with an ARD of 05/02/2023 reflected she scored a 99 on her BIMS assessment which signified the resident had 4 or more items coded 0 because she chose not to answer or game a nonsensical response. She sometimes could understand and sometimes be understood. Resident #1 required extensive assistance with ADL's. Record review of Resident #1's comprehensive person-centered care plan revised 09/28/2023 reflected Focus .has ADL self-care performance deficit r/t limited mobility, CVA, hemiplegia, contractions, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), lack of coordination and pain .Interventions/Tasks .converse with resident while providing care .explain all procedures and tasks before starting .BATHING .requires total assistance. Further review of Resident #1's comprehensive person-centered care plan revised 02/07/2024 reflected Focus .is at risk for communication problem r/t hearing deficit, stroke, confusion .Interventions/Tasks .ensure/provide a safe environment .anticipate and meet needs. Review of a video of Resident #1 taken by CNA A, who admitted to taking the video (unknown date) revealed a picture of a buttock with feces covered on it hanging through the seat hole of a shower chair. A white trash can with a plastic liner was positioned below the shower chair. A close up of the feces coming out of the buttocks was then seen. The video then zooming out and back up to Resident #1's face with an anguished expression and her naked upper half of body exposed as she looked directly at CNA A. The camera zooms out and focuses on Resident #1's anguished face and naked torso with her breast exposed and a partial gown draped over her bottom half sitting in the shower chair. The camera zooms back down to the buttocks with feces coming out positioned over a white plastic lined trash can. As the camera zooms back out to the shower chair legs and trash can the video ends. Observation on 02/14/2024 at 2:40 p.m. of Resident #1 lying in her bed revealed she was quiet, appeared withdrawn and when asked how she was, she responded OK. She did not respond to any other questions. Record review of Resident #1's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024. Record review of Resident #1's psychiatric services note dated 02/06/2024 reflected Visit Note-Initial Psychiatric Diagnostic Interview .seen today for depression/sadness .patient is evaluated laying in her bed .is pleasantly confused and does not appear to be in any emotional or psychosocial distress. Patient states she is not well as she is sick .Mental Status Exam: Behavior was withdrawn and hypoactive .speech was mumbling, slow and soft .attention span and concentration was poor .oriented to person .recent memory severely impaired .severe dementia .Diagnosis-Major depressive disorder .Treatment Plan of Care: Future visits are recommended once a week for 12 months. Interview on 02/15/2024 at 08:50 a.m. with CNA B who admitted to being part of the of the CNA chat group , she stated she saw the video of Resident #1 and did not know why she did not report it. She stated she was trained on abuse and neglect. Interview on 02/16/2024 at 08:20 a.m. with CNA A who admitted to being part of the CNA chat group and who took the video of Resident #1, he stated he did not know what he was thinking when he videotaped Resident #1 naked in the shower room having a bowel movement. He stated he violated Resident #1's rights, privacy, disrespected and abused her. He stated now, he realized how serious it was. He stated he was trained on abuse and neglect. 2. Record review of Resident #2's electronic face sheet dated 02/14/2024 reflected she was originally admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), cognitive communication deficit (difficulty with thinking and how someone uses language), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), need for assistance with personal care and major depressive disorder (feeling of sadness and loss of interest and can interfere with activities of daily living). Record review of Resident #2's quarterly MDS assessment with an ARD of 01/06/2024 reflected she scored a 14/15 on her BIMS which signified she was cognitively intact. She required assistance with her ADLs to include bathing. Record review of Resident #2's comprehensive person-centered care plan revised 01/11/2023 reflected Focus .has ADL self-care deficit performance r/t shortness of breath .Interventions/Tasks .Requires staff participation with bathing. Record review of a photo on a phone with the chat group titled Bitches [facility name] and a phone number with pluses to indicate other contact numbers reflected a photo (undated) time stamped 06:31 a.m. of Resident #2 sitting in a shower chair naked with her back toward the camera. Under the photo in Spanish was Anexo prubas hahaha which interpreted in English Attached Evidence hahaha. A responding comment from (unknown) in Spanish jajajaja te la [NAME] translated in English hahaha we wash you. Record review of Resident #2's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024. Record review of Resident #2's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for depression/sadness, high risk behavior, psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and restlessness .patient is seen sitting on bed eating a snack and watching TV .Patient states I'm good .Diagnoses: Bipolar II disorder (a pattern of depressive episodes and hypomanic episodes) and major depressive disorder .Treatment Plan .future visits recommended once a week for 6 months. Observation on 02/15/2024 at 4:00 p.m. of Resident #2 revealed she was lying on her bed watching television. In an interview on 02/15/2024 at 4:05 p.m. with Resident #2, after being informed of the picture, which she was unaware was taken and what was in the photo, she stated she always trusted CNA B and really liked her. She stated she felt like her rights and privacy were violated . Interview on 02/15/2024 at 07:50 a.m. with CNA F who admitted to being part of the CNA chat group, she stated she saw the photo that CNA B posted of Resident #2 in the shower naked, but she did not report it at that time because she was afraid of retaliation, and she didn't want to get anyone in trouble. She stated she knew taking photos and videos of residents violated their rights and could be considered abuse. She stated she was trained about abuse and neglect. Interview on 02/15/2024 at 08:00 a.m. with CNA D who admitted to being part of the CNA chat group, she stated she did not know how long the group was active. She stated that CNA C started the group and that CNA E posted the first picture . She stated that CNA A posted the video of Resident #1 and she knew it was wrong. She stated she knew better; had training and she did not report and did not know why she did not. She admitted that the resident rights were violated. Interview on 02/15/2024 at 08:50 a.m. with CNA B who admitted to being part of the CNA chat group , she stated she took the picture of Resident #2, naked in the shower chair to show the others in the group she was busy. She stated she knew she violated Resident #2's rights and it was not ok. She stated she knew it could be considered abuse, but she did it anyway . 3. Record review of Resident #3's electronic face sheet dated 02/14/2024 reflected he was a VA resident initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: unspecified dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), anxiety disorder (persistent and excessive worry that interferes with daily activities), diabetes (body doesn't make enough insulin or doesn't use it well), chronic pain (pain that lasts for over 3 months), overactive bladder (causes a frequent and sudden urge to urinate), difficulty walking (problems with joints, bones and circulation) and need for assistance with personal care. Record review of Resident #3's quarterly MDS assessment with an ARD of 02/05/2024 reflected he scored a 09/15 on his BIMS which signified he was moderately cognitively impaired. He was able to understand and be understood. He required total assistance with ADL's. Record review of Resident #3's comprehensive person-centered care plan revised 01/16/2023 reflected Focus .is at risk for impaired cognitive function or impaired thought processes .Interventions/Tasks .keep routine consistent and try to provide consistent care givers as much as possible to avoid confusion. Further record review of Resident #3's comprehensive person-centered care plan revised 01/16/2023 reflected Focus .has an ADL self-care performance deficit r/t limited mobility .Interventions/Tasks .Promote dignity by ensuring privacy. Further record review of Resident #3's comprehensive person-centered care plan revised 01/24/2024 reflected Focus .is at risk for falls r/t unsteady gait and poor safety awareness .Interventions/Tasks .Anticipate and meet needs .follow facility fall protocol. Record review of a photo taken by CNA C (who admitted to taking the photo), (undated, time stamped 11:30 a.m.) reflected Resident #3 sitting on the floor (right side angle looking down), he was naked from the waist down and his legs were spread apart on the floor. Under the photo was an emoji (a small digital image or icon used to express and idea or emotion) laughing so hard there were flooding tears and 2 hearts which indicated others viewing the posting and reacting to the emoji. Underneath the photo was a comment by CNA C in Spanish, Un soldado caido which interprets in English as A fallen soldier. Observation on 02/15/2024 of Resident #3 revealed he was sitting on the side of his bed, and when asked about someone taking a picture of him sitting on the floor when he fell , he stated I don't like it . Record review of Resident #3's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024. Record review of Resident #3's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for anxiety, dementia and depression/sadness .patient is evaluated in his wheelchair completing a word search. is calm and maintains good eye contact with provider .patient states he is not too good as he has chest congestion and reports he has pain in his left hand .Diagnoses: Major depressive disorder, anxiety and dementia .Treatment Plan .see once a week for 6 months. Record review of Resident #3's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024. Record review of Resident #3's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for anxiety, dementia and depression/sadness .patient is evaluated in his wheelchair completing a word search. is calm and maintains good eye contact with provider .patient states he is not too good as he has chest congestion and reports he has pain in his left hand .Diagnoses: Major depressive disorder, anxiety and dementia .Treatment Plan .see once a week for 6 months. Interview on 02/14/2024 at 4:10 p.m. with CNA H, she stated that she received training on abuse and neglect and reporting of violations. She stated that she worked the evening shift on 02/04/2024 with CNA E, and CNA E wanted to show her something that had bothered her. She stated it was the photos of Residents #2 and #3 and the video of Resident #1. She stated CNA E stated she was afraid that she did not know how to report it to the Administrator. CNA H stated she planned to report the incidents in the morning, but she was so disturbed by what she had seen that she reported it at 06:00 a.m. instead of 08:00 a.m. as she had planned. She stated she knew she should have reported the violations immediately and she had other things she had to do, so she waited. Interview on 02/15/2024 at 09:40 a.m. with CNA C who admitted to being part of the CNA chat group, she stated she started the group as an intent to talk and mingle as friends. She stated she started the chat group in November of 2023. She stated she saw the video of Resident #1, but did not open it, but commented on it. She stated she realized the pictures could harm the residents by violating their rights and privacy. She stated she could not recall any other photos or videos and said she was sorry for what happened. She stated she was trained on abuse and neglect. Interview on 02/16/2024 at 09:00 a.m. with the DON, she stated she did not know why staff did not report the photos or video immediately. She stated that training on abuse and neglect was ongoing. She stated she had no idea how it happened. She stated she and the Administrator found out about the chat group and the activities when CNA H reported to them on February 5th. She stated she and the Administrator were accountable for staff actions. She stated there was zero tolerance for abuse and neglect at the facility. Interview on 02/16/2024 at 09:20 a.m. with the Administrator, he stated he received a call from CNA H the morning of February 5th, 2023, and he stated when they figured out who participated in the chat group, all 7 of them were terminated. He reported it and started an investigation immediately. He stated he had no idea why it happened, but that it was unacceptable. He stated he reported the incident as soon as possible and he started an investigation. Interview on 02/16/2024 at 09:35 a.m. with the SW, she stated that she met with Resident's #1, #2 and #3 and she spoke with them about the incident, and Residents #2 and #3 had adapted and felt safe at the facility. She stated she did not think that Resident #1 was aware of what was going on. Record review of the facility Access and Confidentiality Agreements which stipulated confidentiality reflected you will not record or take pictures of anyone or anything in our workplace for your own use without the written permission of the Administrator. Further review reflected CNA A signed on 10/21/2022, CNA B signed on 10/21/2022, CNA C signed on 06/26/23, CNA D signed on 04/12/2023, CNA E signed on 04/12/2023, CNA F signed on 04/12/2023 and CNA G signed on 04/12/2023. The facility course of action prior to surveyor entrance included: Record review revealed : All required notifications were made: the Medical Director, Responsible Party, Physician, Nurse Practitioner, HHS, and to the local police department. Case #24028379. Record review revealed : Initially the 3 CNAs involved in the photo taking and video were terminated and the other 4 suspended. All 7 CNAs (CNA A, CNA B, CNA C, CNA D, CNA E, CNA F and CNA G) were eventually terminated by the time the surveyor exited the facility. Record review of the CNA's personnel folders reflected suspension and termination dates as follow: CNA A, Terminated 02/06/2024, CNA B, Terminated 02/06/2024, CNA C, Suspended 02/06/2024, Terminated 02/07/2024, CNA D, Suspended 02/06/2024, Terminated 02/07/2024, CNA E, Terminated 02/06/2024, CNA F, Suspended 02/06/2024, Terminated 02/07/2024, CNA G, Suspended 02/06/2024, Terminated 02/07/2024. Record review dated : 02/06/2024-Head to toe assessment completed on all residents. The SW evaluated the 3 residents. Record review dated: 02/06/2024- In-serviced 131 staff, all staff, using a staff roster were checked off and signed for In-services titled: Record review in-services dated 02/06/2024, titled: Abuse/Neglect, Dignity, Privacy and Hipaa and Phone Use-Do not take pics or videos of residents. 02/06/2024-Orders and consults for and completed by Psychiatric Services to see all 3 residents. Record review of an in-service titled Reporting Abuse/Neglect Right Away dated 02/14/2024 revealed it was provided for CNA H by the DON. STAFF INTERVIEWS ON TRAINING: 02/15/2024 from 1:10 p.m. to 3:00 p.m. On 02/15/2024 interviewed 8 staff on day shift, 3 CNA's, 2 COTA's, 1 Physical Therapy Assistant, and 2 LVNs revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. On 02/15/2024 interviewed 5 staff on evening shift, 3 CNAs, and 1 LVN and one RN revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. On 02/15/2024 interviewed 4 staff on night shift, 2 LVN's 1, CNA and one 1 MA revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 02/05/2024 and ended on 02/06/2024 when all staff had been in-serviced on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. The 7 CNAs were either terminated or suspended before the surveyor entrance.

Based on interviews, and record reviews, the facility failed to report abuse immediately but no later than 2 hours after the incident for 3 of 3 residents (Residents #1, #2, and #3) reviewed for reporting abuse and neglect in that: CNA H was informed about the abuse of Residents #1, #2 and #3 by CNA F of text chat group and did not report it to the Administrator until February 5th at 06:00 a.m. (8 hours later). CNA F, as part of the CNA chat group, failed to report the phone of Resident #2. CNA D, as part of the CNA chat group, failed to report the video of Resident #1. CNA E, as part of the CNA chat group, failed to report the photos of Resident #2 and Resident #3. The noncompliance was identified as PNC. The IJ began on February 5th and ended on February 6th 2024. The facility had corrected the noncompliance before the survey began. This failure could place the residents at further risk of abuse and neglect due to lack of reporting of incidents. The findings included : 1. Record review of Resident #1's electronic face sheet dated 02/14/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: weakness (lacking strength), contracture of muscle, left hand (tissues tighten or shorten causing a deformity, pain, and loss of function), cognitive communication deficit (difficulty with thinking and how someone uses language) and hemiplegia (paralysis of one side of body), and hemiparesis (one sided weakness) following unspecified cerebrovascular disease ( a group of conditions that affect blood flow and the blood vessels of the brain) affecting left non-dominant side. Record review of Resident #1's quarterly MDS with an ARD of 05/02/2023 reflected she scored a 99 on her BIMS assessment which signified the resident had 4 or more items coded 0 because she chose not to answer or game a nonsensical response. She sometimes could understand and sometimes be understood. Resident #1 required extensive assistance with ADL's. Record review of Resident #1's comprehensive person-centered care plan revised 09/28/2023 reflected Focus .has ADL self-care performance deficit r/t limited mobility, CVA, hemiplegia, contractions, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), lack of coordination and pain .Interventions/Tasks .converse with resident while providing care .explain all procedures and tasks before starting .BATHING .requires total assistance. Further review of Resident #1's comprehensive person-centered care plan revised 02/07/2024 reflected Focus .is at risk for communication problem r/t hearing deficit, stroke, confusion .Interventions/Tasks .ensure/provide a safe environment .anticipate and meet needs. Review of a video of Resident #1 taken by CNA A, who admitted to taking the video (unknown date) revealed a picture of a buttock with feces covered on it hanging through the seat hole of a shower chair. A white trash can with a plastic liner was positioned below the shower chair. A close up of the feces coming out of the buttocks was then seen. The video then zooming out and back up to Resident #1's face with an anguished expression and her naked upper half of body exposed as she looked directly at CNA A. The camera zooms out and focuses on Resident #1's anguished face and naked torso with her breast exposed and a partial gown draped over her bottom half sitting in the shower chair. The camera zooms back down to the buttocks with feces coming out positioned over a white plastic lined trash can. As the camera zooms back out to the shower chair legs and trash can the video ends. Observation on 02/14/2024 at 2:40 p.m. of Resident #1 laying in her bed revealed she was quiet, appeared withdrawn and when asked how she was, she responded OK. She did not respond to any other questions. Record review of Resident #1's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024. Record review of Resident #1's psychiatric services note dated 02/06/2024 reflected Visit Note-Initial Psychiatric Diagnostic Interview .seen today for depression/sadness .patient is evaluated laying in her bed .is pleasantly confused and does not appear to be in any emotional or psychosocial distress. Patient states she is not well as she is sick .Mental Status Exam: Behavior was withdrawn and hypoactive .speech was mumbling, slow and soft .attention span and concentration was poor .oriented to person .recent memory severely impaired .severe dementia .Diagnosis-Major depressive disorder .Treatment Plan of Care: Future visits are recommended once a week for 12 months. Interview on 02/15/2024 at 08:00 a.m. with CNA D who admitted to being part of the CNA chat group, she stated she did not know how long the group was active. She stated that CNA C started the group and that CNA E posted the first picture . She stated that CNA A posted the video of Resident #1 and she knew it was wrong. She stated she knew better; had training and she did not report and did not know why she did not. She admitted that the resident rights were violated. Record review of Resident #2's electronic face sheet dated 02/14/2024 reflected she was originally admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), cognitive communication deficit (difficulty with thinking and how someone uses language), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), need for assistance with personal care and major depressive disorder (feeling of sadness and loss of interest and can interfere with activities of daily living). Record review of Resident #2's quarterly MDS assessment with an ARD of 01/06/2024 reflected she scored a 14/15 on her BIMS which signified she was cognitively intact. She required assistance with her ADLs to include bathing. Record review of Resident #2's comprehensive person-centered care plan revised 01/11/2023 reflected Focus .has ADL self-care deficit performance r/t shortness of breath .Interventions/Tasks .Requires staff participation with bathing. Record review of a photo on a phone with the chat group titled Bitches [facility name] and a phone number with pluses to indicate other contact numbers reflected a photo (undated) time stamped 06:31 a.m. of Resident #2 sitting in a shower chair naked with her back toward the camera. Under the photo in Spanish was Anexo prubas hahaha which interpreted in English Attached Evidence hahaha. A responding comment from (unknown) in Spanish jajajaja te la [NAME] translated in English hahaha we wash you. Record review of Resident #2's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024. Record review of Resident #2's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for depression/sadness, high risk behavior, psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and restlessness .patient is seen sitting on bed eating a snack and watching TV .Patient states I'm good .Diagnoses: Bipolar II disorder (a pattern of depressive episodes and hypomanic episodes) and major depressive disorder .Treatment Plan .future visits recommended once a week for 6 months. Observation on 02/15/2024 at 4:00 p.m. of Resident #2 revealed she was lying on her bed watching television. In an interview on 02/15/2024 at 4:05 p.m. with Resident #2, after being informed of the picture, which she was unaware was taken and what was in the photo, she stated she always trusted CNA B and really liked her. She stated she felt like her rights and privacy were violated. Interview on 02/15/2024 at 07:50 a.m. with CNA F who admitted to being part of the CNA chat group, she stated she saw the photo that CNA B posted of Resident #2 in the shower naked, but she did not report it at that time because she was afraid of retaliation, and she didn't want to get anyone in trouble. She stated she knew taking photos and videos of residents violated their rights and could be considered abuse. She stated she was trained about abuse and neglect. Record review of Resident #3's electronic face sheet dated 02/14/2024 reflected he was a VA resident initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: unspecified dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), anxiety disorder (persistent and excessive worry that interferes with daily activities), diabetes (body doesn't make enough insulin or doesn't use it well), chronic pain (pain that lasts for over 3 months), overactive bladder (causes a frequent and sudden urge to urinate), difficulty walking (problems with joints, bones and circulation) and need for assistance with personal care. Record review of Resident #3's quarterly MDS assessment with an ARD of 02/05/2024 reflected he scored a 09/15 on his BIMS which signified he was moderately cognitively impaired. He was able to understand and be understood. He required total assistance with ADL's. Record review of Resident #3's comprehensive person-centered care plan revised 01/16/2023 reflected Focus .is at risk for impaired cognitive function or impaired thought processes .Interventions/Tasks .keep routine consistent and try to provide consistent care givers as much as possible to avoid confusion. Further record review of Resident #3's comprehensive person-centered care plan revised 01/24/2024 reflected Focus .is at risk for falls r/t unsteady gait and poor safety awareness .Interventions/Tasks .Anticipate and meet needs .follow facility fall protocol. Record review of a photo taken by CNA C (undated, time stamped 11:30 a.m.) reflected Resident #3 sitting on the floor (right side angle looking down), he was naked from the waist down and legs were spread apart on the floor. He was not aware of the photo being taken. Under the photo was an emoji (a small digital image or icon used to express and idea or emotion) laughing so hard there were flooding tears and 2 hearts which indicated others viewing the posting and reacting to an emoji. Underneath the photo was a comment by CNA C in Spanish Un soldado caido which interprets in English as A fallen soldier. Interview on 02/14/2024 at 4:10 p.m. with CNA H, she stated that she received training on abuse and neglect and reporting of violations. She stated that she worked the evening shift on 02/04/2024 with CNA E, and CNA E wanted to show her something that had bothered her. She stated it was the photos of Residents #2 and #3 and the video of Resident #1. She stated CNA E stated she was afraid that she did not know how to report it to the Administrator. CNA H stated she planned to report the incidents in the morning, but she was so disturbed by what she had seen that she reported it at 06:00 a.m. instead of 08:00 a.m. as she had planned. She stated she knew she should have reported the violations immediately and she had other things she had to do, so she waited. Interview on 02/15/2024 at 09:15 a.m. with CNA E who admitted to being part of the CNA chat group, she stated she was not part of the group conversation, but was at CNA F's house when she saw the photos (unknown date and time) and the video. She stated that she made a wrong decision and did not report it right away. She stated she showed CNA H and she was aware that she reported the incidents to the Administrator. Interview on 02/16/2024 at 09:00 a.m. with the DON, she stated she did not know why staff did not report the photos or video immediately. She stated that training on abuse and neglect was ongoing. She stated she had no idea how it happened. She stated she and the Administrator were accountable for staff actions. She stated there was zero tolerance for abuse and neglect at the facility. She stated she had no idea that CNA H did not report the violations immediately to the Administrator. Interview on 02/16/2024 at 09:20 a.m. with the Administrator, he stated he received a call from CNA H on February 5th at 06:00 a.m., and he stated when they figured out who participated in the chat group, all 7 (CNA A, CNA B, CNA C, CNA D, CNA E, CNA F and CNA G) of them were terminated. He stated he was told CNA H reported immediately and was not aware she did not. Record review of the facility policy and procedure titled Abuse, Prevention of and Prohibition Against revised 10/2022 reflected H. Reporting/Response .all allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported immediately to the Administrator. The facility course of action prior to surveyor entrance included: Record review revealed : All required notifications were made: the Medical Director, Responsible Party, Physician, Nurse Practitioner, HHS, and to the local police department. Case #24028379. Record review of the CNA's personnel folders reflected suspension and termination dates as follow: CNA A, Terminated 02/06/2024, CNA B, Terminated 02/06/2024, CNA C, Suspended 02/06/2024, Terminated 02/07/2024, CNA D, Suspended 02/06/2024, Terminated 02/07/2024, CNA E, Terminated 02/06/2024, CNA F, Suspended 02/06/2024, Terminated 02/07/2024, CNA G, Suspended 02/06/2024, Terminated 02/07/2024. Record review dated : 02/06/2024-Head to toe assessment completed on all residents. The SW evaluated the 3 residents. Record review dated: 02/06/2024- In-serviced 131 staff, all staff, using a staff roster were checked off and signed for In-services titled: Record review in-services dated 02/06/2024, titled: Abuse/Neglect, Dignity, Privacy and Hipaa and Phone Use-Do not take pics or videos of residents. 02/06/2024-Orders and consults for and completed by Psychiatric Services to see all 3 residents. Record review of an in-service titled Reporting Abuse/Neglect Right Away dated 02/14/2024 revealed it was provided for CNA H by the DON. STAFF INTERVIEWS ON TRAINING: 02/15/2024 from 1:10 p.m. to 3:00 p.m. On 02/15/2024 interviewed 8 staff on day shift, 3 CNA's, 2 COTA's, 1 Physical Therapy Assistant, and 2 LVNs revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. On 02/15/2024 interviewed 5 staff on evening shift, 3 CNAs, and 1 LVN and one RN revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. On 02/15/2024 interviewed 4 staff on night shift, 2 LVN's 1, CNA and one 1 MA revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 02/05/2024 and ended on 02/06/2024 when all staff had been in-serviced on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. The 7 CNAs were either terminated or suspended before the surveyor entrance.

Based on interviews and record reviews, The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of residents property for 3 residents (Residents #1, #2 and #3) out of 5 residents reviewed for abuse and neglect in that: CNA A, as part of a CNA chat group, took a video recording of Resident #1, naked, in the shower having a bowel movement, with a close-up view of her exposed bottom with feces on it and he shared it with the chat group. CNA B, as part of a CNA chat group, took a digital picture of Resident #2, naked, in the shower with her back toward the camera and not aware of the photo and she shared it with the chat group. CNA C as part of a CNA chat group, took a photo of Resident #3 after he had fallen on the floor without pants on, and shared it with the chat group. CNA D as part of a CNA chat group, failed to report the video of Resident #1. CNA E as part of the CNA chat group, failed to report the photos of Resident #2 and Resident #3. CNA F, as part of the CNA chat group, failed to report the photo of Resident #2. The noncompliance was identified as PNC. The IJ began on February 5th and ended on February 6th 2024. The facility had corrected the noncompliance before the survey began. This deficient practice could affect residents who require assistance with ADL's and result in emotional abuse and exploitation. The findings included: 1. Record review of Resident #1's electronic face sheet dated 02/14/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: weakness (lacking strength), contracture of muscle, left hand (tissues tighten or shorten causing a deformity, pain, and loss of function), cognitive communication deficit (difficulty with thinking and how someone uses language) and hemiplegia (paralysis of one side of body), and hemiparesis (one sided weakness) following unspecified cerebrovascular disease ( a group of conditions that affect blood flow and the blood vessels of the brain) affecting left non-dominant side. Record review of Resident #1's quarterly MDS with an ARD of 05/02/2023 reflected she scored a 99 on her BIMS assessment which signified the resident had 4 or more items coded 0 because she chose not to answer or game a nonsensical response. She sometimes could understand and sometimes be understood. Resident #1 required extensive assistance with ADL's. Record review of Resident #1's comprehensive person-centered care plan revised 09/28/2023 reflected Focus .has ADL self-care performance deficit r/t limited mobility, CVA, hemiplegia, contractions, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), lack of coordination and pain .Interventions/Tasks .converse with resident while providing care .explain all procedures and tasks before starting .BATHING .requires total assistance. Further review of Resident #1's comprehensive person-centered care plan revised 02/07/2024 reflected Focus .is at risk for communication problem r/t hearing deficit, stroke, confusion .Interventions/Tasks .ensure/provide a safe environment .anticipate and meet needs. Review of a video of Resident #1 taken by CNA A, who admitted to taking the video (unknown date) revealed a picture of a buttock with feces covered on it hanging through the seat hole of a shower chair. A white trash can with a plastic liner was positioned below the shower chair. A close up of the feces coming out of the buttocks was then seen. The video then zooming out and back up to Resident #1's face with an anguished expression and her naked upper half of body exposed as she looked directly at CNA A. The camera zooms out and focuses on Resident #1's anguished face and naked torso with her breast exposed and a partial gown draped over her bottom half sitting in the shower chair. The camera zooms back down to the buttocks with feces coming out positioned over a white plastic lined trash can. As the camera zooms back out to the shower chair legs and trash can the video ends. Observation on 02/14/2024 at 2:40 p.m. of Resident #1 lying in her bed revealed she was quiet, appeared withdrawn and when asked how she was, she responded OK. She did not respond to any other questions. Record review of Resident #1's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024. Record review of Resident #1's psychiatric services note dated 02/06/2024 reflected Visit Note-Initial Psychiatric Diagnostic Interview .seen today for depression/sadness .patient is evaluated laying in her bed .is pleasantly confused and does not appear to be in any emotional or psychosocial distress. Patient states she is not well as she is sick .Mental Status Exam: Behavior was withdrawn and hypoactive .speech was mumbling, slow and soft .attention span and concentration was poor .oriented to person .recent memory severely impaired .severe dementia .Diagnosis-Major depressive disorder .Treatment Plan of Care: Future visits are recommended once a week for 12 months. Interview on 02/15/2024 at 08:50 a.m. with CNA B who admitted to being part of the of the CNA chat group , she stated she saw the video of Resident #1 and did not know why she did not report it. She stated she was trained on abuse and neglect. Interview on 02/16/2024 at 08:20 a.m. with CNA A who admitted to being part of the CNA chat group and who took the video of Resident #1, he stated he did not know what he was thinking when he videotaped Resident #1 naked in the shower room having a bowel movement. He stated he violated Resident #1's rights, privacy, disrespected and abused her. He stated now, he realized how serious it was. He stated he was trained on abuse and neglect. 2. Record review of Resident #2's electronic face sheet dated 02/14/2024 reflected she was originally admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), cognitive communication deficit (difficulty with thinking and how someone uses language), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), need for assistance with personal care and major depressive disorder (feeling of sadness and loss of interest and can interfere with activities of daily living). Record review of Resident #2's quarterly MDS assessment with an ARD of 01/06/2024 reflected she scored a 14/15 on her BIMS which signified she was cognitively intact. She required assistance with her ADLs to include bathing. Record review of Resident #2's comprehensive person-centered care plan revised 01/11/2023 reflected Focus .has ADL self-care deficit performance r/t shortness of breath .Interventions/Tasks .Requires staff participation with bathing. Record review of a photo on a phone with the chat group titled Bitches [facility name] and a phone number with pluses to indicate other contact numbers reflected a photo (undated) time stamped 06:31 a.m. of Resident #2 sitting in a shower chair naked with her back toward the camera. Under the photo in Spanish was Anexo prubas hahaha which interpreted in English Attached Evidence hahaha. A responding comment from (unknown) in Spanish jajajaja te la [NAME] translated in English hahaha we wash you. Record review of Resident #2's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024. Record review of Resident #2's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for depression/sadness, high risk behavior, psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and restlessness .patient is seen sitting on bed eating a snack and watching TV .Patient states I'm good .Diagnoses: Bipolar II disorder (a pattern of depressive episodes and hypomanic episodes) and major depressive disorder .Treatment Plan .future visits recommended once a week for 6 months. Observation on 02/15/2024 at 4:00 p.m. of Resident #2 revealed she was lying on her bed watching television. In an interview on 02/15/2024 at 4:05 p.m. with Resident #2, after being informed of the picture, which she was unaware was taken and what was in the photo, she stated she always trusted CNA B and really liked her. She stated she felt like her rights and privacy were violated . Interview on 02/15/2024 at 07:50 a.m. with CNA F who admitted to being part of the CNA chat group, she stated she saw the photo that CNA B posted of Resident #2 in the shower naked, but she did not report it at that time because she was afraid of retaliation, and she didn't want to get anyone in trouble. She stated she knew taking photos and videos of residents violated their rights and could be considered abuse. She stated she was trained about abuse and neglect. Interview on 02/15/2024 at 08:00 a.m. with CNA D who admitted to being part of the CNA chat group, she stated she did not know how long the group was active. She stated that CNA C started the group and that CNA E posted the first picture . She stated that CNA A posted the video of Resident #1 and she knew it was wrong. She stated she knew better; had training and she did not report and did not know why she did not. She admitted that the resident rights were violated. Interview on 02/15/2024 at 08:50 a.m. with CNA B who admitted to being part of the CNA chat group, she stated she took the picture of Resident #2, naked in the shower chair to show the others in the group she was busy. She stated she knew she violated Resident #2's rights and it was not ok. She stated she knew it could be considered abuse, but she did it anyway . 3. Record review of Resident #3's electronic face sheet dated 02/14/2024 reflected he was a VA resident initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: unspecified dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), anxiety disorder (persistent and excessive worry that interferes with daily activities), diabetes (body doesn't make enough insulin or doesn't use it well), chronic pain (pain that lasts for over 3 months), overactive bladder (causes a frequent and sudden urge to urinate), difficulty walking (problems with joints, bones and circulation) and need for assistance with personal care. Record review of Resident #3's quarterly MDS assessment with an ARD of 02/05/2024 reflected he scored a 09/15 on his BIMS which signified he was moderately cognitively impaired. He was able to understand and be understood. He required total assistance with ADL's. Record review of Resident #3's comprehensive person-centered care plan revised 01/16/2023 reflected Focus .is at risk for impaired cognitive function or impaired thought processes .Interventions/Tasks .keep routine consistent and try to provide consistent care givers as much as possible to avoid confusion. Further record review of Resident #3's comprehensive person-centered care plan revised 01/16/2023 reflected Focus .has an ADL self-care performance deficit r/t limited mobility .Interventions/Tasks .Promote dignity by ensuring privacy. Further record review of Resident #3's comprehensive person-centered care plan revised 01/24/2024 reflected Focus .is at risk for falls r/t unsteady gait and poor safety awareness .Interventions/Tasks .Anticipate and meet needs .follow facility fall protocol. Record review of a photo taken by CNA C (who admitted to taking the photo), (undated, time stamped 11:30 a.m.) reflected Resident #3 sitting on the floor (right side angle looking down), he was naked from the waist down and his legs were spread apart on the floor. Under the photo was an emoji (a small digital image or icon used to express and idea or emotion) laughing so hard there were flooding tears and 2 hearts which indicated others viewing the posting and reacting to the emoji. Underneath the photo was a comment by CNA C in Spanish, Un soldado caido which interprets in English as A fallen soldier. Observation on 02/15/2024 of Resident #3 revealed he was sitting on the side of his bed, and when asked about someone taking a picture of him sitting on the floor when he fell , he stated I don't like it . Record review of Resident #3's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024. Record review of Resident #3's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for anxiety, dementia and depression/sadness .patient is evaluated in his wheelchair completing a word search. is calm and maintains good eye contact with provider .patient states he is not too good as he has chest congestion and reports he has pain in his left hand .Diagnoses: Major depressive disorder, anxiety and dementia .Treatment Plan .see once a week for 6 months. Record review of Resident #3's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024. Record review of Resident #3's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for anxiety, dementia and depression/sadness .patient is evaluated in his wheelchair completing a word search. is calm and maintains good eye contact with provider .patient states he is not too good as he has chest congestion and reports he has pain in his left hand .Diagnoses: Major depressive disorder, anxiety and dementia .Treatment Plan .see once a week for 6 months. Interview on 02/14/2024 at 4:10 p.m. with CNA H, she stated that she received training on abuse and neglect and reporting of violations. She stated that she worked the evening shift on 02/04/2024 with CNA E, and CNA E wanted to show her something that had bothered her. She stated it was the photos of Residents #2 and #3 and the video of Resident #1. She stated CNA E stated she was afraid that she did not know how to report it to the Administrator. CNA H stated she planned to report the incidents in the morning, but she was so disturbed by what she had seen that she reported it at 06:00 a.m. instead of 08:00 a.m. as she had planned. She stated she knew she should have reported the violations immediately and she had other things she had to do, so she waited. Interview on 02/15/2024 at 09:40 a.m. with CNA C who admitted to being part of the CNA chat group, she stated she started the group as an intent to talk and mingle as friends. She stated she saw the video of Resident #1, but did not open it, but commented on it. She stated she realized the pictures could harm the residents by violating their rights and privacy. She stated she could not recall any other photos or videos and said she was sorry for what happened. She stated she was trained on abuse and neglect. Interview on 02/16/2024 at 09:00 a.m. with the DON, she stated she did not know why staff did not report the photos or video immediately. She stated that training on abuse and neglect was ongoing. She stated she had no idea how it happened. She stated she and the Administrator found out about the chat group and the activities when CNA H reported to them on February 5th. She stated she and the Administrator were accountable for staff actions. She stated there was zero tolerance for abuse and neglect at the facility. Interview on 02/16/2024 at 09:20 a.m. with the Administrator, he stated he received a call from CNA H the morning of February 5th, 2023, and he stated when they figured out who participated in the chat group, all 7 of them were terminated. He reported it and started an investigation immediately. He stated he had no idea why it happened, but that it was unacceptable. He stated he reported the incident as soon as possible and he started an investigation. Interview on 02/16/2024 at 09:35 a.m. with the SW, she stated that she met with Resident's #1, #2 and #3 and she spoke with them about the incident, and Residents #2 and #3 had adapted and felt safe at the facility. She stated she did not think that Resident #1 was aware of what was going on. Record review of the facility Access and Confidentiality Agreements which stipulated confidentiality reflected you will not record or take pictures of anyone or anything in our workplace for your own use without the written permission of the Administrator. Further review reflected CNA A signed on 10/21/2022, CNA B signed on 10/21/2022, CNA C signed on 06/26/23, CNA D signed on 04/12/2023, CNA E signed on 04/12/2023, CNA F signed on 04/12/2023 and CNA G signed on 04/12/2023. The facility course of action prior to surveyor entrance included: Record review revealed : All required notifications were made: the Medical Director, Responsible Party, Physician, Nurse Practitioner, HHS, and to the local police department. Case #24028379. Record review of the CNA's personnel folders reflected suspension and termination dates as follow: CNA A, Terminated 02/06/2024, CNA B, Terminated 02/06/2024, CNA C, Suspended 02/06/2024, Terminated 02/07/2024, CNA D, Suspended 02/06/2024, Terminated 02/07/2024, CNA E, Terminated 02/06/2024, CNA F, Suspended 02/06/2024, Terminated 02/07/2024, CNA G, Suspended 02/06/2024, Terminated 02/07/2024. Record review dated : 02/06/2024-Head to toe assessment completed on all residents. The SW evaluated the 3 residents. Record review dated: 02/06/2024- In-serviced 131 staff, all staff, using a staff roster were checked off and signed for In-services titled: Record review in-services dated 02/06/2024, titled: Abuse/Neglect, Dignity, Privacy and Hipaa and Phone Use-Do not take pics or videos of residents. 02/06/2024-Orders and consults for and completed by Psychiatric Services to see all 3 residents. Record review of an in-service titled Reporting Abuse/Neglect Right Away dated 02/14/2024 revealed it was provided for CNA H by the DON. STAFF INTERVIEWS ON TRAINING: 02/15/2024 from 1:10 p.m. to 3:00 p.m. On 02/15/2024 interviewed 8 staff on day shift, 3 CNA's, 2 COTA's, 1 Physical Therapy Assistant, and 2 LVNs revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. On 02/15/2024 interviewed 5 staff on evening shift, 3 CNAs, and 1 LVN and one RN revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. On 02/15/2024 interviewed 4 staff on night shift, 2 LVN's 1, CNA and one 1 MA revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 02/05/2024 and ended on 02/06/2024 when all staff had been in-serviced on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. The 7 CNAs were either terminated or suspended before the surveyor entrance.

Based on observation, interview and record review, the facility failed to obtain documentation that the resident's representative has been delegated the necessary authority to exercise the resident's rights and must verify that a court-appointed representative has the necessary authority for the decision-making at issue as determined by the court. For example, a court-appointed representative might have the power to make financial decisions, but not health care decisions. Additionally, the facility must make reasonable efforts to ensure that it has access to documentation of any change related to the delegation of rights, including a resident's revocation of delegated rights, to ensure that the resident's preferences, are being upheld for 1 of 5 residents (Resident #1) reviewed for resident representative rights. The facility failed to ensure Resident #1, who was cognitively impaired when admitted to the facility, had had a representative who had the authority to make decisions on his behalf. This failure could lead to the facility making decisions without the resident's right to designate a surrogate or representative to make treatment or transfer decisions for the resident; and could deny the resident through the resident representative their wishes and preferences. The findings included: Record review of Resident#1's face sheet, dated 09/12/23, and EMR (electronic medical record) revealed, the resident was readmitted on [DATE] with diagnoses that included: anoxic brain damage (not enough oxygen to the brain causing brain damage), seizures, cerebral infarction (destructive blood flow in the brain) and PEG (Resident was a Male age 55. RP (responsible party) was listed as the resident per the face sheet. Record review of Resident# 1's Care Plan, dated 02/08/23, revealed goals and interventions that included: ADL care, medications as ordered, Code status DNR, at risk for infection, cognitive deficits, and behaviors. Record review of Resident#1's MDS (minimum data set), dated 8/8/23 revealed: BIMS (brief interview of mental status) Score was zero (severely impaired in cognition). During an interview on 09/12/23 at 8:55 AM, Resident#1's family member stated there was no documented POA or guardianship. The family member stated that a family attorney informed the family a POA was not required because a family member signed the admission for the resident to the facility. The family member stated the facility refused to provide documents involving a resident fall (Resident#1) on 9/8/23. The facility requested that the family member provide written documentation of POA which the family member did not possess before medical files could be released to the family member. The family member expressed the opinion that it was not right for the facility to insist on written documents when the family member signed the admissions packet. Observation and interview on 09/12/23 at 11:00 AM revealed Resident #1 was in bed; TV was on; alert and not oriented. Communication cues card were not visible at the time of the observation. [in interview with SP on 9/12/23 at 5:10 PM below the SP stated cue cards were provided to the resident.] The Resident could not answer any direct questions; or follow simple cues. The surveyor pointed to Resident#1's blue shirt and asked the resident whether the color of the shirt was red and the resident did not provide a response. The surveyor attempted to cue the resident by using the thumb technique; that was, thumb up meant yes and thumb down meant no. The resident did not provide a thumb response to the color of the shirt. The DON was present during the attempted interview with the resident. During a joint interview on 09/12/23 at 4:00 PM with the DON and the ADON, the DON stated Resident #1's family member was denied medical records because the family member was not the RP or the Guardian; the family member was only an emergency contact person. The DON stated on 09/11/23- Resident #1's family member- as requested to provide proof of POA or guardianship because during the weekend the family member wanted medical records concerning Resident #1's fall on 09/08/23. Resident #1's family member was denied the medical records involving the fall on 09/08/23. The DON and the ADON both recognized that on admission (06/03/23) the admissions office failed to establish who was the RP and by default Resident #1 who was cognitively impaired was listed as the RP. This failure prevented the resident designating an RP at admissions; and given the resident could not provide consent the facility failed to encourage the family member to seek guardianship at admissions. During observation and interview on 09/12/23 at 5:10 PM, with the DON and SP A present, the surveyor asked Resident #1 by use of communications cards provided by SP A as to whether the color of the Resident#1's shirt was black [actual color was blue], the resident pointed to yes the color was black. During an interview on 09/12/23 at 5:15 PM, the Administrator stated: Resident#1's family member was denied the medical records involving labs and we identified that the family member was not the RP, POA or guardian. The Administrator stated Resident #1's family member would be encouraged to get guardianship if they want to get the medical records or if they wanted to make medical decisions. The Administrator recognized that Resident #1 who was cognitively impaired was admitted to the facility without an RP being designated. Policy on admission process was requested on 9/12/23 from the Administrator but none was provided at exit on 9/12/23. Record review of facility's Resident Rights policy dated revised 05/2007 read: The Resident has the right: .to have a legal representative .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents (Resident #45) reviewed for care plans in that: Resident #45's comprehensive person-centered care plan indicated the resident was treated with medications for seizures when the resident was not This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. The findings were: Record review of Resident #45's face sheet, dated 4/25/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epileptic seizures (disorder of the brain characterized by repeated seizures; a temporary change in the electrical functioning of the brain), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and lack of coordination. Record review of Resident #45's most recent quarterly MDS assessment, dated 3/31/23 revealed the resident was cognitively intact for daily decision-making skills, was diagnosed with a seizure disorder, bipolar disorder and was treated with an antipsychotic and an antidepressant. Record review of Resident #45's Order Summary Report, dated 4/25/23 revealed the following: -Benztropine Mesylate tablet 0.5 mg, give 1 tablet by mouth at bedtime for tremors, with order date 9/29/22 and no end date -Depakote Sprinkles 125 mg, give 4 capsules by mouth one time a day for bipolar disorder, with order date 2/14/23 and no end date. -Depakote Sprinkles 125 mg, give 6 capsules by mouth at bedtime for bipolar disorder, with order date 2/14/23 and no end date Record review of Resident #45's comprehensive care plan, revision date 12/16/22 revealed the resident had a diagnosis of epilepsy and was at risk for side effects and ineffectiveness of medications with interventions that included to give seizure medications as ordered by doctor. Monitor/document side effects and effectiveness. Further review of the comprehensive care plan, under the same epilepsy focus category revealed Resident #45 received Benztropine Mesylate per the physician's orders. Resident #45's comprehensive care plan revealed the resident received antipsychotic medications related to bipolar disorder with interventions that included to administer medications as ordered, monitor/document for side effects and effectiveness and the resident received Depakote Sprinkles as per the physician orders. During an interview on 4/25/23 at 4:41 p.m., Resident #45 revealed she did not have a seizure disorder. Resident #45 stated, I have dementia and I'm bipolar. During an interview on 4/25/23 at 5:21 p.m., the DON revealed Resident #45 had been diagnosed with bipolar disorder and a seizure disorder. The DON revealed Resident #45 had not had any seizures since the DON had been employed at the facility since 10/24/22. The DON, after reviewing Resident #45's Order Summary Report revealed Resident #45 did not have an active order for medications to treat seizures. The DON stated, the MDS Coordinator oversaw revising and updating the comprehensive care plans. During an interview on 4/25/23 at 5:44 p.m. the LVN MDS Coordinator revealed, the comprehensive care plan was generated by an RN and the LVN MDS Coordinator, under the direction of the RN, revised the care plan, as necessary. The LVN MDS Coordinator stated, I know Resident #45 has a seizure disorder diagnosis. We (MDS Coordinator) rely on the orders and the nurse practitioner's notes to help develop and revise the comprehensive care plan, as necessary. The LVN MDS Coordinator revealed, the purpose of the care plan was to set goals and had to be measurable and used as a guide to know how to provide care to the resident. The LVN MDS Coordinator stated, regardless of the use, Resident #45 was on Depakote, so was still on a seizure medication even though it was prescribed for mood. We are just not being specific to the medication, and I believe there is a fine line. I think the care plan is accurate. During a follow up interview on 4/25/23 at 6:38 p.m., the DON revealed, the purpose of the comprehensive care plan was to provide information on the care and treatment for the residents. The DON stated, even though the Depakote (for resident #45) was care planned for bipolar disorder, the Depakote could be prescribed for seizure disorder and the care plan is accurate. The DON further revealed, Resident #45 was treated with Benztropine Mesylate and was indicated on the care plan as an intervention for the treatment of seizures. The DON then revealed, Resident #45's care plan was inaccurate because Benztropine Mesylate was a medication that would not be prescribed for seizures. The DON revealed she did not believe the inaccuracy of the care plan would cause Resident #45 to have a negative outcome. Record review of the facility policy and procedure titled, Comprehensive Person-Centered Care Planning, undated, revealed in part, .It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .5. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment and as needed. Interventions put in place are to (be) followed as the plan of care for the resident. These interventions may be adjusted or resolved as needed to facilitate resident needs .

Based on observation, interview, and record review. The facility failed to provide services that met professional standards for five (R #302, R #64, R #70, R #88, and R #43) of 27 residents reviewed for standards of care. 1.) Resident #64: -RN A failed to perform hand hygiene practices as per the facility's policy and procedure, prior to initiating R #64's wound care on her pressure ulcers. -RN A contaminated R #64's pressure ulcer after cleaning and treating R #64's two separate open wounds simultaneously. 2.) Resident #70: -RN A failed to consult with R #70's physician when a new Deep Tissue Injury (DTI) was identified and before treating the new DTI. 3.) LVN B did not thoroughly sanitize or use sanitizing supplies to sanitize the glucometer before using on Resident #88. LVN B did not sanitize the glucometer after used on Resident #88 or before or after used for Resident #43. LVN B did not perform hand hygiene and glove usage techniques, during medication pass, as per the facility's policy and procedure for Resident #88 and Resident #43. 4.) Resident #302: -Registered Nurse (RN) A failed to provide Resident #302 pressure ulcer treatments as prescribed by the physician. -The facility's documentation of Resident #302's pressure ulcers was conflicting on separate forms making it difficult to track the progress and accurate staging of the pressure ulcers. -RN A did not consistently identify all of Resident #302's pressure ulcers in their Skin-Weekly Pressure Ulcer Record or the Skin Head to Toe Check. -RN A failed to perform hand hygiene practices as per the facility's policy and procedure, prior to initiating Resident #302's wound care on her pressure ulcers. -RN A contaminated clean gloves she used while providing Resident #302 wound care on her pressure ulcers. -The facility failed to ensure RN A providing wound care was knowledgeable and competent in the identification, assessment, documentation, and treatment of [REDACTED]. -RN A did not perform thorough incontinent care on Resident #302 as per the facility's protocol/guidelines. The above failures resulted in an IJ situation on 12/15/17. While the IJ was removed on 12/16/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 11 residents with pressure ulcers and 86 residents receiving preventative skin care, and 26 residents receiving insulin and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers; and risk for infections. The findings included: The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11, Standards of Nursing Practice states: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; .(iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; . (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; . (O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; . The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.12, Unprofessional Conduct states: The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurse which the board believes are likely to deceive, defraud, or injure clients or public. Actual injury to a client need not be established. These behaviors include but are not limited to: (1) Unsafe Practice--actions or conduct including, but not limited to: (A) Carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered, or advance practice nursing in conformity with the standards of minimum acceptable level of nursing practice set out in Rule 217.11 1.) Record review of Resident #64's Medical Record revealed the resident was admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #64's December 2017 physician's orders [REDACTED]. 1. wear multi podus boots for a total of 3 hours either consecutively or as tolerated or bilateral lower extremities for 5x week indefinitely without skin breakdown or irritation. initiated 8/18/2017 2. wound care right buttock wound (cluster) - every day shift for cluster wound to right buttock clean area with wound cleanser, pack wound from superior opening down with calcium alginate rope cover wound with silicone dressing change every day. 3. [MEDICATION NAME] Packet - Give 1 patch by mouth two times a day for wound healing one packet mixed with 8 oz of water until wound resolved 4. Low Air Loss Mattress 5. Weekly skin assessment and PRN - one time a day every Tuesday for preventative 6. Pressure Relieving Mattress at all times when in bed - every shift 7. Low air loss mattress 8. Weekly skin assessment. Complete head to toe skin assessment and document findings on weekly skin observation tool . 11. May use transfer bar for positioning and turning. 12. Resident may see (Wound Care specialist) for surgical consultation for Right buttock wound. - as needed for right buttock wound . Record review of Resident #64's Annual MDS dated [DATE], revealed: BIMS=12 (mildly cognitively impaired); No mood or behaviors; R #64 required extensive assistance with at least one staff physical assist for bed mobility, transfers, dressing, and toileting. Resident #64 was totally dependent on staff for personal hygiene. Resident #64 had an indwelling catheter & was always incontinent for bowel; Resident #64 was at risk for pressure ulcers and had a 1 Stage III Pressure Ulcer measuring 1.1 x 0.7 x 0.6 with granulation tissue, no healed or worsened pressure ulcers / Turning/repositioning program, Pressure Ulcer Care, Application of nonsurgical dressings (with or without topical medications) other than to feet. Record review of Resident #64's Care Plan, dated 11/07/17, revealed: Resident #64 Has a pressure ulcer to right buttock related to history of ulcers and immobility. Interventions: -Monitor/document/report to MD PRN changes in skin status. -Air mattress -Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to MD/resident/responsible party . The record also revealed Resident #64 had a feeding tube and an indwelling urinary catheter. The record further revealed Resident #64 had limited physical mobility related to contractures. At risk for deformity and skin breakdown. Interventions - The resident will be able to wear multi podus boots for a total of 3 hours either consecutively or as tolerated or bilateral lower extremities 5x's a week indefinitely without skin breakdown or irritation. During observation on 12/12/17 at 10:18 a.m. of Resident #64 revealed she was laying on her back on a LALM set at 150 lbs. RN A stated She has a Stage 3 pressure ulcer on her right buttock and an abscess formed a couple of centimeters above it that is also open. Her treatment is clean with wound cleanser, pack with Calcium Alginate roll and secure with a self adhesive dressing. The pressure ulcer was acquired in-house. She does not like to turn, we have talked to her about turning. She likes to see TV, if she turns then she can't see TV, that's why she doesn't turn. RN A washed her hands, scrubbing with soap for nine seconds before rinsing. RN A removed Resident #64's dressing from her right buttock dated 12/11/17; the dressing had noticeable red drainage. Beneath the dressing were two separate open areas, one above the other, both with red and yellow tissue within the wound beds. RN A cleansed both wounds simultaneously, instead of separately. RN A began packing the superior wound which she identified as an abscess. The abscess actively bled as RN A packed the wound using a cotton tip applicator. RN A then used the same bloody cotton tip applicator to push in the Calcium Alginate dressing into the inferior wound, identified as the Stage 3 pressure ulcer. RN A then placed one dressing over both wounds. RN A washed her hands, scrubbing her hands with soap under the running water for a total of 10 seconds prior to drying. RN A contaminated Resident #64's pressure ulcer by cleansing both wounds simultaneously and then by using the same cotton tip applicator to pack Calcium Alginate into each wound. On 12/13/17 at 3:10 p.m., RN A stated she was trained to wash her hands for at least 20 seconds. RN A said I sing the happy birthday song in my head. When RN A was informed of her hand washing techniques observed, RN A stated I guess I sang too fast. RN A confirmed she was not suppose to scrub her hands under running water because it defeats the purpose of hand washing, the water washes off the soap. RN A was asked if her wound care techniques could have placed Resident #64 at risk for cross-contamination. she replied I used one cotton tip applicator to pack both wounds because I only had one. I should have stopped the treatment and gotten another applicator. I contaminated the clean pressure ulcer with the bloody applicator I used for the abscess. Yes, her wounds are separate wounds so I should have cleaned and treated them separately to decrease cross contamination and infection. Interview with the DON on 12/13/17 at 3:42 p.m. revealed she stated RN A Should have cleaned and dressed each wound separately to decrease cross contamination. She contaminated them. 2.) Record review of Resident #70's face sheet, dated 12/16/17, revealed she admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident #70's Quarterly MDS, dated [DATE], revealed Resident #70 had a BIMS score of 11 (moderately impaired cognitive skills), required extensive assist with two person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #70 was frequently incontinent of urine and bowel. Resident #70's Skin Conditions Section documented Resident #70 was at risk for developing pressure ulcers and had one Stage 3 pressure ulcer that was present upon admission/entry or reentry. Record review of Resident #70's Care Plan, dated 11/03/17, revealed Resident with Stage 3 to left side of sacrum. At risk for further skin breakdown .Goal: My pressure ulcer will show signs of healing and remain free from infection .Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines top the declines to the physician . Record review of Resident #70's December 2017 physician's orders [REDACTED]. Observation on 12/12/17 at 12:18 p.m. of RN A as she prepared to provide Resident #70 wound care revealed She has a Stage 3 pressure ulcer on left buttock acquired in house. Treatment: clean with wound cleanser, apply Calcium Alginate then cover with a [MEDICATION NAME] dressing. RN A scrubbed her hands with soap for 11 seconds before rinsing with water. RN A removed a dressing dated 12/11/17, that had drainage. RN A cleaned the open dime sized wound with wound cleanser and 4 X 4s, wound open, red wound bed. LVN measured 1.4 X 0.9 X 0.2 centimeters. Resident has dark brown discoloration to right buttock approximately half index finger in width. LVN attempts to clean area with wipes but unsuccessful and at the same time, R #70 said Ouch, what are you doing there. LVN says, It looks like a stain, I don't know what it is. When the surveyor asked RN A what the stain could be, she replied It could be a DTI but not sure. Let me measure it just in case. It was not there yesterday when I did wound care on her. It is 1.5 X 0.8 centimeters. LVN applied skin prep to wound (without consulting physician or retrieving orders). RN A said I only measured the darker lower part of the brown spot because the rest of it seemed to get a little lighter when I wiped it, I will check on it tomorrow. No, the lateral portion did not entirely disappear after wiping it. There are no orders for it, this is new, it was not there yesterday. Interview with the DON on 12/13/17 at 3:42 p.m. revealed she stated RN A should have covered Resident #70's wound and called the physician for treatment orders. Treating without orders is beyond her scope of practice. 3.) Observation of Licensed Voational Nurse (LVN) B, while conducting medication pass, on 12/12/17 at 11:43 a.m. revealed LVN B washed his hands in the Shower Room of the 300 Hall. LVN B approached his medication cart and retrieved a glucometer from the top drawer and wiped the front and back of glucometer with one alcohol swab then fanned the glucometer in the air. LVN B entered Resident 88's room and donned clean gloves. LVN B collected blood from Resident #88's right middle finger to check her sugar level. LVN B doffed his gloves and walked out of Resident #88's room into the hallway and approached his medication cart. LVN B secured the glucometer in the top drawer of the medication cart (without sanitizing the device). LVN B said R #88's blood sugar was 346 and drew 8 units of [MEDICATION NAME] Regular insulin. LVN B re-entered R #88's room and donned clean gloves and administered the insulin on Resident #88's lower abdomen. LVN B doffed his gloves and exited R #88's room. LVN B did not thoroughly sanitize the glucometer before it was used. LVN B did not perform hand hygiene prior to providing care, after doffing gloves, before donning clean gloves, or before exiting the room. Continued observation of medication pass on 12/12/17 at 12:00 p.m. revealed LVN B again retrieved the same glucometer previously used on Resident #88 and entered Resident #43's room. LVN B donned one glove to his right hand and retrieved blood from Resident #43's right second finger. LVN B doffed his glove and exited the room to approach his medication cart. LVN B secured the glucometer in the medication cart's top drawer and drew up two units of Humalog insulin. LVN B then re-entered Resident #43's room and administered the insulin on Resident #43's posterior upper arm then LVN B exited Resident #43's room. LVN B did not sanitize the glucometer before or after use. LVN B did not perform hand hygiene before or after providing care or after doffing his glove. LVN B used one glove to check Resident #43's blood sugar level. Interview with LVN B on 12/12/17 at 12:14 p.m. revealed he stated We are supposed to use sanitizing wipes between each resident use. I did not have any so I used an alcohol swab. The Corporate nurse told me we should be using the sanitizing wipes. I should have washed my hands before and after resident contact/in between residents; not sanitizing could cause cross contamination between residents. LVN acknowledged he only wore one glove when assisting Resident #43 then said I just messed up. 4.) Record review of Resident #302's face sheet, dated 12/14/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Facility's Pressure Wounds Log, dated 12/8/17, revealed Resident #302 was not listed. Record review of the Facility's Pressure Wounds Log, dated 12/8/17, revealed Resident #302 was indicated as having 4 pressure wounds that she admitted with. The record also revealed Resident #302 had one stage 2 pressure ulcer to the left buttock and three unstageable pressure wounds to the right buttock, left buttock and sacrum. The record further revealed the stage 2 to the left buttocks measured (length, width, depth) 1.0 cm x 0.3 cm x 0.1 cm, the unstageable to the right buttocks 6.0 cm x 3.5 cm x 0.1 cm, the unstageable to the left buttock 6.5 cm x 4.0 cm, and the unstageable to the sacrum measured 4.0 cm x 4.5 cm. The record also revealed the family/resident and the physician were notified of the pressure wounds on 12/7/17 and that the resident had treatment documented with the treatment being santyl/dressing for the unstageable wounds and the stage 2 wound received a treatment of [REDACTED]. Record review of Resident #302's Hospital's Wound Assessment/Treatment Report, dated run 12/4/17, revealed revealed a surgical wound to the Right guillotine amputation, a unstageable pressure ulcer/injury to the left buttock that received a [MEDICATION NAME] dressing, a pressure ulcer/injury of the sacral to right buttock that had no staging information that received a [MEDICATION NAME] dressing, an unstageable pressure ulcer/injury to the forehead that no dressing information, and a diabetic wound to the left Transmetatarsal Amputation plantar surface no dressing information. Record review of Resident #302's Nursing Admission Report from the hospital, undated, revealed the resident had [DIAGNOSES REDACTED]. The same record revealed the resident was on contact isolation for MDRO of the urine, incontinent, and had a stage 2 to the buttocks each side. Record review of Resident #302's Nursing Admission Assessment with Functional Abilities, dated 12/7/17, revealed the resident had an ulcer to the right and left buttock, 19 staples to the R-BKA, and a wound to the right shoulder from a removed permacath. The record also revealed the resident was incontinent of bowel and bladder; and she required substantial/maximal assistance with bed mobility, transfers, sit to stand, and foliating transfer. The record also revealed an Interim Care Plan that revealed the resident was at risk for pressure ulcers related to limited mobility and the goal was that the resident would not develop a pressure ulcer with interventions to assess resident for risk, provide preventative equipment if indicated, skin assessment upon admission and at minimum weekly thereafter, and turn and reposition resident per facility protocol. The Interim Care Plan also revealed the resident had a problem with altered skin integrity related to buttock ulcers with goals for the resident to be free of further/new skin alterations for 90 days and that the resident will show improvement to impaired skin area; with interventions to assess the skin on admit and weekly thereafter, follow the treatment per the physician orders, notify the physician for concerns. Record review of Resident #302's Weekly Skin Assessment Check, dated 12/8/17, revealed yes the resident had skin impairments. The record also revealed the resident had: -a dried scab to the forehead that measured 0.5 cm x 0.5 cm -a wound from removal of a [MEDICAL TREATMENT] port cluster that measured 1.5 cm x 1.2 cm with a dried scab -a dried scab to the inner left forearm that measured 2.5 cm x 1.0 cm -a stage 2 pressure ulcer to the sacrum that measured 1.2 cm x 1.0 cm -a unstageable pressure ulcer to coccyx that measured 4.0 cm x 4.5 cm -a stage 2 pressure ulcer to the superior left buttock that measured 1.0 cm x 0.3 cm x 0.1 cm -a unstageable pressure ulcer to the left buttock that measured 6.5 cm x 4.0 cm -a dried scab to the right thigh that measured 10.4 cm x 1.2 cm -a dried scab to the right thigh that measured 0.7 cm x 0.8 cm -a R-BKA incision that measured 18 cm and had 19 staples and 8 sutures -a scabbed area above the BKA incision that measured 0.7 cm x 0.7 cm -an old small ulcer to the left foot TMA plantar that measured 2.8 cm x 2.0 cm. Record review of Resident #302's Daily Skilled Nurse's Notes, dated 12/9/17 and 12/10/17, revealed in the Skin section the resident was checked as having skin within normal limits. The record also revealed in the Skin Concerns section that the resident was described to have a RBKA UTI/CONTACT ISOLATION MDRO, and in the box where it asked if the skin concerns were existing or new the box was left blank. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/11/17, revealed in the Skin Concerns section that the resident was checked for having a bruise and pressure ulcer and was described to have a RBKA UTI/CONTACT ISOLATION MDRO, and in the box where it asked if the skin concerns were existing or new the box was left blank. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/12/17, revealed in the Skin Concerns section that the resident was not checked for having any skin concerns, but was described to have a RBKA UTI/CONTACT ISOLATION MDRO STAGE 2 TO BUTT(NAME)K TX BY TX NURSE, and in the box where it asked if the skin concerns were existing or new the box was left blank. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/13/17, revealed in the Skin Concerns section that the resident was checked for having a rash and pressure ulcer and the description are was left blank. Record review of Resident #302's Weekly Wound Progress Note, dated 12/14/17, revealed the resident had 5 or more wounds and that the responsible party was notified on 12/13/17 and the physician was notified on 12/7/17. The record also revealed the resident had a stage 3 pressure ulcer to the right buttock with moist, thin, and yellow exudate, no odor, tan wound bed appearance, slough tissue, 40 percent of the of the wound bed tissue seen, dark red/purple surrounding skin color, with no undermining or tunneling present, measured 9.0 cm x 4.0 cm x 0.1 cm, and the wound has shown improvement. The same record also revealed the resident had a stage 3 pressure ulcer to the sacrum moist, thin, and yellow exudate, no odor, pink wound bed appearance, granulation tissue, 80 percent of the of the wound bed tissue seen, pink surrounding skin color, with no undermining or tunneling present, measured 4.0 cm x 7.0 cm x 0.1 cm, and the wound has shown improvement. The record also revealed the resident had a stage 3 pressure ulcer to the left buttock with small, thin, and yellow exudate, no odor, tan wound bed appearance, slough tissue, 15 percent of the of the wound bed tissue seen, dark red/purple surrounding skin color, with no undermining or tunneling present, measured 10.0 cm x 5.5 cm x 0.1 cm, and the wound has shown improvement. The record further revealed that all of the wounds were treated with by cleaning with normal saline apply nickel thickness santyl to wound bed and cover with dressing. Record review of Resident #302's second Weekly Wound Progress Note, dated 12/14/17, revealed the resident had 5 or more wounds and that the responsible party was notified on 12/13/17 and the physician was notified on 12/7/17. The record also revealed the resident had a surgical incision with the wound location on the R-BKA with dry exudate, no odor, tan wound bed appearance, [MEDICATION NAME] tissue, 100 percent of the of the wound bed tissue seen, normal surrounding skin color, with no undermining or tunneling present, not measure staples and sutures intact, and the wound has shown improvement. The record also revealed the resident had a stage 3 diabetic ulcer to the plantar surface of the left Transmetatarsal amputation with dry exudate, no odor, black wound bed appearance, slough tissue, 0 percent of the of the wound bed tissue seen, normal surrounding skin color, with no undermining or tunneling present, measured 4.2 cm x 4.0 cm, and the wound has not shown improvement. The record further revealed no treatments for the surgical incision, but a treatment to apply skin prep every day for the stage 3 diabetic ulcer. During an interview on 12/12/17 at 10:15 a.m. LVN E revealed Resident #302 was on contact isolation for an infection of the urine and was contained, but because she was incontinent and had been over saturating her brief, they had been keeping her in her room to keep the urine from spilling in the common area of the facility. LVN E revealed she only has a few more day of antibiotics left, and then they could discharge her from isolation. Record review on 12/14/17 of Resident #302's Consolidated Physician order [REDACTED]. The record further revealed not until four days after admission (12/11/17) did the resident receive wound treatment orders to be started on 12/12/17 at 6:00 a.m. for: - Santyl Ointment 250 unit/gm- apply to left buttock topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. - Santyl Ointment 250 unit/gm- apply to right buttock topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. - Santyl Ointment 250 unit/gm- apply to sacrum topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. Record review on 12/14/17 of Resident #302's December MAR and TAR, revealed no documentation of treatment or monitoring of resident's surgical incision or diabetic ulcer. The record also revealed until four days after admission (12/11/17) did the resident receive wound treatment orders for the left and right buttocks and the sacrum to clean the wounds with normal saline and apply santyl ointment nickel thickness to the unstageable wounds and cover with a foam dressing every day, and were administered 12/12/17-12/14/17. Observation of Resident #302 on 12/14/17 at 10:02 a.m. revealed RN A entered Resident #302's room and explained she was preparing to perform wound care. RN A gathered unpackaged gauzes and ointments from her medication cart; RN A did not perform hand hygiene prior to gathering clean dressings and supplies from medication cart. RN A retrieved three medicine cups and swirled two copious layers of Santyl ointment into each cup. RN A put on a yellow gown while in the hallway, before entering the room and proceeded in Resident #302's room, applied gloves and began wiping Resident #302's bedside table, without performing hand hygiene. RN A stated She has a left foot diabetic ulcer on her plantar, a right [MEDICAL CONDITION] (BKA) with sutures and 19 staples, the scab on that fell off yesterday when I was cleaning it. Her bottom has wounds that look like stage 3's. On Monday the Wound Specialist came in and debrided her bottom wounds a little but still has slough in all the wounds. The sacral area has some pink tissue. Resident #302 laid on her back with the head of her bed slightly elevated, on an inflated low air loss mattress. Resident #302's mattress had a white fitted sheet in place and a cloth facility incontinent pad over the sheet and Resident #302 wore a brief. Resident #302 had a nasal cannula in place attached to an oxygen concentrator that was set at 3 liters. Resident #302 was alert and oriented to person, place, and time and was verbal. Resident #302 attempted to turn herself to her right side but was unsuccessful. LVN E assisted to turn Resident #302 to her right side while RN A, removed Resident #302's dressing off her buttocks. The dressing had evidence of wetness, no color. The left buttock had an open wound with approximately 75% of yellow/brown tissue and 25% red tissue within the wound bed and the surrounding peri-wound tissue had brown discoloration. Above this wound was another smaller open wound that was separate from the lower larger wound. This superior wound was open and had a red wound bed. Resident #302's sacrum/gluteal cleft had an open wound that appeared wet and had a butterfly appearance, the wound bed was approximately 75% red and approximately 15% of yellow tissue on the lower distal end of the wound. The left inferior buttock had an open wound with approx. 70% yellow/brown and 20% red wound bed that had linear striated incisions on the yellow/brown tissue. RN A cleaned the right buttock wound with normal saline and 4 X 4 dressings. RN A measured both superior and inferior wound on the right buttock as one wound and said 10.0 X 5.5 centimeters. RN A then applied all the Santyl ointment from one medication cup and spread it throughout the entire wound (being more than a nickel thick). RN A cleaned the sacrum/gluteal cleft wound with normal saline and 4 X 4 dressings. RN A measured the wound and said 4.0 X 7.0 centimeters. RN A then applied all of the Santyl from one medicine cup throughout the entire wound. RN A cleaned the left buttock wound with normal saline and 4 X 4 dressings. RN A measured the wound and said 9.0 X 4.0 centimeters. RN A applied all the Santyl from another medicine cup and spread throughout the entire wound (being more than a nickel thick). RN A placed a large self-adhesive dressing that covered all the wounds. Resident #302 was positioned on her back and RN A used wet cleansing disposable cloths and cleaned the left outer labia, wiping using a downward stoke. With a clean cloth RN A wiped the center of the vagina using a downward stoke and repeated this process two more times. RN A did not open Resident #302's labias and thoroughly clean the vagina and did not clean Resident #302's buttocks from incontinent urine (exposing Resident #302 at risk for infection since she currently had an infection in her urine). Interview with Resident #302 on 12/14/17 at 11:00 a.m. revealed she stated she had pain to her wounds. Resident #302 asked LVN E for a pain pill. R #302 said she had not been offered a pain pill prior to wound care. Resident #302 revealed she only felt pain to her wounds when they were touched/treated. R #302 said she was not able to reposition herself. Resident #302 revealed staff did reposition her daily but not every two hours. Resident #302 said staff repositioned her about every 3 1/2-4 hours. Resident #302 revealed she knew it was 3-4 hours because she has a clock on her wall she looked at. Interview on 12/14/17 at 11:08 a.m. with LVN E revealed Resident #302 had not asked for any pain medication prior to wound care. LVN E said she had not offered any pain medication to R #302. When asked if Resident #302's mattress should have a

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 5 of 11 residents (Residents #302, #64, #70, #3 and #44) reviewed for pressure ulcers. 1.) Resident #302: -The facility failed to assess and document a detailed description of R #302's pressure ulcers upon admission. -The facility failed to consult and retrieve wound care orders for R #302's pressure ulcers upon admission therefore, R #302 did not receive treatments on her community acquired Stage 2 and two Unstageable Pressure Ulcers for five days after admission. -Registered Nurse (RN) A failed to provide R #302 pressure ulcer treatments as prescribed by the physician. -The facility's documentation of R #302's pressure ulcers was conflicting on separate forms making it difficult to track the progress and accurate staging of the pressure ulcers. -The facility did not consistently identify all of R #302's pressure ulcers in their Skin-Weekly Pressure Ulcer Record or the Skin Head to Toe Check. -RN A failed to perform hand hygiene practices as per the facility's policy and procedure, prior to initiating R #302's wound care on her pressure ulcers. -RN A contaminated clean gloves she used while providing R #302 wound care on her pressure ulcers. -The facility failed to ensure the licensed staff providing wound care were knowledgeable and competent in the identification, assessment, documentation, and treatment of [REDACTED]. These failures resulted in the resident's pressure ulcers worsening in size and staging. 2) Resident #64: -RN A failed to perform hand hygiene practices as per the facility's policy and procedure, prior to initiating R #64's wound care on her pressure ulcers. -RN A contaminated R #64's pressure ulcer after cleaning and treating R #64's two separate open wounds simultaneously. 3) Resident #70: - The facility failed to consult with R #70's physician when a new DTI was identified and before treating the new DTI. 4) Resident #3's low air mattress was set at level 9 setting instead of level 2 setting as indicated on the manufacturer's control panel for 2 of 6 days. 5) Resident #44's pressure ulcers on the left and right buttocks were not recorded on the Weekly Skin Check by Wound Nurse A. The above failures resulted in an IJ situation on 12/15/17. While the IJ was removed on 12/16/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could place 11 residents with pressure ulcers and 48 residents receiving preventive skin care at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: 1.) Record review of Resident #302's face sheet, dated 12/14/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #302's Hospital's Wound Assessment/Treatment Report, dated run 12/4/17, revealed a surgical wound to the Right guillotine amputation, a unstageable pressure ulcer/injury to the left buttock that received a [MEDICATION NAME] dressing, a pressure ulcer/injury of the sacral to right buttock that had no staging information that received a [MEDICATION NAME] dressing, an unstageable pressure ulcer/injury to the forehead that no dressing information, and a diabetic wound to the left Transmetatarsal Amputation plantar surface no dressing information. During an interview on 12/14/17 at 12:46 PM LVN E confirmed Resident #302's hospital record did not give any orders to follow for the wounds or surgical site. LVN E revealed she was not the nurse who completed the admission assessment, but it was LVN N. LVN E confirmed she did not call the Resident #302's physician to get orders for the resident's surgical incision or pressure ulcers. Record review of Resident #302's Nursing Admission Report from the hospital, undated, revealed the resident had [DIAGNOSES REDACTED]. The same record revealed the resident was on contact isolation for MDRO of the urine, incontinent, and had a stage 2 to the buttocks each side. Record review of Resident #302's Nursing Admission Assessment with Functional Abilities, dated 12/7/17, revealed the resident had an ulcer to the right and left buttock, 19 staples to the R-BKA, and a wound to the right shoulder from a removed permacath. The record also revealed the resident was incontinent of bowel and bladder; and she required substantial/maximal assistance with bed mobility, transfers, sit to stand, and foliating transfer. The record also revealed an Interim Care Plan that revealed the resident was at risk for pressure ulcers related to limited mobility and the goal was that the resident would not develop a pressure ulcer with interventions to assess resident for risk, provide preventative equipment if indicated, skin assessment upon admission and at minimum weekly thereafter, and turn and reposition resident per facility protocol. The Interim Care Plan also revealed the resident had a problem with altered skin integrity related to buttock ulcers with goals for the resident to be free of further/new skin alterations for 90 days and that the resident will show improvement to impaired skin area; with interventions to assess the skin on admit and weekly thereafter, follow the treatment per the physician orders, notify the physician for concerns. Record review of the Facility's Pressure Wounds Log, dated 12/8/17, revealed Resident #302 was not listed. Record review of Resident #302's Braden Scale Assessments, dated 12/8/17, revealed a score of 15 meaning the resident was at risk for pressure ulcers. Record review of Resident #302's Weekly Skin Assessment Check, dated 12/8/17, revealed yes the resident had skin impairments. The record also revealed the resident had: -a stage 2 pressure ulcer to the sacrum that measured 1.2 cm x 1.0 cm -a unstageable pressure ulcer to coccyx that measured 4.0 cm x 4.5 cm -a stage 2 pressure ulcer to the superior left buttock that measured 1.0 cm x 0.3 cm x 0.1 cm -a unstageable pressure ulcer to the left buttock that measured 6.5 cm x 4.0 cm Record review of Resident #302's Daily Skilled Nurse's Notes, dated 12/9/17 and 12/10/17, revealed in the Skin section the resident was checked as having skin within normal limits. The record also revealed in the Skin Concerns section that the resident was described to have a RBKA UTI/CONTACT ISOLATION MDRO, and in the box where it asked if the skin concerns were existing or new the box was left blank. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/11/17, revealed in the Skin Concerns section that the resident was checked for having a bruise and pressure ulcer and was described to have a RBKA UTI/CONTACT ISOLATION MDRO, and in the box where it asked if the skin concerns were existing or new the box was left blank. After surveyor request, the DON provided an up to date copy of the Facility's Pressure Wounds Log, dated 12/11/17, that revealed Resident #302 was indicated as having 4 pressure wounds that she admitted with. The record also revealed Resident #302 had one stage 2 pressure ulcer to the left buttock and three unstageable pressure wounds to the right buttock, left buttock and sacrum. The record further revealed the stage 2 to the left buttocks measured (length, width, depth) 1.0 cm x 0.3 cm x 0.1 cm, the unstageable to the right buttocks 6.0 cm x 3.5 cm x 0.1 cm, the unstageable to the left buttock 6.5 cm x 4.0 cm, and the unstageable to the sacrum measured 4.0 cm x 4.5 cm. The record also revealed the family/resident and the physician were notified of the pressure wounds on 12/7/17 and that the resident had treatment documented with the treatment being santyl/dressing for the unstageable wounds and the stage 2 wound received a treatment of [REDACTED]. Record review of Resident #302's EMR Orders, revealed not until four days after the resident admitted (12/11/17) did she receive wound treatment orders to be started on 12/12/17 at 6:00 a.m. for: - Santyl Ointment 250 unit/gm- apply to left buttock topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. - Santyl Ointment 250 unit/gm- apply to right buttock topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. - Santyl Ointment 250 unit/gm- apply to sacrum topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. This record revealed these 3 orders were created/input by RN A. Interview with RN A on 12/14/17 at 10:00 a.m. revealed she stated she was present during R #302's Wound Care Specialist's Initial Evaluation on 12/11/17. RN A said she received verbal orders from the Specialist to apply nickel thickness of Santyl to each pressure ulcer wound bed and cover with a foam dressing and therefore documented the order above. RN A stated the Wound Care Specialist documented their assessment/evaluation and recommendations electronically. RN A said the facility did not have a copy of the Wound Specialist's Evaluation. RN A said she had not requested a copy of the evaluation but would do so to provide a copy for the surveyor. Record review of Resident #302's December 2017 MAR and TAR, revealed no documentation of treatment or monitoring of resident's surgical incision or diabetic ulcer. The record also revealed not until five days after admission (12/12/17) did the resident start wound treatment for [REDACTED]. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/12/17, revealed in the Skin Concerns section that the resident was not checked for having any skin concerns, but was described to have a RBKA UTI/CONTACT ISOLATION MDRO STAGE 2 TO BUTT(NAME)K TX BY TX NURSE, and in the box where it asked if the skin concerns were existing or new the box was left blank. During an interview on 12/12/17 at 10:15 a.m. LVN E revealed Resident #302 was on contact isolation for an infection of the urine and was contained, but because she was incontinent and had been over saturating her brief, they had been keeping her in her room to keep the urine from spilling in the common area of the facility. LVN E revealed she only has a few more day of antibiotics left, and then they could discharge her from isolation. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/13/17, revealed in the Skin Concerns section that the resident was checked for having a rash and pressure ulcer and the description are was left blank. Record review of Resident #302's Weekly Wound Progress Note, dated 12/14/17, revealed the resident had 5 or more wounds and that the responsible party was notified on 12/13/17 and the physician was notified on 12/7/17. The record also revealed the resident had a stage 3 pressure ulcer to the right buttock with moist, thin, and yellow exudate, no odor, tan wound bed appearance, slough tissue, 40 percent of the of the wound bed tissue seen, dark red/purple surrounding skin color, with no undermining or tunneling present, measured 9.0 cm x 4.0 cm x 0.1 cm, and the wound has shown improvement. The same record also revealed the resident had a stage 3 pressure ulcer to the sacrum moist, thin, and yellow exudate, no odor, pink wound bed appearance, granulation tissue, 80 percent of the of the wound bed tissue seen, pink surrounding skin color, with no undermining or tunneling present, measured 4.0 cm x 7.0 cm x 0.1 cm, and the wound has shown improvement. The record also revealed the resident had a stage 3 pressure ulcer to the left buttock with small, thin, and yellow exudate, no odor, tan wound bed appearance, slough tissue, 15 percent of the of the wound bed tissue seen, dark red/purple surrounding skin color, with no undermining or tunneling present, measured 10.0 cm x 5.5 cm x 0.1 cm, and the wound has shown improvement. The record further revealed that all of the wounds were treated with by cleaning with normal saline apply nickel thickness santyl to wound bed and cover with dressing. Observation of Resident #302 on 12/14/17 at 10:02 a.m. revealed RN A entered Resident #302's room and explained she was preparing to perform wound care. RN A gathered unpackaged gauzes and ointments from her medication cart; RN A did not perform hand hygiene prior to gathering clean dressings and supplies from medication cart. RN A retrieved three medicine cups and swirled two copious layers of Santyl ointment into each cup. RN A put on a yellow gown while in the hallway, before entering the room and proceeded in Resident #302's room, applied gloves and began wiping Resident #302's bedside table, without performing hand hygiene. RN A stated Her bottom has wounds that look like stage 3's. On Monday the Wound Specialist came in and debrided her bottom wounds a little but still has slough in all the wounds. The sacral area has some pink tissue. Resident #302 laid on her back with the head of her bed slightly elevated, on an inflated low air loss mattress. Resident #302's mattress had a white fitted sheet in place and a cloth facility incontinent pad over the sheet and Resident #302 wore a brief. Resident #302 had a nasal cannula in place attached to an oxygen concentrator that was set at 3 liters. Resident #302 was alert and oriented to person, place, and time and was verbal. Resident #302 attempted to turn herself to her right side but was unsuccessful. LVN E assisted to turn Resident #302 to her right side while RN A, removed Resident #302's dressing off her buttocks. The dressing had evidence of wetness, no color. The left buttock had an open wound with approximately 75% of yellow/brown tissue and 25% red tissue within the wound bed and the surrounding peri-wound tissue had brown discoloration. Above this wound was another smaller open wound that was separate from the lower larger wound. This superior wound was open and had a red wound bed. Resident #302's sacrum/gluteal cleft had an open wound that appeared wet and had a butterfly appearance, the wound bed was approximately 75% red and approximately 15% of yellow tissue on the lower distal end of the wound. The left inferior buttock had an open wound with approx. 70% yellow/brown and 20% red wound bed that had linear striated incisions on the yellow/brown tissue. RN A cleaned the right buttock wound with normal saline and 4 X 4 dressings. RN A measured both superior and inferior wound on the right buttock as one wound and said 10.0 X 5.5 centimeters. RN A then applied all the Santyl ointment from one medication cup and spread it throughout the entire wound (being more than a nickel thick). RN A cleaned the sacrum/gluteal cleft wound with normal saline and 4 X 4 dressings. RN A measured the wound and said 4.0 X 7.0 centimeters. RN A then applied all of the Santyl from one medicine cup throughout the entire wound. RN A cleaned the left buttock wound with normal saline and 4 X 4 dressings. RN A measured the wound and said 9.0 X 4.0 centimeters. RN A applied all the Santyl from another medicine cup and spread throughout the entire wound (being more than a nickel thick). RN A placed a large self-adhesive dressing that covered all the wounds. Resident #302 was positioned on her back and RN A used wet cleansing disposable cloths and cleaned the left outer labia, wiping using a downward stroke. With a clean cloth RN A wiped the center of the vagina using a downward stoke and repeated this process two more times. RN A did not open Resident #302's labias and thoroughly clean the vagina and did not clean R #302's buttocks from incontinent urine (exposing Resident #302 at risk for infection since she currently had an infection in her urine). Interview with Resident #302 on 12/14/17 at 11:00 a.m. revealed she stated she had pain to her wounds. Resident #302 asked LVN E for a pain pill. Resident #302 said she had not been offered a pain pill prior to wound care. Resident #302 stated she only felt pain to her wounds when they were touched/treated. Resident #302 said she was not able to reposition herself. Resident #302 said staff did reposition her daily but not every two hours. Resident #302 said staff repositioned her about every 3 1/2-4 hours. Resident #302 stated she knew it was 3-4 hours because she has a clock on her wall she looked at. During an interview on 12/14/17 at 11:08 a.m., LVN E revealed Resident #302 had not asked for any pain medication prior to wound care. LVN E said she had not offered any pain medication to Resident #302. When asked if Resident #302's mattress should have a fitted sheet and a cloth pad, LVN E said I did not notice that. Does she have a regular cloth pad? I did not notice the pad. She should not have the fitted sheet and she should have a thin barrier pad. No, the cloth pad is not the barrier pad. She should not have the least amount of linen underneath her to avoid friction and shearing or trauma to her wound. During an interview on 12/14/17 at 11:13 a.m. with RN A revealed she said Resident #302 should not have the fitted sheet and cloth pad on the air mattress. I've been educated that an air mattress should only have a thin breathable disposable barrier pad but this facility does not have any of those. The cloth pads block air flow and could cause moisture within the wound that could allow the skin to become macerated and worsen. During an interview on 12/14/17 at 12:33 p.m., LVN E revealed the resident admitted with pressure sores. LVN E reviewed the resident's hospital discharge record and said that she could not find any other for treatment or monitoring for the pressure sores. LVN E confirmed that she wrote the Nursing Home Admission report received from the hospital that said the resident has a stage 2 pressure ulcer. LVN E confirmed the nurse when the called the physician to reconcile the resident admitting medication, they should have informed the physician of the resident's pressure sores and see if he wanted to give orders to monitor/treat. LVN E confirmed that the only orders for the resident's pressure sores was started on 12/12/17 5 days after the resident admitted . LVN E confirmed that the resident's skin assessments were inconsistent in saying that the resident had skin impairment of pressure ulcers to the skin was within normal limits. LVN E confirmed that her Daily Nurses' note on 12/11/17 was wrong and should have accurately documented the wound and incision site. LVN E revealed the assessments and daily nurses' notes for 12/9-12/10 were inaccurate for saying the skin was within normal limits because the resident had pressure sores and still currently has them. Further interview on 12/14/17 at 1:16 p.m., with LVN E revealed she noticed that RN A did not open her labias to clean her vagina. Yes she should have opened her labias to thoroughly clean her. She did not clean her buttocks either and she should have especially since (Resident #302) has a contagious infection in her urine. I was nervous, next time I should speak up. Further interview with RN A on 12/14/17 at 4:11 p.m. revealed the facility did not have a copy of the Wound Care Specialist's Evaluation from Monday, 12/11/17. RN A said she just called the physician and was told the report had not been synced and would work on it. RN A said she had not noticed that the facility did not have a copy of the evaluation. RN A said the evaluation included the physician's assessment and/or recommendations. RN A said Normally we get the reports the next day, I don't know what happened this time. RN A stated that Santyl was an enzymatic debrider but did not do damage to healthy tissue but was recommended not to put on the healthy surrounding skin. RN A said the Sacrum/Gluteal Cleft pressure ulcer had significant slough in the wound bed as of Tuesday, 12/12/17. RN A stated the slough in that wound was no longer there yesterday. When RN A was asked if the physician normally ordered Santyl for wound beds without slough, RN A stated she would have to call the physician and ask if she wanted to change the treatment because it was not normally used for healthy tissue. RN A verified Resident #302's sacral wound had changed in condition by no longer having slough in the center of the wound bed since yesterday and had not consulted with Resident #302's physician to notify of the change and possible treatment change but she would inform her. RN A explained she did not know how to exactly measure nickel thick amount of Santyl so she just Put a little more than a thin layer. Interview with the DON on 12/14/17 at 5:30 p.m. revealed she stated Resident #302 was admitted on [DATE] with multiple pressure ulcers and a new R-BKA with 19 staples intact. The DON reviewed Resident #302's documents and verified there were no orders to monitor or treat the surgical site at right BKA incision, nor orders to treat the resident's pressure ulcers until 12/12/17. The DON stated she would expect the nurses to call the physician and verify orders to include monitoring or treatment of [REDACTED].#302's surgical incision. When the DON was asked about Resident #302's pressure ulcers she stated Each wound should be described as accurately as possible on their admission assessments and head to toe assessments/Weekly Pressure Ulcer Report. The DON reviewed the Daily Skilled Nurses Notes dated 12/09/17-12/10/17 and acknowledged that the note indicated that Resident #302's skin was Within Normal Limits then the DON said I do not agree with that entry because she had a couple of pressure ulcers and a surgical incision, it's not possible that her skin was within normal limits. The DON said the Daily Skilled Nurses Notes dated 12/11/17 revealed no detailed description of Resident #302's pressure ulcers or surgical incision and the note dated 12/12/17 revealed a Stage 2 to buttock but had no detail of the wound and did not indicate more than one wound, which the resident had. The DON stated the documentation on 12/14/17 indicated a Stage 3 to right buttock, a Stage 3 to left buttock and sacrum. The DON said the assessment indicated LTMA however, the DON said I don't know what that means, I'll have to ask RN A what she meant by that, she should know. The DON said through her review of all of Resident #302's documentation, she saw issues with staging of the pressure ulcers, identifying and measuring pressure ulcers as separate ulcers, no detailed description of the wounds, she should have a Wound Progress Record with detailed description of wounds. The DON said she could not track Resident #302's wound and stages because of missing information and inconsistent staging documented. The DON said she tracked the wounds in the facility by reviewing the measurements of the wounds. The DON said she would also look at the description of the wounds but since Resident #302 did not have a description of her wounds upon admission she could not tell what the wound looked like then. The DON said if there is no accurate assessment documented then it would be difficult to track the status of the wound or track whether the wound was getting better or worse. The DON said after reviewing the measurements of Resident #302's initial wound measurements in comparison to 12/14/17, Resident #302's wounds were getting bigger. It appears they have progressed. The DON said the treatment nurse had years of wound care experience and had been wound care certified within the last 3 1/2 months. The DON said she monitored the treatment nurse and wounds by participating in weekly at risk (WAR) meetings where residents at risk for pressure ulcers were discussed. The DON said the treatment nurse had requested her assistance on several occasions when she had a question. The DON said she last conducted observations of the wounds in the facility was approximately one month ago. The DON said she had not seen Resident #302's wounds. The DON said the physician should send in their evaluations and usually took a day. The DON said the treatment nurse should have called the physician and attempted to retrieve the physician's evaluation. The DON said from her experience, Santyl was a chemical debrider that shouldn't be used on healthy granulated tissue and should only be used for slough or necrotic tissue. The DON said if the nurse had seen a change in the wound that may no longer need the Santyl then the nurse should call the physician and describe the wound and ask the physician if she wanted to continue current treatment or change the treatment. The DON said if the resident no longer had slough then the resident would no longer need the treatment for [REDACTED]. The DON stated We are not supposed to put anything on air mattresses except a draw sheet or a thin paper disposable pad, which this facility does not use. Too many layers of linen can cause blockage of air flow which would allow the resident to have moisture build-up that causes skin breakdown and worsening of the wounds. The DON stated if staff did not thoroughly provide incontinent/perineal care, the resident would be at risk of infection and for Resident #302, since she already had a urine infection and she was incontinent, she would be at risk for her current infection to extend into her wounds. The DON stated RN A needs immediate training. Observation on 12/14/17 at 08:32 p.m. the surveyor accompanied the DON, RN A, and ADON M into Resident #302's room. Resident #302 was informed she was going to be turned to her right side, Resident #302 attempted to turn herself but after a couple of attempts, was unsuccessful. Resident #302 was turned to her right side by the DON and RN A; The DON positioned herself on the right side of R #302 and RN A on the left side. The DON assisted Resident #302 to stay on her right side by supporting the resident's back. R #302 did not have a dressing on her buttocks and sacral wounds. RN A began to measure Resident #302's right buttock and said 10.0 X 4.0, no 3.5. 10.0 X 3.5 centimeters. When RN A was asked to describe the wound she stated It's a Stage 3, it could be an Unstageable and eventually a Stage 2 because it doesn't have a lot of depth. RN A applied Santyl throughout the entire wound bed.(RN A spoke of back staging which per the National Pressure Ulcer Advisory Panel-NPUAP, should not occur). The DON stated I'd wait for the physician to stage, we will describe it to her. The DON instructed RN A that the left buttock had two separate areas and to measure them separately. RN A measured and said Left superior buttock is 0.9 X 2.2 centimeters. The DON described the wound and said It appears like a Stage 2, it has a pink wound bed, no odor, no drainage, and surrounding skin is dark. RN A applied Santyl throughout the entire wound bed. RN A measured and said Left inferior left buttock- 7.3 X 6.0. The DON described the wound as It has yellow slough, its moist, and has dark surrounding skin. RN A applied Santyl throughout the entire wound bed. The DON raised Resident #302's left buttock exposing the wound identified as the Sacrum. RN A walked to the wall beside the door and with donned dirty gloves, grabbed a handful of clean gloves and placed them on the bedside table on her clean supply field and used them to continue wound care. RN A measured and said 3.8 X 6.4 centimeters. RN A applied Santyl throughout the entire wound bed and then applied one large border foam dressing that covered all the wounds. RN A was asked if she cleaned the wounds prior to her applying treatment to the wounds and she replied No I didn't. I did not clean them, I should have. The aides cleaned her when they gave her a bed bath just before we walked in her. RN A was asked if the aides could clean wounds as per the physician prescribed and she responded No they can't. The DON or ADON did not intervene as RN A continued to apply treatment and dressings to Resident #302's wounds without cleaning the wounds first. Record review on 12/15/17 at 9:09 a.m. of Resident #302's Progress Notes in the EMR, revealed there were no notes on the resident's pressure ulcers or surgical incision except on 12/8/17 and 12/14/17. During an interview on 12/14/17 at 9:22 p.m., the DON revealed that they had just gotten out of the room supervising RN A with Resident #302's wounds. DON revealed that the resident just got a shower and the RN A performed wound treatment. The DON revealed RN A did not clean the wounds during the treatment, but just applied the medication and dressing. During an interview on 12/15/17 at 8:22 a.m., Physician I revealed she was the Wound Care Specialist that was consulted for initial evaluation of Resident #302 on 12/11/17. Physician I said she clustered the two wounds on Resident #302's left buttock because they were within the same proximity on the left buttock. Physician I reported the left buttock wound measured 10.5 X 5.0 centimeters. Physician I said she debrided the left and right buttock eschar/slough. Physician I said she ordered a nickel thick amount of Santyl on each wound due to the resident having slough in the wound bed. Physician I said she had no concern with a little of Santyl getting on red healthy tissue but it should be minimized because it beats up the tissue. Physician I stated Resident #302's current treatment was to clean with normal saline or wound cleanser, apply a nickel thick amount of Santyl to remove the slough, and Calcium Alginate to keep the wound moistened but stabilizing blood flow. Physician I was asked if the facility did not have her evaluation for reference how would the facility be aware of her orders; Physician I said The treatment nurse knows because I verbally told her the orders when I was there. I work with the treatment nurse on a one to one basis as I do the assessments. Physician I said she was not aware that her evaluation had not uploaded into the facility's electronic system until the facility called her on 12/14/17 asking for it. Physician I said the facility could have called her sooner. Physician I said If staff are not following the physician's orders [REDACTED]. During an interview on 12/15/17 11:25 a.m., Clinical Specialist BB revealed that he started working with the RN A at 8 a.m. and trained her by videos and observed training. Clinical Specialist BB revealed that he did not observe Resident #302's wound. Clinical Specialist BB revealed that you usually want to keep wounds separate if there is skin in between and measure two seperate with skin in between as one. Clinical Specialist BB confirmed that RN A was back on the floor and completing assessments and seeing residents. Record review of Resident #302's Braden Scale Assessments, dated 12/15/17, revealed a score of 12 meaning the resident was a high risk for pressure ulcers. Record of review of Resident #302's Wound Care Specialist Initial Evaluation, dated 12/11/17, revealed: -Unstageable (Due to necrosis) of the Right Buttock (site 2): Etiology: Pressure. 7.0 X 2.8 X not measurable depth cm, light serous exudate, 70% thick

Based on observation, interview, and record review, the facility failed implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 7 newly admitted residents (Residents #302)reviewed for baseline care plan. The facility did not accurately implement the intervention listed in the Interim Care Plan for Resident #302's problem with pressure ulcers and incontinence, and the ulcers increased in size and staging. This failure could affect 10 newly admitted residents at risk for a decreased quality of life. The findings were: Record review of Resident #302's face sheet, dated 12/14/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #302's Interim Care Plan in the Nursing Admission Assessment with Functional Abilities, dated 12/7/17, revealed the resident had a problem with altered skin integrity related to buttock ulcers with goals for the resident to be free of further/new skin alterations for 90 days and that the resident will show improvement to impaired skin area; with interventions to assess the skin on admit and weekly thereafter, follow the treatment per the physician orders, (and) notify the physician for concerns. The Interim Care Plan further revealed a problem of the resident having incontinence and the goal was to maintain good skin integrity for the next 90 days with interventions to keep the skin clean and dry (and provide) prompt incontinent care. Record review of the Facility's Pressure Wounds Log, dated 12/8/17, revealed Resident #302 was indicated as having 4 pressure wounds that she admitted with. The record also revealed Resident #302 had one stage 2 pressure ulcer to the left buttock and three unstageable pressure wounds to the right buttock, left buttock and sacrum. The record further revealed the stage 2 to the left buttocks measured (length, width, depth) 1.0 cm x 0.3 cm x 0.1 cm, the unstageable to the right buttocks 6.0 cm x 3.5 cm x 0.1 cm, the unstageable to the left buttock 6.5 cm x 4.0 cm, and the unstageable to the sacrum measured 4.0 cm x 4.5 cm. The record also revealed the family/resident and the physician were notified of the pressure wounds on 12/7/17 and that the resident had treatment documented with the treatment being santyl/dressing for the unstageable wounds and the stage 2 wound received a treatment of [REDACTED]. Record review of Resident #302's Braden Scale Assessments, dated 12/8/17, revealed a score of 15 meaning the resident was at risk for pressure ulcers. Record review of Resident #302's Weekly Skin Assessment Check, dated 12/8/17, revealed yes the resident had skin impairments. The record also revealed the resident had: -a dried scab to the forehead that measured 0.5 cm x 0.5 cm -a wound from removal of a [MEDICAL TREATMENT] port cluster that measured 1.5 cm x 1.2 cm with a dried scab -a dried scab to the inner left forearm that measured 2.5 cm x 1.0 cm -a stage 2 pressure ulcer to the sacrum that measured 1.2 cm x 1.0 cm -a unstageable pressure ulcer to coccyx that measured 4.0 cm x 4.5 cm -a stage 2 pressure ulcer to the superior left buttock that measured 1.0 cm x 0.3 cm x 0.1 cm -a unstageable pressure ulcer to the left buttock that measured 6.5 cm x 4.0 cm -a dried scab to the right thigh that measured 10.4 cm x 1.2 cm -a dried scab to the right thigh that measured 0.7 cm x 0.8 cm -a R-BKA incision that measured 18 cm and had 19 staples and 8 sutures -a scabbed area above the BKA incision that measured 0.7 cm x 0.7 cm -an old small ulcer to the left foot TMA plantar that measured 2.8 cm x 2.0 cm. Record review of Resident #302's Daily Skilled Nurse's Notes, dated 12/9/17 and 12/10/17, revealed in the Skin section the resident was checked as having skin within normal limits. The record also revealed in the Skin Concerns section that the resident was described to have a RBKA UTI/CONTACT ISOLATION MDRO, and in the box where it asked if the skin concerns were existing or new the box was left blank. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/11/17, revealed in the Skin Concerns section that the resident was checked for having a bruise and pressure ulcer and was described to have a RBKA UTI/CONTACT ISOLATION MDRO, and in the box where it asked if the skin concerns were existing or new the box was left blank. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/12/17, revealed in the Skin Concerns section that the resident was not checked for having any skin concerns, but was described to have a RBKA UTI/CONTACT ISOLATION MDRO STAGE 2 TO BUTT(NAME)K TX BY TX NURSE, and in the box where it asked if the skin concerns were existing or new the box was left blank. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/13/17, revealed in the Skin Concerns section that the resident was checked for having a rash and pressure ulcer and the description are was left blank. Record review of Resident #302's Weekly Wound Progress Note, dated 12/14/17, revealed the resident had 5 or more wounds and that the responsible party was notified on 12/13/17 and the physician was notified on 12/7/17. The record also revealed the resident had a stage 3 pressure ulcer to the right buttock with moist, thin, and yellow exudate, no odor, tan wound bed appearance, slough tissue, 40 percent of the of the wound bed tissue seen, dark red/purple surrounding skin color, with no undermining or tunneling present, measured 9.0 cm x 4.0 cm x 0.1 cm, and the wound has shown improvement. The same record also revealed the resident had a stage 3 pressure ulcer to the sacrum moist, thin, and yellow exudate, no odor, pink wound bed appearance, granulation tissue, 80 percent of the of the wound bed tissue seen, pink surrounding skin color, with no undermining or tunneling present, measured 4.0 cm x 7.0 cm x 0.1 cm, and the wound has shown improvement. The record also revealed the resident had a stage 3 pressure ulcer to the left buttock with small, thin, and yellow exudate, no odor, tan wound bed appearance, slough tissue, 15 percent of the of the wound bed tissue seen, dark red/purple surrounding skin color, with no undermining or tunneling present, measured 10.0 cm x 5.5 cm x 0.1 cm, and the wound has shown improvement. The record further revealed that all of the wounds were treated with by cleaning with normal saline apply nickel thickness santyl to wound bed and cover with dressing. Record review of Resident #302's second Weekly Wound Progress Note, dated 12/14/17, revealed the resident had 5 or more wounds and that the responsible party was notified on 12/13/17 and the physician was notified on 12/7/17. The record also revealed the resident had a surgical incision with the wound location on the R-BKA with dry exudate, no odor, tan wound bed appearance, [MEDICATION NAME] tissue, 100 percent of the of the wound bed tissue seen, normal surrounding skin color, with no undermining or tunneling present, not measure staples and sutures intact, and the wound has shown improvement. The record also revealed the resident had a stage 3 diabetic ulcer to the plantar surface of the left Trans metatarsal amputation with dry exudate, no odor, black wound bed appearance, slough tissue, 0 percent of the of the wound bed tissue seen, normal surrounding skin color, with no undermining or tunneling present, measured 4.2 cm x 4.0 cm, and the wound has not shown improvement. The record further revealed no treatments for the surgical incision, but a treatment to apply skin prep every day for the stage 3 diabetic ulcer. Record review on 12/14/17 of Resident #302's Consolidated Physician Orders, revealed no order to monitor and/or treat the surgical incision to the R-BKA with 19 staples and 8 sutures nor any treatment for [REDACTED]. The record further revealed not until four days after admission (12/11/17) did the resident receive wound treatment orders for: - Santyl Ointment 250 unit/gm- apply to left buttock topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. - Santyl Ointment 250 unit/gm- apply to right buttock topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. - Santyl Ointment 250 unit/gm- apply to sacrum topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. Record review on 12/14/17 of Resident #302's December MAR and TAR, revealed no documentation of treatment or monitoring of resident's surgical incision or diabetic ulcer. The record also revealed until four days after admission (12/12/17) did the resident receive wound treatment orders for the left and right buttocks and the sacrum to clean the wounds with normal saline and apply santyl ointment nickel thickness to the unstageable wounds and cover with a foam dressing every day, and were administered 12/12/17-12/14/17. Observation of Resident #302 on 12/14/17 at 10:02 a.m. revealed RN A retrieved three medicine cups and swirled two copious layers of Santyl ointment into each cup. RN A stated She has a left foot diabetic ulcer on her plantar, R-BKA with sutures and 19 staples, the scab on that fell off yesterday when I was cleaning it. Her bottom has wounds that look like stage 3's. On Monday the Wound Specialist came in and debrided her bottom wounds a little but still has slough in all the wounds. The sacral area has some pink tissue. Resident #302 layed on her back with the head of her bed slightly elevated, on an inflated low air loss mattress. LVN E assisted to turn Resident #302 to her right side while RN A, removed R #302's dressing off her buttocks. The dressing had evidence of wetness, no color. The left buttock had an open wound with approximately 75% of yellow/brown tissue and 25% red tissue within the wound bed and the surrounding peri-wound tissue had brown discoloration. Above this wound was another smaller open wound that was separate from the lower larger wound. This superior wound was open and had a red wound bed. Resident #302's sacrum/gluteal cleft had an open wound that appeared wet and had a butterfly appearance, the wound bed was approximately 75% red and approximately 15% of yellow tissue on the lower distal end of the wound. The left inferior buttock had an open wound with approx. 70% yellow/brown and 20% red wound bed that had linear striated incisions on the yellow/brown tissue. RN A cleaned the right buttock wound with normal saline and 4 X 4 dressings. RN A measured both superior and inferior wound on the right buttock as one wound and said 10.0 X 5.5 centimeters. RN A then applied all the Santyl ointment from one medication cup and spread it throughout the entire wound (being more than a nickel thick). RN A cleaned the sacrum/gluteal cleft wound with normal saline and 4 X 4 dressings. RN A measured the wound and said 4.0 X 7.0 centimeters. RN A then applied all of the Santyl from one medicine cup throughout the entire wound. RN A cleaned the left buttock wound with normal saline and 4 X 4 dressings. RN A measured the wound and said 9.0 X 4.0 centimeters. RN A applied all the Santyl from another medicine cup and spread throughout the entire wound (being more than a nickel thick). RN A placed a large self-adhesive dressing that covered all the wounds. R #302 was positioned on her back. During an interview on 12/14/17 at 11:13 a.m., RN A revealed she said Resident #302 should not have the fitted sheet and cloth pad on the air mattress. I've been educated that an air mattress should only have a thin breathable disposable barrier pad but this facility does not have any of those. The cloth pads block air flow and could cause moisture within the wound that could allow the skin to become macerated and worsen. During an interview on 12/14/17 at 12:33 p.m., LVN E revealed that she could not find the admitting order for Resident #302's R-BKA incision site with sutures and staples to monitor or treat. LVN E revealed the resident admitted with pressure sores and the R-BKA with sutures and staples. LVN E reviewed the resident's hospital discharge record and said that she could not find any other for treatment or monitoring for the pressure sores or R-BKA. LVN E confirmed that she wrote the Nursing Home Admission report received from the hospital that said the resident has a stage 2 pressure ulcer. LVN E confirmed that the nurse when he/she called the physician to reconcile the resident admitting medication, they should have informed the physician of the resident's pressure sores and RBKA and see if he wanted to give orders to monitor/treat. LVN E confirmed that the only orders for the resident's pressure sores was started on 12/12/17 5 days after the resident admitted . LVN E confirmed that the resident's skin assessments were inconsistent in saying that the resident had skin impairment of pressure ulcers to the skin was within normal limits. LVN E confirmed that her Daily Nurses' note on 12/11/17 was wrong and should have accurately documented the wound and incision site. LVN E revealed the assessments and daily nurses' notes for 12/9-12/10 were inaccurate for saying the skin was within normal limits because the resident had pressure sores and still currently has them. During an interview on 12/14/17 at 12:37 p.m., LVN E confirmed Resident #302 had pressure ulcers and staples upon admit. Nurse revealed the resident was supposed to be getting the staples out the following morning of 12/8/17 but due to short notice for the facility transportation system they missed the appointment and had to reschedule for the suture removal. During an interview on 12/14/17 12:46 p.m., LVN E confirmed Resident #302's hospital record did not give any orders to follow for the wounds or surgical site. LVN E revealed she was not the nurse who completed the admission assessment, but it was LVN N. LVN E revealed Resident #302's December TAR revealed no orders to monitor or treat the surgical site/staples. LVN E confirmed that there was on one day of nurses' notes that revealed notation of the resident's RBKA sutures and staples were being monitored. LVN E revealed the nurses and treatment nurse are responsible for making sure that if there are not orders for a resident that has wounds or surgical incisions sent from the hospital that they are to call the physician for orders to monitor or treat. LVN E confirmed she did not call the Resident #302's physician to get orders for the resident's surgical incision or pressure ulcers. Further interview on 12/14/17 at 1:16 p.m., with LVN E revealed she noticed that RN A Did not open her labias to clean her vagina. Yes she should have opened her labias to thoroughly clean her. She did not clean her buttocks either and she should have especially since (Resident #302) has a contagious infection in her urine. I was nervous, next time I should speak up. Further interview with RN A on 12/14/17 at 4:11 p.m. revealed the facility did not have a copy of the Wound Care Specialist's Evaluation from Monday, 12/11/17. RN A said she just called the physician and was told the report had not been synced and would work on it. RN A said she had not noticed that the facility did not have a copy of the evaluation. RN A said the evaluation included the physician's assessment and/or recommendations. RN A said Normally we get the reports the next day, I don't know what happened this time. RN A stated that Santyl was an enzymatic debrider but did not do damage to healthy tissue but was recommended not to put on the healthy surrounding skin. RN A said the Sacrum/Gluteal Cleft pressure ulcer had significant slough in the wound bed as of Tuesday, 12/12/17. RN A stated the slough in that wound was no longer there yesterday. When RN A was asked if the physician normally ordered Santyl for wound beds without slough, RN A stated she would have to call the physician and ask if she wanted to change the treatment because it was not normally used for healthy tissue. RN A verified Resident #302's sacral wound had changed in condition by no longer having slough in the center of the wound bed since yesterday and had not consulted with Resident #302's physician to notify of the change and possible treatment change but she would inform her. RN A explained she did not know how to exactly measure nickel thick amount of Santyl so she just Put a little more than a thin layer. During an interview on 12/14/17 05:30 p.m. the DON revealed she stated Resident #302 was admitted on [DATE] with multiple pressure ulcers and a new right BKA with 19 staples intact. The DON reviewed Resident #302's documents and verified there were no orders to monitor or treat the surgical site at right BKA incision, nor orders to treat the resident's pressure ulcers until 12/12/17. The DON stated she would expect the nurses to call the physician and verify orders to include monitoring or treatment of [REDACTED].#302's surgical incision. When the DON was asked about Resident #302's pressure ulcers she stated Each wound should be described as accurately as possible on their admission assessments and head to toe assessments/Weekly Pressure Ulcer Report. The DON reviewed the Daily Skilled Nurses Notes dated 12/09/17-12/10/17 and acknowledged that the note indicated that Resident #302's skin was Within Normal Limits then the DON said I do not agree with that entry because she had a couple of pressure ulcers and a surgical incision, it's not possible that her skin was within normal limits. The DON said the Daily Skilled Nurses Notes dated 12/11/17 revealed no detailed description of Resident #302's pressure ulcers or surgical incision and the note dated 12/12/17 revealed a Stage 2 to buttock but had no detail of the wound and did not indicate more than one wound, which the resident had. The DON stated the documentation on 12/14/17 indicated a Stage 3 to right buttock, a Stage 3 to left buttock and sacrum. The DON said the assessment indicated LTMA (left Trans-metatarsal amputation) however, the DON said I don't know what that means, I'll have to ask RN A what she meant by that, she should know. The DON said through her review of all of Resident #302's documentation, she saw issues with staging of the pressure ulcers, identifying and measuring pressure ulcers as separate ulcers, no detailed description of the wounds, she should have a Wound Progress Record with detailed description of wounds. The DON said she could not track Resident #302's wound and stages because of missing information and inconsistent staging documented. The DON said she tracked the wounds in the facility by reviewing the measurements of the wounds. The DON said she would also look at the description of the wounds but since Resident #302 did not have a description of her wounds upon admission she could not tell what the wound looked like then. The DON said if there is no accurate assessment documented then it would be difficult to track the status of the wound or track whether the wound was getting better or worse. The DON said after reviewing the measurements of Resident #302's initial wound measurements in comparison to 12/14/17, Resident #302's wounds were getting bigger. It appears they have progressed. The DON said the treatment nurse had years of wound care experience and had been wound care certified within the last 3 1/2 months. The DON said she monitored the treatment nurse and wounds by participating in weekly at risk (WAR) meetings where residents at risk for pressure ulcers were discussed. The DON said the treatment nurse had requested her assistance on several occasions when she had a question. The DON said she last conducted observations of the wounds in the facility was approximately one month ago. The DON said she had not seen Resident #302's wounds. The DON said the physician should send in their evaluations and usually took a day. The DON said the treatment nurse should have called the physician and attempted to retrieve the physician's evaluation. The DON said from her experience, Santyl was a chemical debrider that shouldn't be used on healthy granulated tissue and should only be used for slough or necrotic tissue. The DON said if the nurse had seen a change in the wound that may no longer need the Santyl then the nurse should call the physician and describe the wound and ask the physician if she wanted to continue current treatment or change the treatment. The DON said if the resident no longer had slough then the resident would no longer need the treatment for [REDACTED]. The DON stated We are not supposed to put anything on air mattresses except a draw sheet or a thin paper disposable pad, which this facility does not use. Too many layers of linen can cause blockage of air flow which would allow the resident to have moisture build-up that causes skin breakdown and worsening of the wounds. The DON stated if staff did not thoroughly provide incontinent/perineal care, the resident would be at risk of infection and for Resident #302, since she already had a urine infection and she was incontinent, she would be at risk for her current infection to extend into her wounds. The DON stated RN A needs immediate training. Observation on 12/14/17 at 08:32 p.m. the surveyor accompanied the DON, RN A, and Assistant DON (ADON) M into Resident #302's room. Resident #302 was informed she was going to be turned to her right side, R #302 attempted to turn herself but after a couple of attempts, was unsuccessful. Resident #302 was turned to her right side by the DON and RN A; The DON positioned herself on the right side of R #302 and RN A on the left side. The DON assisted Resident #302 to stay on her right side by supporting the resident's back. Resident #302 did not have a dressing on her buttocks and sacral wounds. RN A began to measure Resident #302's right buttock and said 10.0 X 4.0, no 3.5. 10.0 X 3.5 centimeters. When RN A was asked to describe the wound she stated It's a Stage 3, it could be an Unstageable and eventually a Stage 2 because it doesn't have a lot of depth. RN A applied Santyl throughout the entire wound bed. (RN A spoke of back staging which per the National Pressure Ulcer Advisory Panel-NPUAP, should not occur). The DON stated I'd wait for the physician to stage, we will describe it to her. The DON instructed RN A that the left buttock had two separate areas and to measure them separately. RN A measured and said Left superior buttock is 0.9 X 2.2 centimeters. The DON described the wound and said It appears like a Stage 2, it has a pink wound bed, no odor, no drainage, and surrounding skin is dark. RN A applied Santyl throughout the entire wound bed. RN A measured and said Left inferior left buttock- 7.3 X 6.0. The DON described the wound as It has yellow slough, its moist, and has dark surrounding skin. RN A applied Santyl throughout the entire wound bed. The DON raised Resident #302's left buttock exposing the wound identified as the Sacrum. RN A walked to the wall beside the door and with donned dirty gloves, grabbed a handful of clean gloves and placed them on the bedside table on her clean supply field and used them to continue wound care. RN A measured and said 3.8 X 6.4 centimeters. RN A applied Santyl throughout the entire wound bed and then applied one large border foam dressing that covered all the wounds. RN A was asked if she cleaned the wounds prior to her applying treatment to the wounds and she replied No I didn't. I did not clean them, I should have. The aides cleaned her when they gave her a bed bath just before we walked in her. RN A was asked if the aides could clean wounds as per the physician prescribed and she responded No they can't. The DON or ADON did not intervene as RN A continued to apply treatment and dressings to Resident #302's wounds without cleaning the wounds first. Record review on 12/15/17 at 9:09 a.m. of Resident #302's Progress Notes in the EMR, revealed there were no notes on the resident's pressure ulcers or surgical incision except on 12/8/17 and 12/14/17. During an interview on 12/14/17 at 9:22 PM the DON revealed that they had just gotten out of the room supervising RN A with Resident #302's wounds. DON revealed that the resident just got a shower and the RN A performed wound treatment. The DON revealed RN A did not clean the wounds during the treatment, but just applied the medication and dressing. During an interview on 12/15/17 at 8:22 a.m., Physician I revealed she was the Wound Care Specialist that was consulted for initial evaluation of R #302 on 12/11/17. Physician I said she clustered the two wounds on Resident #302's left buttock because they were within the same proximity on the left buttock. Physician I reported the left buttock wound measured 10.5 X 5.0 centimeters. Physician I said she debrided the left and right buttock eschar/slough. Physician I said she ordered a nickel thick amount of Santyl on each wound due to the resident having slough in the wound bed. Physician I said she had no concern with a little of Santyl getting on red healthy tissue but it should be minimized because it beats up the tissue. Physician I stated Resident #302's current treatment was to clean with normal saline or wound cleanser, apply a nickel thick amount of Santyl to remove the slough, and Calcium Alginate to keep the wound moistened but stabilizing blood flow. Physician I was asked if the facility did not have her evaluation for reference how the facility would be aware of her orders; Physician I said The treatment nurse knows because I verbally told her the orders when I was there. I work with the treatment nurse on a one to one basis as I do the assessments. Physician I said she was not aware that her evaluation had not uploaded into the facility's electronic system until the facility called her on 12/14/17 asking for it. Physician I said the facility could have called her sooner. Physician I said If staff are not following the physician's orders [REDACTED]. Record review of Resident #302's Braden Scale Assessments, dated 12/15/17, revealed a score of 12 meaning the resident was a high risk for pressure ulcers. Record of review on 12/16/17 (the date the facility provided the report to the surveyor) of Resident #302's Wound Care Specialist Initial Evaluation, dated 12/11/17, revealed: -Unstageable (Due to necrosis) of the Right Buttock (site 2): Etiology: Pressure. 7.0 X 2.8 X not measurable depth cm, light serous exudate, 70% thick adherent black necrotic tissue (eschar)/slough, 30% granulation tissue. Surgical excisional debridement performed. Recommendation: Off-load wound, reposition per facility protocol. Dry protective dressing Calcium Alginate and Santyl daily. -Unstageable (Due to Necrosis) of the Left Buttock (site 3): Etiology: Pressure. 10.5 X 5.0 X not measurable depth cm, light serous exudate, 40% thick adherent black necrotic tissue (Eschar)/slough, 60% granulation tissue. Surgical excisional debridement performed. Recommendation: Off-load wound, reposition per facility protocol. Dry protective dressing Calcium Alginate and Santyl daily. -Unstageable (Due to Necrosis) Sacrum (site 4): Etiology: Pressure. 3.5 X 3.0 X not measurable depth cm, moderate serous exudate, 10% thick adherent black necrotic tissue (Eschar)/slough, 90% granulation tissue. Surgical excisional debridement performed. Recommendation: Off-load wound, reposition per facility protocol. Dry protective dressing Calcium Alginate and Santyl daily I discussed plan of care with the wound care nurse and patient and why sheets do not allow low air loss mattresses to function properly. I also discussed plan of care with the wound care nurse and patient. During an interview on 12/15/17 at 8:59 a.m., the DON revealed she provided a copy of Wound Care Specialist Initial Evaluation dated 12/11/17 and after reviewing the evaluation was asked if she was aware that the physician had ordered Calcium Alginate along with Santyl as the treatment for [REDACTED]. The DON stated she was not aware and confirmed that the treatment nurse did not use Calcium Alginate while treating the wound on yesterday. The DON verified Calcium Alginate was not included in the orders the facility currently had. The DON said Maybe RN A forgot to write the order or did not hear the doctor verbalize the order, I don't know, I have to ask her. The DON said RN A was not available since she was sent to training. The DON said it was important to have the Wound Care Specialist evaluation and assessments at the facility to review for reference and for continuation of care. Record review on 12/16/17 of Resident #302's December MAR and TAR, revealed no documentation of treatment or monitoring of resident's surgical incision or diabetic ulcer. The records also revealed the resident received the same wound treatment from 12/12/17-12/15/17 to clean the wounds with normal saline and apply santyl ointment nickel thickness to the unstageable wounds (left and right buttocks and the sacrum) and cover with a foam dressing every day. The records also revealed on 12/15/17, Resident #302 was ordered an antibiotic [MEDICATION NAME] Tablet 750 mg- give 1 tab by mouth one time a day every other day related to pressure ulcer of sacral region state 2 for 8 days. The Facility Resident Matrix form, dated 12/11/17, indicated there were 10 admissions within the last 30 days.

Based on observation, interview, and record review the facility failed to ensure residents have the right to be free from neglect for 5 of 11 residents (Residents #302, #64, #70, #3 and #44) reviewed for neglect. 1.) Resident #302: -The facility failed to assess and document a detailed description of R #302's pressure ulcers upon admission. -The facility failed to consult and retrieve wound care orders for R #302's pressure ulcers upon admission therefore, R #302 did not receive treatments on her community acquired Stage 2 and two Unstageable Pressure Ulcers for five days after admission. -Registered Nurse (RN) A failed to provide R #302 pressure ulcer treatments as prescribed by the physician. -The facility's documentation of R #302's pressure ulcers was conflicting on separate forms making it difficult to track the progress and accurate staging of the pressure ulcers. -The facility did not consistently identify all of R #302's pressure ulcers in their Skin-Weekly Pressure Ulcer Record or the Skin Head to Toe Check. -RN A failed to perform hand hygiene practices as per the facility's policy and procedure, prior to initiating R #302's wound care on her pressure ulcers. -RN A contaminated clean gloves she used while providing R #302 wound care on her pressure ulcers. -The facility failed to ensure the licensed staff providing wound care were knowledgeable and competent in the identification, assessment, documentation, and treatment of [REDACTED]. These failures resulted in the resident's pressure ulcers worsening in size and staging. 2) Resident #64: -RN A failed to perform hand hygiene practices as per the facility's policy and procedure, prior to initiating R #64's wound care on her pressure ulcers. -RN A contaminated R #64's pressure ulcer after cleaning and treating R #64's two separate open wounds simultaneously. 3) Resident #70: - The facility failed to consult with R #70's physician when a new DTI was identified and before treating the new DTI. 4) Resident #3's low air mattress was set at level 9 setting instead of level 2 setting as indicated on the manufacturer's control panel for 2 of 6 days. 5) Resident #44's pressure ulcers on the left and right buttocks were not recorded on the Weekly Skin Check by Wound Nurse A. The above failures resulted in an IJ situation on 12/15/17. While the IJ was removed on 12/16/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could place 11 residents with pressure ulcers and 48 residents receiving preventive skin care at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: 1.) Record review of Resident #302's face sheet, dated 12/14/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #302's Hospital's Wound Assessment/Treatment Report, dated run 12/4/17, revealed a surgical wound to the Right guillotine amputation, a unstageable pressure ulcer/injury to the left buttock that received a [MEDICATION NAME] dressing, a pressure ulcer/injury of the sacral to right buttock that had no staging information that received a [MEDICATION NAME] dressing, an unstageable pressure ulcer/injury to the forehead that no dressing information, and a diabetic wound to the left Transmetatarsal Amputation plantar surface no dressing information. During an interview on 12/14/17 at 12:46 PM LVN E confirmed Resident #302's hospital record did not give any orders to follow for the wounds or surgical site. LVN E revealed she was not the nurse who completed the admission assessment, but it was LVN N. LVN E confirmed she did not call the Resident #302's physician to get orders for the resident's surgical incision or pressure ulcers. Record review of Resident #302's Nursing Admission Report from the hospital, undated, revealed the resident had [DIAGNOSES REDACTED]. The same record revealed the resident was on contact isolation for MDRO of the urine, incontinent, and had a stage 2 to the buttocks each side. Record review of Resident #302's Nursing Admission Assessment with Functional Abilities, dated 12/7/17, revealed the resident had an ulcer to the right and left buttock, 19 staples to the R-BKA, and a wound to the right shoulder from a removed permacath. The record also revealed the resident was incontinent of bowel and bladder; and she required substantial/maximal assistance with bed mobility, transfers, sit to stand, and foliating transfer. The record also revealed an Interim Care Plan that revealed the resident was at risk for pressure ulcers related to limited mobility and the goal was that the resident would not develop a pressure ulcer with interventions to assess resident for risk, provide preventative equipment if indicated, skin assessment upon admission and at minimum weekly thereafter, and turn and reposition resident per facility protocol. The Interim Care Plan also revealed the resident had a problem with altered skin integrity related to buttock ulcers with goals for the resident to be free of further/new skin alterations for 90 days and that the resident will show improvement to impaired skin area; with interventions to assess the skin on admit and weekly thereafter, follow the treatment per the physician orders, notify the physician for concerns. Record review of the Facility's Pressure Wounds Log, dated 12/8/17, revealed Resident #302 was not listed. Record review of Resident #302's Braden Scale Assessments, dated 12/8/17, revealed a score of 15 meaning the resident was at risk for pressure ulcers. Record review of Resident #302's Weekly Skin Assessment Check, dated 12/8/17, revealed yes the resident had skin impairments. The record also revealed the resident had: -a stage 2 pressure ulcer to the sacrum that measured 1.2 cm x 1.0 cm -a unstageable pressure ulcer to coccyx that measured 4.0 cm x 4.5 cm -a stage 2 pressure ulcer to the superior left buttock that measured 1.0 cm x 0.3 cm x 0.1 cm -a unstageable pressure ulcer to the left buttock that measured 6.5 cm x 4.0 cm Record review of Resident #302's Daily Skilled Nurse's Notes, dated 12/9/17 and 12/10/17, revealed in the Skin section the resident was checked as having skin within normal limits. The record also revealed in the Skin Concerns section that the resident was described to have a RBKA UTI/CONTACT ISOLATION MDRO, and in the box where it asked if the skin concerns were existing or new the box was left blank. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/11/17, revealed in the Skin Concerns section that the resident was checked for having a bruise and pressure ulcer and was described to have a RBKA UTI/CONTACT ISOLATION MDRO, and in the box where it asked if the skin concerns were existing or new the box was left blank. After surveyor request, the DON provided an up to date copy of the Facility's Pressure Wounds Log, dated 12/11/17, that revealed Resident #302 was indicated as having 4 pressure wounds that she admitted with. The record also revealed Resident #302 had one stage 2 pressure ulcer to the left buttock and three unstageable pressure wounds to the right buttock, left buttock and sacrum. The record further revealed the stage 2 to the left buttocks measured (length, width, depth) 1.0 cm x 0.3 cm x 0.1 cm, the unstageable to the right buttocks 6.0 cm x 3.5 cm x 0.1 cm, the unstageable to the left buttock 6.5 cm x 4.0 cm, and the unstageable to the sacrum measured 4.0 cm x 4.5 cm. The record also revealed the family/resident and the physician were notified of the pressure wounds on 12/7/17 and that the resident had treatment documented with the treatment being santyl/dressing for the unstageable wounds and the stage 2 wound received a treatment of [REDACTED]. Record review of Resident #302's EMR Orders, revealed not until four days after the resident admitted (12/11/17) did she receive wound treatment orders to be started on 12/12/17 at 6:00 a.m. for: - Santyl Ointment 250 unit/gm- apply to left buttock topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. - Santyl Ointment 250 unit/gm- apply to right buttock topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. - Santyl Ointment 250 unit/gm- apply to sacrum topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. This record revealed these 3 orders were created/input by RN A. Interview with RN A on 12/14/17 at 10:00 a.m. revealed she stated she was present during R #302's Wound Care Specialist's Initial Evaluation on 12/11/17. RN A said she received verbal orders from the Specialist to apply nickel thickness of Santyl to each pressure ulcer wound bed and cover with a foam dressing and therefore documented the order above. RN A stated the Wound Care Specialist documented their assessment/evaluation and recommendations electronically. RN A said the facility did not have a copy of the Wound Specialist's Evaluation. RN A said she had not requested a copy of the evaluation but would do so to provide a copy for the surveyor. Record review of Resident #302's December 2017 MAR and TAR, revealed no documentation of treatment or monitoring of resident's surgical incision or diabetic ulcer. The record also revealed not until five days after admission (12/12/17) did the resident start wound treatment for [REDACTED]. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/12/17, revealed in the Skin Concerns section that the resident was not checked for having any skin concerns, but was described to have a RBKA UTI/CONTACT ISOLATION MDRO STAGE 2 TO BUTT(NAME)K TX BY TX NURSE, and in the box where it asked if the skin concerns were existing or new the box was left blank. During an interview on 12/12/17 at 10:15 a.m. LVN E revealed Resident #302 was on contact isolation for an infection of the urine and was contained, but because she was incontinent and had been over saturating her brief, they had been keeping her in her room to keep the urine from spilling in the common area of the facility. LVN E revealed she only has a few more day of antibiotics left, and then they could discharge her from isolation. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/13/17, revealed in the Skin Concerns section that the resident was checked for having a rash and pressure ulcer and the description are was left blank. Record review of Resident #302's Weekly Wound Progress Note, dated 12/14/17, revealed the resident had 5 or more wounds and that the responsible party was notified on 12/13/17 and the physician was notified on 12/7/17. The record also revealed the resident had a stage 3 pressure ulcer to the right buttock with moist, thin, and yellow exudate, no odor, tan wound bed appearance, slough tissue, 40 percent of the of the wound bed tissue seen, dark red/purple surrounding skin color, with no undermining or tunneling present, measured 9.0 cm x 4.0 cm x 0.1 cm, and the wound has shown improvement. The same record also revealed the resident had a stage 3 pressure ulcer to the sacrum moist, thin, and yellow exudate, no odor, pink wound bed appearance, granulation tissue, 80 percent of the of the wound bed tissue seen, pink surrounding skin color, with no undermining or tunneling present, measured 4.0 cm x 7.0 cm x 0.1 cm, and the wound has shown improvement. The record also revealed the resident had a stage 3 pressure ulcer to the left buttock with small, thin, and yellow exudate, no odor, tan wound bed appearance, slough tissue, 15 percent of the of the wound bed tissue seen, dark red/purple surrounding skin color, with no undermining or tunneling present, measured 10.0 cm x 5.5 cm x 0.1 cm, and the wound has shown improvement. The record further revealed that all of the wounds were treated with by cleaning with normal saline apply nickel thickness santyl to wound bed and cover with dressing. Observation of Resident #302 on 12/14/17 at 10:02 a.m. revealed RN A entered Resident #302's room and explained she was preparing to perform wound care. RN A gathered unpackaged gauzes and ointments from her medication cart; RN A did not perform hand hygiene prior to gathering clean dressings and supplies from medication cart. RN A retrieved three medicine cups and swirled two copious layers of Santyl ointment into each cup. RN A put on a yellow gown while in the hallway, before entering the room and proceeded in Resident #302's room, applied gloves and began wiping Resident #302's bedside table, without performing hand hygiene. RN A stated Her bottom has wounds that look like stage 3's. On Monday the Wound Specialist came in and debrided her bottom wounds a little but still has slough in all the wounds. The sacral area has some pink tissue. Resident #302 laid on her back with the head of her bed slightly elevated, on an inflated low air loss mattress. Resident #302's mattress had a white fitted sheet in place and a cloth facility incontinent pad over the sheet and Resident #302 wore a brief. Resident #302 had a nasal cannula in place attached to an oxygen concentrator that was set at 3 liters. Resident #302 was alert and oriented to person, place, and time and was verbal. Resident #302 attempted to turn herself to her right side but was unsuccessful. LVN E assisted to turn Resident #302 to her right side while RN A, removed Resident #302's dressing off her buttocks. The dressing had evidence of wetness, no color. The left buttock had an open wound with approximately 75% of yellow/brown tissue and 25% red tissue within the wound bed and the surrounding peri-wound tissue had brown discoloration. Above this wound was another smaller open wound that was separate from the lower larger wound. This superior wound was open and had a red wound bed. Resident #302's sacrum/gluteal cleft had an open wound that appeared wet and had a butterfly appearance, the wound bed was approximately 75% red and approximately 15% of yellow tissue on the lower distal end of the wound. The left inferior buttock had an open wound with approx. 70% yellow/brown and 20% red wound bed that had linear striated incisions on the yellow/brown tissue. RN A cleaned the right buttock wound with normal saline and 4 X 4 dressings. RN A measured both superior and inferior wound on the right buttock as one wound and said 10.0 X 5.5 centimeters. RN A then applied all the Santyl ointment from one medication cup and spread it throughout the entire wound (being more than a nickel thick). RN A cleaned the sacrum/gluteal cleft wound with normal saline and 4 X 4 dressings. RN A measured the wound and said 4.0 X 7.0 centimeters. RN A then applied all of the Santyl from one medicine cup throughout the entire wound. RN A cleaned the left buttock wound with normal saline and 4 X 4 dressings. RN A measured the wound and said 9.0 X 4.0 centimeters. RN A applied all the Santyl from another medicine cup and spread throughout the entire wound (being more than a nickel thick). RN A placed a large self-adhesive dressing that covered all the wounds. Resident #302 was positioned on her back and RN A used wet cleansing disposable cloths and cleaned the left outer labia, wiping using a downward stroke. With a clean cloth RN A wiped the center of the vagina using a downward stoke and repeated this process two more times. RN A did not open Resident #302's labias and thoroughly clean the vagina and did not clean R #302's buttocks from incontinent urine (exposing Resident #302 at risk for infection since she currently had an infection in her urine). Interview with Resident #302 on 12/14/17 at 11:00 a.m. revealed she stated she had pain to her wounds. Resident #302 asked LVN E for a pain pill. Resident #302 said she had not been offered a pain pill prior to wound care. Resident #302 stated she only felt pain to her wounds when they were touched/treated. Resident #302 said she was not able to reposition herself. Resident #302 said staff did reposition her daily but not every two hours. Resident #302 said staff repositioned her about every 3 1/2-4 hours. Resident #302 stated she knew it was 3-4 hours because she has a clock on her wall she looked at. During an interview on 12/14/17 at 11:08 a.m., LVN E revealed Resident #302 had not asked for any pain medication prior to wound care. LVN E said she had not offered any pain medication to Resident #302. When asked if Resident #302's mattress should have a fitted sheet and a cloth pad, LVN E said I did not notice that. Does she have a regular cloth pad? I did not notice the pad. She should not have the fitted sheet and she should have a thin barrier pad. No, the cloth pad is not the barrier pad. She should not have the least amount of linen underneath her to avoid friction and shearing or trauma to her wound. During an interview on 12/14/17 at 11:13 a.m. with RN A revealed she said Resident #302 should not have the fitted sheet and cloth pad on the air mattress. I've been educated that an air mattress should only have a thin breathable disposable barrier pad but this facility does not have any of those. The cloth pads block air flow and could cause moisture within the wound that could allow the skin to become macerated and worsen. During an interview on 12/14/17 at 12:33 p.m., LVN E revealed the resident admitted with pressure sores. LVN E reviewed the resident's hospital discharge record and said that she could not find any other for treatment or monitoring for the pressure sores. LVN E confirmed that she wrote the Nursing Home Admission report received from the hospital that said the resident has a stage 2 pressure ulcer. LVN E confirmed the nurse when the called the physician to reconcile the resident admitting medication, they should have informed the physician of the resident's pressure sores and see if he wanted to give orders to monitor/treat. LVN E confirmed that the only orders for the resident's pressure sores was started on 12/12/17 5 days after the resident admitted . LVN E confirmed that the resident's skin assessments were inconsistent in saying that the resident had skin impairment of pressure ulcers to the skin was within normal limits. LVN E confirmed that her Daily Nurses' note on 12/11/17 was wrong and should have accurately documented the wound and incision site. LVN E revealed the assessments and daily nurses' notes for 12/9-12/10 were inaccurate for saying the skin was within normal limits because the resident had pressure sores and still currently has them. Further interview on 12/14/17 at 1:16 p.m., with LVN E revealed she noticed that RN A did not open her labias to clean her vagina. Yes she should have opened her labias to thoroughly clean her. She did not clean her buttocks either and she should have especially since (Resident #302) has a contagious infection in her urine. I was nervous, next time I should speak up. Further interview with RN A on 12/14/17 at 4:11 p.m. revealed the facility did not have a copy of the Wound Care Specialist's Evaluation from Monday, 12/11/17. RN A said she just called the physician and was told the report had not been synced and would work on it. RN A said she had not noticed that the facility did not have a copy of the evaluation. RN A said the evaluation included the physician's assessment and/or recommendations. RN A said Normally we get the reports the next day, I don't know what happened this time. RN A stated that Santyl was an enzymatic debrider but did not do damage to healthy tissue but was recommended not to put on the healthy surrounding skin. RN A said the Sacrum/Gluteal Cleft pressure ulcer had significant slough in the wound bed as of Tuesday, 12/12/17. RN A stated the slough in that wound was no longer there yesterday. When RN A was asked if the physician normally ordered Santyl for wound beds without slough, RN A stated she would have to call the physician and ask if she wanted to change the treatment because it was not normally used for healthy tissue. RN A verified Resident #302's sacral wound had changed in condition by no longer having slough in the center of the wound bed since yesterday and had not consulted with Resident #302's physician to notify of the change and possible treatment change but she would inform her. RN A explained she did not know how to exactly measure nickel thick amount of Santyl so she just Put a little more than a thin layer. Interview with the DON on 12/14/17 at 5:30 p.m. revealed she stated Resident #302 was admitted on [DATE] with multiple pressure ulcers and a new R-BKA with 19 staples intact. The DON reviewed Resident #302's documents and verified there were no orders to monitor or treat the surgical site at right BKA incision, nor orders to treat the resident's pressure ulcers until 12/12/17. The DON stated she would expect the nurses to call the physician and verify orders to include monitoring or treatment of [REDACTED].#302's surgical incision. When the DON was asked about Resident #302's pressure ulcers she stated Each wound should be described as accurately as possible on their admission assessments and head to toe assessments/Weekly Pressure Ulcer Report. The DON reviewed the Daily Skilled Nurses Notes dated 12/09/17-12/10/17 and acknowledged that the note indicated that Resident #302's skin was Within Normal Limits then the DON said I do not agree with that entry because she had a couple of pressure ulcers and a surgical incision, it's not possible that her skin was within normal limits. The DON said the Daily Skilled Nurses Notes dated 12/11/17 revealed no detailed description of Resident #302's pressure ulcers or surgical incision and the note dated 12/12/17 revealed a Stage 2 to buttock but had no detail of the wound and did not indicate more than one wound, which the resident had. The DON stated the documentation on 12/14/17 indicated a Stage 3 to right buttock, a Stage 3 to left buttock and sacrum. The DON said the assessment indicated LTMA however, the DON said I don't know what that means, I'll have to ask RN A what she meant by that, she should know. The DON said through her review of all of Resident #302's documentation, she saw issues with staging of the pressure ulcers, identifying and measuring pressure ulcers as separate ulcers, no detailed description of the wounds, she should have a Wound Progress Record with detailed description of wounds. The DON said she could not track Resident #302's wound and stages because of missing information and inconsistent staging documented. The DON said she tracked the wounds in the facility by reviewing the measurements of the wounds. The DON said she would also look at the description of the wounds but since Resident #302 did not have a description of her wounds upon admission she could not tell what the wound looked like then. The DON said if there is no accurate assessment documented then it would be difficult to track the status of the wound or track whether the wound was getting better or worse. The DON said after reviewing the measurements of Resident #302's initial wound measurements in comparison to 12/14/17, Resident #302's wounds were getting bigger. It appears they have progressed. The DON said the treatment nurse had years of wound care experience and had been wound care certified within the last 3 1/2 months. The DON said she monitored the treatment nurse and wounds by participating in weekly at risk (WAR) meetings where residents at risk for pressure ulcers were discussed. The DON said the treatment nurse had requested her assistance on several occasions when she had a question. The DON said she last conducted observations of the wounds in the facility was approximately one month ago. The DON said she had not seen Resident #302's wounds. The DON said the physician should send in their evaluations and usually took a day. The DON said the treatment nurse should have called the physician and attempted to retrieve the physician's evaluation. The DON said from her experience, Santyl was a chemical debrider that shouldn't be used on healthy granulated tissue and should only be used for slough or necrotic tissue. The DON said if the nurse had seen a change in the wound that may no longer need the Santyl then the nurse should call the physician and describe the wound and ask the physician if she wanted to continue current treatment or change the treatment. The DON said if the resident no longer had slough then the resident would no longer need the treatment for [REDACTED]. The DON stated We are not supposed to put anything on air mattresses except a draw sheet or a thin paper disposable pad, which this facility does not use. Too many layers of linen can cause blockage of air flow which would allow the resident to have moisture build-up that causes skin breakdown and worsening of the wounds. The DON stated if staff did not thoroughly provide incontinent/perineal care, the resident would be at risk of infection and for Resident #302, since she already had a urine infection and she was incontinent, she would be at risk for her current infection to extend into her wounds. The DON stated RN A needs immediate training. Observation on 12/14/17 at 08:32 p.m. the surveyor accompanied the DON, RN A, and ADON M into Resident #302's room. Resident #302 was informed she was going to be turned to her right side, Resident #302 attempted to turn herself but after a couple of attempts, was unsuccessful. Resident #302 was turned to her right side by the DON and RN A; The DON positioned herself on the right side of R #302 and RN A on the left side. The DON assisted Resident #302 to stay on her right side by supporting the resident's back. R #302 did not have a dressing on her buttocks and sacral wounds. RN A began to measure Resident #302's right buttock and said 10.0 X 4.0, no 3.5. 10.0 X 3.5 centimeters. When RN A was asked to describe the wound she stated It's a Stage 3, it could be an Unstageable and eventually a Stage 2 because it doesn't have a lot of depth. RN A applied Santyl throughout the entire wound bed.(RN A spoke of back staging which per the National Pressure Ulcer Advisory Panel-NPUAP, should not occur). The DON stated I'd wait for the physician to stage, we will describe it to her. The DON instructed RN A that the left buttock had two separate areas and to measure them separately. RN A measured and said Left superior buttock is 0.9 X 2.2 centimeters. The DON described the wound and said It appears like a Stage 2, it has a pink wound bed, no odor, no drainage, and surrounding skin is dark. RN A applied Santyl throughout the entire wound bed. RN A measured and said Left inferior left buttock- 7.3 X 6.0. The DON described the wound as It has yellow slough, its moist, and has dark surrounding skin. RN A applied Santyl throughout the entire wound bed. The DON raised Resident #302's left buttock exposing the wound identified as the Sacrum. RN A walked to the wall beside the door and with donned dirty gloves, grabbed a handful of clean gloves and placed them on the bedside table on her clean supply field and used them to continue wound care. RN A measured and said 3.8 X 6.4 centimeters. RN A applied Santyl throughout the entire wound bed and then applied one large border foam dressing that covered all the wounds. RN A was asked if she cleaned the wounds prior to her applying treatment to the wounds and she replied No I didn't. I did not clean them, I should have. The aides cleaned her when they gave her a bed bath just before we walked in her. RN A was asked if the aides could clean wounds as per the physician prescribed and she responded No they can't. The DON or ADON did not intervene as RN A continued to apply treatment and dressings to Resident #302's wounds without cleaning the wounds first. Record review on 12/15/17 at 9:09 a.m. of Resident #302's Progress Notes in the EMR, revealed there were no notes on the resident's pressure ulcers or surgical incision except on 12/8/17 and 12/14/17. During an interview on 12/14/17 at 9:22 p.m., the DON revealed that they had just gotten out of the room supervising RN A with Resident #302's wounds. DON revealed that the resident just got a shower and the RN A performed wound treatment. The DON revealed RN A did not clean the wounds during the treatment, but just applied the medication and dressing. During an interview on 12/15/17 at 8:22 a.m., Physician I revealed she was the Wound Care Specialist that was consulted for initial evaluation of Resident #302 on 12/11/17. Physician I said she clustered the two wounds on Resident #302's left buttock because they were within the same proximity on the left buttock. Physician I reported the left buttock wound measured 10.5 X 5.0 centimeters. Physician I said she debrided the left and right buttock eschar/slough. Physician I said she ordered a nickel thick amount of Santyl on each wound due to the resident having slough in the wound bed. Physician I said she had no concern with a little of Santyl getting on red healthy tissue but it should be minimized because it beats up the tissue. Physician I stated Resident #302's current treatment was to clean with normal saline or wound cleanser, apply a nickel thick amount of Santyl to remove the slough, and Calcium Alginate to keep the wound moistened but stabilizing blood flow. Physician I was asked if the facility did not have her evaluation for reference how would the facility be aware of her orders; Physician I said The treatment nurse knows because I verbally told her the orders when I was there. I work with the treatment nurse on a one to one basis as I do the assessments. Physician I said she was not aware that her evaluation had not uploaded into the facility's electronic system until the facility called her on 12/14/17 asking for it. Physician I said the facility could have called her sooner. Physician I said If staff are not following the physician's orders [REDACTED]. During an interview on 12/15/17 11:25 a.m., Clinical Specialist BB revealed that he started working with the RN A at 8 a.m. and trained her by videos and observed training. Clinical Specialist BB revealed that he did not observe Resident #302's wound. Clinical Specialist BB revealed that you usually want to keep wounds separate if there is skin in between and measure two seperate with skin in between as one. Clinical Specialist BB confirmed that RN A was back on the floor and completing assessments and seeing residents. Record review of Resident #302's Braden Scale Assessments, dated 12/15/17, revealed a score of 12 meaning the resident was a high risk for pressure ulcers. Record of review of Resident #302's Wound Care Specialist Initial Evaluation, dated 12/11/17, revealed: -Unstageable (Due to necrosis) of the Right Buttock (site 2): Etiology: Pressure. 7.0 X 2.8 X not measurable depth cm, light serous exudate, 70% thick adherent black necrotic tissue (eschar)/slough, 30% granulation tissue. Surgical excisional debridement performed. Recommendation: Off-load wound, reposition per facility protocol. Dry protective dressing Calcium Alginate and Santyl daily. -Unst

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 5 of 11 residents (Residents #302, #64, #70, #3 and #44) reviewed for residents reviewed for quality of care and assessments. The Administrator failed to: 1) Implement policies and procedures for Resident Rights and Quality of Care. The administrator did not ensure the nursing staff could accurately assess, document, and communicate changes in resident's wound status to residents Physician. 2) Supervise the DON by ensuring a monitoring process was in place for Licensed Nurse competency with wound assessments, documentation and reporting resident's wound status to Physician. The DON failed to: 1) Implement policies and procedures for Resident's Rights and Quality of care by ensuring Licensed Nurse Competency with wound assessments, accuracy of wound documentation, and communication with Physicians with wound changes and obtain treatment orders. 2) Put effective measures into place to ensure staff accurately provided Head to Toe assessments. 3.) Train the nursing staff on accurate wound assessment and documentation process and obtaining physician's orders [REDACTED]. The above failures resulted in an Immediate Jeopardy (IJ) situation on 12/15/17. While the IJ was removed on 12/17/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could place 11 residents with pressure ulcers and 48 residents receiving preventive skin care at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: 1.) Record review of Resident #302's face sheet, dated 12/14/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #302's Hospital's Wound Assessment/Treatment Report, dated run 12/4/17, revealed a surgical wound to the Right guillotine amputation, a unstageable pressure ulcer/injury to the left buttock that received a [MEDICATION NAME] dressing, a pressure ulcer/injury of the sacral to right buttock that had no staging information that received a [MEDICATION NAME] dressing, an unstageable pressure ulcer/injury to the forehead that no dressing information, and a diabetic wound to the left Transmetatarsal Amputation plantar surface no dressing information. During an interview on 12/14/17 at 12:46 PM LVN E confirmed Resident #302's hospital record did not give any orders to follow for the wounds or surgical site. LVN E revealed she was not the nurse who completed the admission assessment, but it was LVN N. LVN E confirmed she did not call the Resident #302's physician to get orders for the resident's surgical incision or pressure ulcers. Record review of Resident #302's Nursing Admission Report from the hospital, undated, revealed the resident had [DIAGNOSES REDACTED]. The same record revealed the resident was on contact isolation for MDRO of the urine, incontinent, and had a stage 2 to the buttocks each side. Record review of Resident #302's Nursing Admission Assessment with Functional Abilities, dated 12/7/17, revealed the resident had an ulcer to the right and left buttock, 19 staples to the R-BKA, and a wound to the right shoulder from a removed permacath. The record also revealed the resident was incontinent of bowel and bladder; and she required substantial/maximal assistance with bed mobility, transfers, sit to stand, and foliating transfer. The record also revealed an Interim Care Plan that revealed the resident was at risk for pressure ulcers related to limited mobility and the goal was that the resident would not develop a pressure ulcer with interventions to assess resident for risk, provide preventative equipment if indicated, skin assessment upon admission and at minimum weekly thereafter, and turn and reposition resident per facility protocol. The Interim Care Plan also revealed the resident had a problem with altered skin integrity related to buttock ulcers with goals for the resident to be free of further/new skin alterations for 90 days and that the resident will show improvement to impaired skin area; with interventions to assess the skin on admit and weekly thereafter, follow the treatment per the physician orders, notify the physician for concerns. Record review of the Facility's Pressure Wounds Log, dated 12/8/17, revealed Resident #302 was not listed. Record review of Resident #302's Braden Scale Assessments, dated 12/8/17, revealed a score of 15 meaning the resident was at risk for pressure ulcers. Record review of Resident #302's Weekly Skin Assessment Check, dated 12/8/17, revealed yes the resident had skin impairments. The record also revealed the resident had: -a stage 2 pressure ulcer to the sacrum that measured 1.2 cm x 1.0 cm -a unstageable pressure ulcer to coccyx that measured 4.0 cm x 4.5 cm -a stage 2 pressure ulcer to the superior left buttock that measured 1.0 cm x 0.3 cm x 0.1 cm -a unstageable pressure ulcer to the left buttock that measured 6.5 cm x 4.0 cm Record review of Resident #302's Daily Skilled Nurse's Notes, dated 12/9/17 and 12/10/17, revealed in the Skin section the resident was checked as having skin within normal limits. The record also revealed in the Skin Concerns section that the resident was described to have a RBKA UTI/CONTACT ISOLATION MDRO, and in the box where it asked if the skin concerns were existing or new the box was left blank. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/11/17, revealed in the Skin Concerns section that the resident was checked for having a bruise and pressure ulcer and was described to have a RBKA UTI/CONTACT ISOLATION MDRO, and in the box where it asked if the skin concerns were existing or new the box was left blank. After surveyor request, the DON provided an up to date copy of the Facility's Pressure Wounds Log, dated 12/11/17, that revealed Resident #302 was indicated as having 4 pressure wounds that she admitted with. The record also revealed Resident #302 had one stage 2 pressure ulcer to the left buttock and three unstageable pressure wounds to the right buttock, left buttock and sacrum. The record further revealed the stage 2 to the left buttocks measured (length, width, depth) 1.0 cm x 0.3 cm x 0.1 cm, the unstageable to the right buttocks 6.0 cm x 3.5 cm x 0.1 cm, the unstageable to the left buttock 6.5 cm x 4.0 cm, and the unstageable to the sacrum measured 4.0 cm x 4.5 cm. The record also revealed the family/resident and the physician were notified of the pressure wounds on 12/7/17 and that the resident had treatment documented with the treatment being santyl/dressing for the unstageable wounds and the stage 2 wound received a treatment of [REDACTED]. Record review of Resident #302's EMR Orders, revealed not until four days after the resident admitted (12/11/17) did she receive wound treatment orders to be started on 12/12/17 at 6:00 a.m. for: - Santyl Ointment 250 unit/gm- apply to left buttock topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. - Santyl Ointment 250 unit/gm- apply to right buttock topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. - Santyl Ointment 250 unit/gm- apply to sacrum topically every day shift for unstageable wounds to buttocks clean with normal saline apply nickel thickness of Santyl to wound bed and cover with foam dressing every day. This record revealed these 3 orders were created/input by RN A. Interview with RN A on 12/14/17 at 10:00 a.m. revealed she stated she was present during R #302's Wound Care Specialist's Initial Evaluation on 12/11/17. RN A said she received verbal orders from the Specialist to apply nickel thickness of Santyl to each pressure ulcer wound bed and cover with a foam dressing and therefore documented the order above. RN A stated the Wound Care Specialist documented their assessment/evaluation and recommendations electronically. RN A said the facility did not have a copy of the Wound Specialist's Evaluation. RN A said she had not requested a copy of the evaluation but would do so to provide a copy for the surveyor. Record review of Resident #302's December 2017 MAR and TAR, revealed no documentation of treatment or monitoring of resident's surgical incision or diabetic ulcer. The record also revealed not until five days after admission (12/12/17) did the resident start wound treatment for [REDACTED]. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/12/17, revealed in the Skin Concerns section that the resident was not checked for having any skin concerns, but was described to have a RBKA UTI/CONTACT ISOLATION MDRO STAGE 2 TO BUTT(NAME)K TX BY TX NURSE, and in the box where it asked if the skin concerns were existing or new the box was left blank. During an interview on 12/12/17 at 10:15 a.m. LVN E revealed Resident #302 was on contact isolation for an infection of the urine and was contained, but because she was incontinent and had been over saturating her brief, they had been keeping her in her room to keep the urine from spilling in the common area of the facility. LVN E revealed she only has a few more day of antibiotics left, and then they could discharge her from isolation. Record review of Resident #302's Daily Skilled Nurse's Note, dated 12/13/17, revealed in the Skin Concerns section that the resident was checked for having a rash and pressure ulcer and the description are was left blank. Record review of Resident #302's Weekly Wound Progress Note, dated 12/14/17, revealed the resident had 5 or more wounds and that the responsible party was notified on 12/13/17 and the physician was notified on 12/7/17. The record also revealed the resident had a stage 3 pressure ulcer to the right buttock with moist, thin, and yellow exudate, no odor, tan wound bed appearance, slough tissue, 40 percent of the of the wound bed tissue seen, dark red/purple surrounding skin color, with no undermining or tunneling present, measured 9.0 cm x 4.0 cm x 0.1 cm, and the wound has shown improvement. The same record also revealed the resident had a stage 3 pressure ulcer to the sacrum moist, thin, and yellow exudate, no odor, pink wound bed appearance, granulation tissue, 80 percent of the of the wound bed tissue seen, pink surrounding skin color, with no undermining or tunneling present, measured 4.0 cm x 7.0 cm x 0.1 cm, and the wound has shown improvement. The record also revealed the resident had a stage 3 pressure ulcer to the left buttock with small, thin, and yellow exudate, no odor, tan wound bed appearance, slough tissue, 15 percent of the of the wound bed tissue seen, dark red/purple surrounding skin color, with no undermining or tunneling present, measured 10.0 cm x 5.5 cm x 0.1 cm, and the wound has shown improvement. The record further revealed that all of the wounds were treated with by cleaning with normal saline apply nickel thickness santyl to wound bed and cover with dressing. Observation of Resident #302 on 12/14/17 at 10:02 a.m. revealed RN A entered Resident #302's room and explained she was preparing to perform wound care. RN A gathered unpackaged gauzes and ointments from her medication cart; RN A did not perform hand hygiene prior to gathering clean dressings and supplies from medication cart. RN A retrieved three medicine cups and swirled two copious layers of Santyl ointment into each cup. RN A put on a yellow gown while in the hallway, before entering the room and proceeded in Resident #302's room, applied gloves and began wiping Resident #302's bedside table, without performing hand hygiene. RN A stated Her bottom has wounds that look like stage 3's. On Monday the Wound Specialist came in and debrided her bottom wounds a little but still has slough in all the wounds. The sacral area has some pink tissue. Resident #302 laid on her back with the head of her bed slightly elevated, on an inflated low air loss mattress. Resident #302's mattress had a white fitted sheet in place and a cloth facility incontinent pad over the sheet and Resident #302 wore a brief. Resident #302 had a nasal cannula in place attached to an oxygen concentrator that was set at 3 liters. Resident #302 was alert and oriented to person, place, and time and was verbal. Resident #302 attempted to turn herself to her right side but was unsuccessful. LVN E assisted to turn Resident #302 to her right side while RN A, removed Resident #302's dressing off her buttocks. The dressing had evidence of wetness, no color. The left buttock had an open wound with approximately 75% of yellow/brown tissue and 25% red tissue within the wound bed and the surrounding peri-wound tissue had brown discoloration. Above this wound was another smaller open wound that was separate from the lower larger wound. This superior wound was open and had a red wound bed. Resident #302's sacrum/gluteal cleft had an open wound that appeared wet and had a butterfly appearance, the wound bed was approximately 75% red and approximately 15% of yellow tissue on the lower distal end of the wound. The left inferior buttock had an open wound with approx. 70% yellow/brown and 20% red wound bed that had linear striated incisions on the yellow/brown tissue. RN A cleaned the right buttock wound with normal saline and 4 X 4 dressings. RN A measured both superior and inferior wound on the right buttock as one wound and said 10.0 X 5.5 centimeters. RN A then applied all the Santyl ointment from one medication cup and spread it throughout the entire wound (being more than a nickel thick). RN A cleaned the sacrum/gluteal cleft wound with normal saline and 4 X 4 dressings. RN A measured the wound and said 4.0 X 7.0 centimeters. RN A then applied all of the Santyl from one medicine cup throughout the entire wound. RN A cleaned the left buttock wound with normal saline and 4 X 4 dressings. RN A measured the wound and said 9.0 X 4.0 centimeters. RN A applied all the Santyl from another medicine cup and spread throughout the entire wound (being more than a nickel thick). RN A placed a large self-adhesive dressing that covered all the wounds. Resident #302 was positioned on her back and RN A used wet cleansing disposable cloths and cleaned the left outer labia, wiping using a downward stroke. With a clean cloth RN A wiped the center of the vagina using a downward stoke and repeated this process two more times. RN A did not open Resident #302's labias and thoroughly clean the vagina and did not clean R #302's buttocks from incontinent urine (exposing Resident #302 at risk for infection since she currently had an infection in her urine). Interview with Resident #302 on 12/14/17 at 11:00 a.m. revealed she stated she had pain to her wounds. Resident #302 asked LVN E for a pain pill. Resident #302 said she had not been offered a pain pill prior to wound care. Resident #302 stated she only felt pain to her wounds when they were touched/treated. Resident #302 said she was not able to reposition herself. Resident #302 said staff did reposition her daily but not every two hours. Resident #302 said staff repositioned her about every 3 1/2-4 hours. Resident #302 stated she knew it was 3-4 hours because she has a clock on her wall she looked at. During an interview on 12/14/17 at 11:08 a.m., LVN E revealed Resident #302 had not asked for any pain medication prior to wound care. LVN E said she had not offered any pain medication to Resident #302. When asked if Resident #302's mattress should have a fitted sheet and a cloth pad, LVN E said I did not notice that. Does she have a regular cloth pad? I did not notice the pad. She should not have the fitted sheet and she should have a thin barrier pad. No, the cloth pad is not the barrier pad. She should not have the least amount of linen underneath her to avoid friction and shearing or trauma to her wound. During an interview on 12/14/17 at 11:13 a.m. with RN A revealed she said Resident #302 should not have the fitted sheet and cloth pad on the air mattress. I've been educated that an air mattress should only have a thin breathable disposable barrier pad but this facility does not have any of those. The cloth pads block air flow and could cause moisture within the wound that could allow the skin to become macerated and worsen. During an interview on 12/14/17 at 12:33 p.m., LVN E revealed the resident admitted with pressure sores. LVN E reviewed the resident's hospital discharge record and said that she could not find any other for treatment or monitoring for the pressure sores. LVN E confirmed that she wrote the Nursing Home Admission report received from the hospital that said the resident has a stage 2 pressure ulcer. LVN E confirmed the nurse when the called the physician to reconcile the resident admitting medication, they should have informed the physician of the resident's pressure sores and see if he wanted to give orders to monitor/treat. LVN E confirmed that the only orders for the resident's pressure sores was started on 12/12/17 5 days after the resident admitted . LVN E confirmed that the resident's skin assessments were inconsistent in saying that the resident had skin impairment of pressure ulcers to the skin was within normal limits. LVN E confirmed that her Daily Nurses' note on 12/11/17 was wrong and should have accurately documented the wound and incision site. LVN E revealed the assessments and daily nurses' notes for 12/9-12/10 were inaccurate for saying the skin was within normal limits because the resident had pressure sores and still currently has them. Further interview on 12/14/17 at 1:16 p.m., with LVN E revealed she noticed that RN A did not open her labias to clean her vagina. Yes she should have opened her labias to thoroughly clean her. She did not clean her buttocks either and she should have especially since (Resident #302) has a contagious infection in her urine. I was nervous, next time I should speak up. Further interview with RN A on 12/14/17 at 4:11 p.m. revealed the facility did not have a copy of the Wound Care Specialist's Evaluation from Monday, 12/11/17. RN A said she just called the physician and was told the report had not been synced and would work on it. RN A said she had not noticed that the facility did not have a copy of the evaluation. RN A said the evaluation included the physician's assessment and/or recommendations. RN A said Normally we get the reports the next day, I don't know what happened this time. RN A stated that Santyl was an enzymatic debrider but did not do damage to healthy tissue but was recommended not to put on the healthy surrounding skin. RN A said the Sacrum/Gluteal Cleft pressure ulcer had significant slough in the wound bed as of Tuesday, 12/12/17. RN A stated the slough in that wound was no longer there yesterday. When RN A was asked if the physician normally ordered Santyl for wound beds without slough, RN A stated she would have to call the physician and ask if she wanted to change the treatment because it was not normally used for healthy tissue. RN A verified Resident #302's sacral wound had changed in condition by no longer having slough in the center of the wound bed since yesterday and had not consulted with Resident #302's physician to notify of the change and possible treatment change but she would inform her. RN A explained she did not know how to exactly measure nickel thick amount of Santyl so she just Put a little more than a thin layer. Interview with the DON on 12/14/17 at 5:30 p.m. revealed she stated Resident #302 was admitted on [DATE] with multiple pressure ulcers and a new R-BKA with 19 staples intact. The DON reviewed Resident #302's documents and verified there were no orders to monitor or treat the surgical site at right BKA incision, nor orders to treat the resident's pressure ulcers until 12/12/17. The DON stated she would expect the nurses to call the physician and verify orders to include monitoring or treatment of [REDACTED].#302's surgical incision. When the DON was asked about Resident #302's pressure ulcers she stated Each wound should be described as accurately as possible on their admission assessments and head to toe assessments/Weekly Pressure Ulcer Report. The DON reviewed the Daily Skilled Nurses Notes dated 12/09/17-12/10/17 and acknowledged that the note indicated that Resident #302's skin was Within Normal Limits then the DON said I do not agree with that entry because she had a couple of pressure ulcers and a surgical incision, it's not possible that her skin was within normal limits. The DON said the Daily Skilled Nurses Notes dated 12/11/17 revealed no detailed description of Resident #302's pressure ulcers or surgical incision and the note dated 12/12/17 revealed a Stage 2 to buttock but had no detail of the wound and did not indicate more than one wound, which the resident had. The DON stated the documentation on 12/14/17 indicated a Stage 3 to right buttock, a Stage 3 to left buttock and sacrum. The DON said the assessment indicated LTMA however, the DON said I don't know what that means, I'll have to ask RN A what she meant by that, she should know. The DON said through her review of all of Resident #302's documentation, she saw issues with staging of the pressure ulcers, identifying and measuring pressure ulcers as separate ulcers, no detailed description of the wounds, she should have a Wound Progress Record with detailed description of wounds. The DON said she could not track Resident #302's wound and stages because of missing information and inconsistent staging documented. The DON said she tracked the wounds in the facility by reviewing the measurements of the wounds. The DON said she would also look at the description of the wounds but since Resident #302 did not have a description of her wounds upon admission she could not tell what the wound looked like then. The DON said if there is no accurate assessment documented then it would be difficult to track the status of the wound or track whether the wound was getting better or worse. The DON said after reviewing the measurements of Resident #302's initial wound measurements in comparison to 12/14/17, Resident #302's wounds were getting bigger. It appears they have progressed. The DON said the treatment nurse had years of wound care experience and had been wound care certified within the last 3 1/2 months. The DON said she monitored the treatment nurse and wounds by participating in weekly at risk (WAR) meetings where residents at risk for pressure ulcers were discussed. The DON said the treatment nurse had requested her assistance on several occasions when she had a question. The DON said she last conducted observations of the wounds in the facility was approximately one month ago. The DON said she had not seen Resident #302's wounds. The DON said the physician should send in their evaluations and usually took a day. The DON said the treatment nurse should have called the physician and attempted to retrieve the physician's evaluation. The DON said from her experience, Santyl was a chemical debrider that shouldn't be used on healthy granulated tissue and should only be used for slough or necrotic tissue. The DON said if the nurse had seen a change in the wound that may no longer need the Santyl then the nurse should call the physician and describe the wound and ask the physician if she wanted to continue current treatment or change the treatment. The DON said if the resident no longer had slough then the resident would no longer need the treatment for [REDACTED]. The DON stated We are not supposed to put anything on air mattresses except a draw sheet or a thin paper disposable pad, which this facility does not use. Too many layers of linen can cause blockage of air flow which would allow the resident to have moisture build-up that causes skin breakdown and worsening of the wounds. The DON stated if staff did not thoroughly provide incontinent/perineal care, the resident would be at risk of infection and for Resident #302, since she already had a urine infection and she was incontinent, she would be at risk for her current infection to extend into her wounds. The DON stated RN A needs immediate training. Observation on 12/14/17 at 08:32 p.m. the surveyor accompanied the DON, RN A, and ADON M into Resident #302's room. Resident #302 was informed she was going to be turned to her right side, Resident #302 attempted to turn herself but after a couple of attempts, was unsuccessful. Resident #302 was turned to her right side by the DON and RN A; The DON positioned herself on the right side of R #302 and RN A on the left side. The DON assisted Resident #302 to stay on her right side by supporting the resident's back. R #302 did not have a dressing on her buttocks and sacral wounds. RN A began to measure Resident #302's right buttock and said 10.0 X 4.0, no 3.5. 10.0 X 3.5 centimeters. When RN A was asked to describe the wound she stated It's a Stage 3, it could be an Unstageable and eventually a Stage 2 because it doesn't have a lot of depth. RN A applied Santyl throughout the entire wound bed.(RN A spoke of back staging which per the National Pressure Ulcer Advisory Panel-NPUAP, should not occur). The DON stated I'd wait for the physician to stage, we will describe it to her. The DON instructed RN A that the left buttock had two separate areas and to measure them separately. RN A measured and said Left superior buttock is 0.9 X 2.2 centimeters. The DON described the wound and said It appears like a Stage 2, it has a pink wound bed, no odor, no drainage, and surrounding skin is dark. RN A applied Santyl throughout the entire wound bed. RN A measured and said Left inferior left buttock- 7.3 X 6.0. The DON described the wound as It has yellow slough, its moist, and has dark surrounding skin. RN A applied Santyl throughout the entire wound bed. The DON raised Resident #302's left buttock exposing the wound identified as the Sacrum. RN A walked to the wall beside the door and with donned dirty gloves, grabbed a handful of clean gloves and placed them on the bedside table on her clean supply field and used them to continue wound care. RN A measured and said 3.8 X 6.4 centimeters. RN A applied Santyl throughout the entire wound bed and then applied one large border foam dressing that covered all the wounds. RN A was asked if she cleaned the wounds prior to her applying treatment to the wounds and she replied No I didn't. I did not clean them, I should have. The aides cleaned her when they gave her a bed bath just before we walked in her. RN A was asked if the aides could clean wounds as per the physician prescribed and she responded No they can't. The DON or ADON did not intervene as RN A continued to apply treatment and dressings to Resident #302's wounds without cleaning the wounds first. Record review on 12/15/17 at 9:09 a.m. of Resident #302's Progress Notes in the EMR, revealed there were no notes on the resident's pressure ulcers or surgical incision except on 12/8/17 and 12/14/17. During an interview on 12/14/17 at 9:22 p.m., the DON revealed that they had just gotten out of the room supervising RN A with Resident #302's wounds. DON revealed that the resident just got a shower and the RN A performed wound treatment. The DON revealed RN A did not clean the wounds during the treatment, but just applied the medication and dressing. During an interview on 12/15/17 at 8:22 a.m., Physician I revealed she was the Wound Care Specialist that was consulted for initial evaluation of Resident #302 on 12/11/17. Physician I said she clustered the two wounds on Resident #302's left buttock because they were within the same proximity on the left buttock. Physician I reported the left buttock wound measured 10.5 X 5.0 centimeters. Physician I said she debrided the left and right buttock eschar/slough. Physician I said she ordered a nickel thick amount of Santyl on each wound due to the resident having slough in the wound bed. Physician I said she had no concern with a little of Santyl getting on red healthy tissue but it should be minimized because it beats up the tissue. Physician I stated Resident #302's current treatment was to clean with normal saline or wound cleanser, apply a nickel thick amount of Santyl to remove the slough, and Calcium Alginate to keep the wound moistened but stabilizing blood flow. Physician I was asked if the facility did not have her evaluation for reference how would the facility be aware of her orders; Physician I said The treatment nurse knows because I verbally told her the orders when I was there. I work with the treatment nurse on a one to one basis as I do the assessments. Physician I said she was not aware that her evaluation had not uploaded into the facility's electronic system until the facility called her on 12/14/17 asking for it. Physician I said the facility could have called her sooner. Physician I said If staff are not following the physician's orders [REDACTED]. During an interview on 12/15/17 11:25 a.m., Clinical Specialist BB revealed that he started working with the RN A at 8 a.m. and trained her by videos and observed training. Clinical Specialist BB revealed that he did not observe Resident #302's wound. Clinical Specialist BB revealed that you usually want to keep wounds separate if there is skin in between and measure two seperate with skin in between as one. Clinical Specialist BB confirmed that RN A was back on the floor and completing assessments and seeing residents. Record review of Resident #302's Braden Scale Assessments, dated 12/15/17, revealed a score of 12 meaning the resident was a high risk for pressure ulcers. Record of review of Resident #302's Wound Care Specialist Initial Evaluation, dated 12/11/17, revealed: -Unstageable (Due to necrosis) of the Right Buttock (site 2): Etiology: Pressure. 7.0 X 2.8 X not measurable depth cm, light serous exudate, 70% thick adherent black necrotic tissue (eschar)/slough, 30% granulation tissue. Surgical excisional debridement performed. Recommendation: Off-load wound, reposition per facility protocol. Dry protective dressing Calcium Alginate and Santyl daily. -Unstageable (Due to Necrosis) of the Left Buttock (site 3): Etiology: Pressure. 10.5 X 5.0 X not measurable depth cm, light serous exudate, 40% thick adherent black necrotic tissue (Eschar)/slough, 60% granulation tissue. Surgical excisional debridement performed. Recommendation: Off-load wound, reposition per facility protocol. Dry protective dressing Calcium Alginate and Santyl daily. -Unstageable (Due to Necrosis) Sacrum (site 4): Etiology: Pressure. 3.5 X 3.0 X not measurable depth cm, moderate serous exudate, 10% thick adherent black necrotic tissue (Eschar)/slough, 90% granulation tissue. Surgical excisional debridement performed. Recommendation: Off-load wound, reposition per facility protocol. Dry protective dressing Calcium Alginate and Santyl daily I discussed plan of care with the wound care nurse and patient and why sheets do not allow low air loss mattresses to function properly. I also discussed plan of c