Every finding on record at Langley Post Acute

Based on observation and staff interview, the facility staff failed to prepare, distribute, and serve food in a manner that would prevent foodborne illnesses. The wash cycle of the dish machine was not working properly. The findings include: The facility staff failed to ensure the dish machine was in working order. The wash cycle failed to reach a temperature of 120 degrees. On 10/01/24 at approximately 9:50 a.m., the surveyor observed two dietary staff (dietary employee #1 and #2) running the dish machine in the facility kitchen. The surveyor approached the staff and observed these staff to run the dish machine three additional times. During these observations the wash cycle never went over 112 degrees. The directions on the dish machine read minimum wash cycle 120 degrees. The dietary manager identified this machine as a low temperature machine and stated they would call maintenance and hand wash the dishes. On 10/01/24 at 12:00 p.m., the Maintenance Director (MD) was observed working on the dish machine. The MD stated they had cut the temperature up on the hot water heater and cleaned the temperature sensor. During this observation the wash cycle temperature was observed to reach 120 degrees. During an end of the day meeting on 10/01/24 at 5:15 p.m., with the [NAME] President of Operations, Director of Nursing, [NAME] President of Nursing Services, and Director of Clinical Support, the issue with the dish machine not reaching the correct wash temperature was reviewed. The surveyor attempted to interview dietary employee #1 on 10/03/24 at 9:10 a.m. but was unsuccessful. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, facility document review, facility staff failed to provide written notice of transfer for 2 of 18 current residents in the survey sample. (Resident #19 and Resident #36). The findings were: 1. For Resident #19, the facility staff failed to provide the resident representative a written notice of transfer when the resident was transferred to the hospital on 08/02/24 or 09/25/24. The minimum data set assessment with an assessment reference date of 08/25/24 coded the resident a brief interview for mental status (BIMS) score of 11 out of 15 indicating moderately impaired cognition (Section C - cognitive patterns). During a review of Resident #19's clinical record, progress notes read the resident was transferred to a hospital on both 08/02/24 and 09/25/24. A licensed practical nurse (LPN) note dated 08/02/24 at 2:56 a.m. read 911 in to [sic] transport resident to (hospital initials omitted) ER at 2:40 AM. Message was left on (family member name omitted) answering machine asking him to call the facility at his earliest convenience. Another LPN note dated 09/25/24 at 5:10 p.m. read Resident presenting objective Signs [sic] that she may have Sepsis and is Hypotensive with a B/P of 87/61. Son is aware and insist [sic] although the Resident is Comfort Measures that the Resident be sent to the hospital for Eval. and Treatment. Order received from MD to send the Resident 911. 515 pm.[sic] 911 Transport Team in. Resident taken to (hospital name omitted) for treatment. The surveyor was unable to find evidence of written notification to Resident #19's representative of the transfer for both dates. On 10/03/24 at 11:05 a.m., the facility's [NAME] President of Nursing Services and [NAME] President of Quality were interviewed. Both employees reported they were unaware of anyone sending resident representatives written notification of transfer/discharges for emergency transfers, in general. The V.P. of Quality provided the facility's employee with the title of navigator who stated that after residents were admitted to a hospital, she calls the responsible party (RP) and informs them of the bed hold information. The RP usually comes to the facility to pay for the bed hold if they want. The navigator denied sending any written information to residents' representatives regarding transfers to hospitals. On 10/03/24 in the afternoon, the VP of Quality provided documents she stated would be what was sent with the emergency medical services when Resident #19 was transferred to the hospital on both 08/02/24 and 09/25/24. The documents did not contain specific information about where the resident was being transferred to or for what reason. The VP of Quality acknowledged the documents did not contain that specific information. The concern regarding no evidence of written notification to the resident representative of Resident #19's transfer to the hospital on 08/02/24 and 09/25/24 was discussed with the Director of Clinical Services, Director of Nursing, [NAME] President of Quality, [NAME] President of Nursing Services and [NAME] President of Clinical Affairs on 10/03/24 at 3:37 p.m. No further information was provided prior to the exit conference. 34307 2. For Resident #36 the facility staff failed to provide written notice of transfer to the hospital. Resident #36's face sheet listed diagnoses which included but not limited to sepsis, heart failure and dementia. Resident #36's most recent minimum data set with an assessment reference date of 09/20/24 assigned the resident a brief interview for mental status score of 7 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively intact. Resident #36's clinical record was reviewed and contained a nurse's progress note dated 09/25/24 at 12:29 am which read in part, 11:10 pm-resident lying in the bed with eyes open, and eyes are rolling back in her head. 02 sats are 88% on room are, vital signs are 121/78-102.9, 70, 24 (blood pressure, temperature, pulse, respirations). Resident was put on 2 liters of oxygen, and 02 came up to 94%. She had high fever, difficult breathing and altered mental status. 911 called. MD made aware. Attempted to notify son but no answer received so voice message left for him to call facility. Did talk to resident's sister who wanted resident transferred to . (name omitted) and stated she would meet them there. Surveyor reviewed resident's clinical record and could not locate any information that a written notice of transfer was provided to the resident's responsible party (RP). Surveyor spoke with the vice-president of quality and vice-president of nursing services on 10/03/24 at 11:05 am regarding Resident #36's hospital transfer information. These two staff provided surveyor with a copy of Transfer Clinical Summary dated 09/25/24 which included a Notice of Transfer. This portion of the transfer summary did not include a date, location resident was transferred to, or reason for transfer. Vice-president of quality stated this form is only sent to the receiving facility. Surveyor spoke with the resident navigator on 10/03/24 at 11:20 am. Resident navigator stated they were not providing written notification of transfer/discharge to the resident's RP when a resident is sent out to the hospital. Surveyor requested and was provided with a facility policy entitled, Admission, Transfer & Discharge Rights Policy which read in part, Notice before transfer. Before a resident is transferred or discharged , the facility will notify the resident, and if known, the resident representative of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. This notice shall be in writing and shall include the reason for transfer. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. The concern of not providing written notification of transfer/discharge to the resident's RP was discussed with the vice-president of nursing services, vice-president of quality, and director of nursing on 10/03/24 at 3 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review the facility staff failed to ensure that a resident and/or the resident representative had the opportunity to develop an Advanced Directive for 1 of 18 current residents, Resident #16. The findings include: The facility staff failed to provide evidence that they had offered Resident #16 and/or the resident representative the opportunity to develop an Advance Directive. Resident #16's diagnoses included chronic respiratory failure and adult failure to thrive. Section C (cognitive patterns) of Resident #16's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 07/09/24 included a brief interview for mental status (BIMS) score of 10 out of a possible 15 points. Per the MDS manual a 10=moderate cognitive impairment. During the record review the surveyor was unable to locate any information to indicate this resident and/or the resident representative had been offered the opportunity to develop an Advance Directive. On 10/02/24 at 4:35 p.m., during an end of the day meeting with the Director of Clinical Support, [NAME] President of Quality, Director of Nursing, and [NAME] President of Nursing Services the issue with the missing advance directive information was reviewed. On 10/03/24 at 8:40 a.m., the [NAME] President of Quality stated they were unable to locate advance directive information for this resident. The facility staff provided the surveyor with a copy of a policy titled, ADVANCE DIRECTIVES. This policy read in part, Advanced Directives will be discussed with resident and/or family member upon admission or as soon as clinically appropriate so the resident's wishes, with respect to life prolonging treatments, can be documented in the medical record . No further information regarding this issue was provided to the survey team prior to the exit conference.

2. For Resident #19, the facility staff failed to provide the resident representative a written notice which specifies the duration of the bed hold policy when the resident was transferred to the hospital on 08/02/24 or 09/25/24. The minimum data set assessment with an assessment reference date of 08/25/24 coded the resident a brief interview for mental status (BIMS) score of 11 out of 15 indicating moderately impaired cognition (Section C - cognitive patterns). During a review of Resident #19's clinical record, progress notes read the resident was transferred to a hospital on both 08/02/24 and 09/25/24. A licensed practical nurse (LPN) note dated 08/02/24 at 2:56 a.m. read 911 in to [sic] transport resident to (hospital initials omitted) ER at 2:40 AM. Message was left on (family member name omitted) answering machine asking him to call the facility at his earliest convenience. Another LPN note dated 09/25/24 at 5:10 p.m. read Resident presenting objective Signs [sic] that she may have Sepsis and is Hypotensive with a B/P of 87/61. Son is aware and insist [sic] although the Resident is Comfort Measures that the Resident be sent to the hospital for Eval. and Treatment. Order received from MD to send the Resident 911. 515 pm.[sic] 911 Transport Team in. Resident taken to (hospital name omitted) for treatment. The surveyor was unable to find evidence of written notification to Resident #19's representative of the facility's bed hold policy for both dates. On 10/03/24 at 11:05 a.m., the facility's [NAME] President of Nursing Services and [NAME] President of Quality were interviewed. Both employees reported they were unaware of anyone sending resident representatives written notification of the bed hold policy for emergency transfers, in general. The V.P. of Quality provided the facility's employee with the title of navigator who stated that after residents were admitted to a hospital, she calls the responsible party (RP) and informs them of the bed hold information. The RP usually comes to the facility to pay for the bed hold if they want. The navigator denied sending any written information to residents' representatives which specifies the duration of the bed hold policy when the resident was transferred to the hospital on 08/02/24 or 09/25/24. The concern regarding no evidence of written notification of the bed hold policy provided to Resident #19's representative when the resident was transferred to the hospital on 08/02/24 and 09/25/24 was discussed with the Director of Clinical Services, Director of Nursing, [NAME] President of Quality, [NAME] President of Nursing Services and [NAME] President of Clinical Affairs on 10/03/24 at 3:37 p.m. No further information was provided prior to the exit conference. 34307 Based on staff interview, clinical record review and facility policy review the facility staff failed to provide written notice of bed hold policy for 2 of 18 residents, Resident #36 and Resident #19. The findings included: 1. For Resident #36 the facility staff failed to provide written notice of bed hold. Resident #36's face sheet listed diagnoses which included but not limited to sepsis, heart failure and dementia. Resident #36's most recent minimum data set with an assessment reference date of 09/20/24 assigned the resident a brief interview for mental status score of 7 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively intact. Resident #36's clinical record was reviewed and contained a nurse's progress note dated 09/25/24 at 12:29 am which read in part, 11:10 pm-resident lying in the bed with eyes open, and eyes are rolling back in her head. 02 sats are 88% on room are, vital signs are 121/78-102.9, 70, 24 (blood pressure, temperature, pulse, respirations). Resident was put on 2 liters of oxygen, and 02 came up to 94%. She had high fever, difficult breathing and altered mental status. 911 called. MD made aware. Attempted to notify son but no answer received so voice message left for him to call facility. Did talk to resident's sister who wanted resident transferred to . (name omitted) and stated she would meet them there. Surveyor reviewed resident's clinical record and could not locate any information that information related to bed hold was provided to the resident/responsible party. Surveyor spoke with the vice-president of quality and vice-president of nursing services on 10/03/24 at 11:05 am regarding Resident #36's hospital transfer information. These two staff provided surveyor with a copy of Transfer Clinical Summary dated 09/25/24 which included a Bed Hold Policy Notice. This notice did not include information on duration of bed hold or information on reserve payment. Surveyor spoke with the resident navigator on 10/03/24 at 11:20 am. Resident navigator stated they call the resident's RP if the resident is admitted to the hospital, with information on duration of bed hold and payment amount. Resident navigator stated if family want to do a bed hold, they come into the facility and sign the agreement, and pay for the bed hold. Surveyor requested and was provided with a facility policy entitled, Admission, Transfer & Discharge Rights Policy which read in part, Notice of bed-hold policy and return. If a resident requires transfer to an acute hospital, the facility will offer the resident the opportunity of electing to have the bed held. Upon admission, the facility will notify the resident or the resident's representative of the bed-hold option. If the bed-hold option is exercised, the resident or the resident's representative is liable to pay reasonable charges, not to exceed the resident's daily room rate, for the bed-hold period. Before a resident is transferred to a hospital or goes on therapeutic leave, the facility will provide written information to the resident or resident representative specifying: 2. A notice that includes the items provided in the Notice of Transfer and Contents of Notice sections. The concern of not providing written notification of bed hold to the resident/RP was discussed with the vice-president of nursing, vice-president of quality and director of nursing on 10/03/24 at 3 pm. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, the facility staff failed to ensure narcotics were secured in a permanently affixed compartment on 1 of 2 units, the [NAME] unit. The findings include: The facility staff failed to provide a permanently affixed compartment for narcotics on the [NAME] unit On 10/02/24 at 3:40 p.m., the surveyor and Licensed Practical Nurse (LPN) #3 checked the medication refrigerator on the [NAME] unit. This refrigerator contained a locked black metal box. The surveyor was able to remove this box from the refrigerator and place it on the counter. LPN #3 unlocked the box, and it was observed to contain 5 vials of 1 ml Lorazepam. On 10/02/24 at 4:05 p.m., the [NAME] President of Quality provided the surveyor with a copy of their policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles. This policy read in part, Medications, biologicals, syringes, and needles are stored under proper conditions as directed by state and federal regulations and manufacturer guidelines to ensure their stability, quality, safety, and security . On 10/02/24 at 4:35 p.m., during an end of the day meeting with the Director of Clinical Support, [NAME] President of Quality, Director of Nursing, and [NAME] President of Nursing Services the issue with the unsecured narcotic box was reviewed. On 10/03/24 at 8:40 a.m., the [NAME] President of Quality stated they had secured the narcotic box. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to assist residents in obtaining dental care from an outside source for 1 of 18 sampled residents, Resident #1. The findings included: For Resident #1, the facility staff failed to obtain a dental consult. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Dementia, Spastic Hemiplegia Cerebral Palsy, Epilepsy, and Thrombocytopenia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/22/24 assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of 15 indicating the resident was severely cognitively impaired. A review of Resident #1's clinical record revealed the following documentation: A nursing progress note dated 5/30/23 at 3:19 PM read Resident [adult child] in facility and said [their] mom's mouth hurts. Writer let PA [physician's assistant] [name omitted] know . Resident #1 was seen by the PA the following day on 5/31/23. The progress note read in part On exam, [his/her] mouth is bloody as [he/she] just received oral care and gums are bleeding .Gingivitis .referral for dental evaluation . Resident #1 was again seen by the PA on 6/02/23, the progress note read in part .F/u [follow-up] gingival Bleeding - No bleeding today but gums are still very irritated. The RU [right upper] gingival line is swollen with white plaque . Resident #1 was seen by the PA on 6/05/23, the progress note read in part .F/u gingival Bleeding - bleeding still present per CNA [Certified Nursing Assistant] this morning. Excessive plaque and gingival irritation along with thrombocytopenia 2/2 [secondary] to Keppra makes them bleed more than they typically would .gums inflamed, caries present, white plaque on right lateral incisor .Gingivitis .awaiting referral to dentist . On 10/03/24, surveyor reviewed Resident #1's clinical record and was unable to locate evidence of a dental referral for the resident. On 10/03/24 at 9:50 AM, surveyor spoke with the Director of Nursing (DON) regarding the dental referral. The DON stated an order for the dental consult was never entered into the record by the provider and that was how staff were made aware to schedule an appointment and arrange transportation. Surveyor spoke with the PA via telephone on 10/03/24 at 1:48 PM regarding the dental referral. PA stated Resident #1 had a lot of buildup and their mouth was getting worse, but Peridex was helping. PA stated it was difficult to get a dental appointment and transportation, but they needed to at least attempt it. PA stated they did not know what happened on the other side of a referral after the order goes in, but the process has improved by leaps and bounds as she now notifies the person responsible for setting up consults when she places an order. PA stated prior to this change she had noticed a couple referral orders did not go through. Surveyor requested and received the facility policy titled Administration Policy with a reviewed/revised date of 7/21/23 which read in part .Services not provided by a qualified professional employee of the facility shall be furnished to residents by a person or agency outside the facility under an arrangement. Arrangements for services to residents specify (in writing) that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing the services. The facility also assumes responsibility for the timeliness of the services provided under an arrangement. On 10/03/24 at 3:36 PM, the survey team met with the Administrator, [NAME] President (VP) of Clinical Affairs, VP of Quality, VP of Nursing Services, DON, and Director of Clinical Support and discussed the concern of staff failing to obtain a dental consult for Resident #1. No further information regarding this concern was presented to the survey team prior to the exit conference on 10/03/24.

Based on staff interview, clinical record review and facility document review, the facility staff failed to maintain a complete and accurate medical record for one of 35 residents in the closed record sample, resident # 311. The findings included: Resident # 311's diagnoses included but were not limited to muscle weakness, osteoarthritis, bradycardia, and dementia. The minimum data set (MDS) with an assessment reference date of 11/29/22 assigned the resident a brief interview for mental status score of 3 out of 15 indicating the resident had severe cognitive impairment. According to the MDS data the resident was dependant for transfers and non-ambulatory without at least extensive assistance. The care plan for resident # 311 was reviewed. A problem statement read, (resident) has a potential to fall (High Risk) R/T: Reduced mobility, History of falls and poor safety awareness, Impulsive behavior, Dementia- cognitive impairment, restlessness. During a review of the progress notes, the following was noted on 1/16/24 at 6:40 AM, resident up through the night and continue to try and get up out of chair resident did not sleep at all. resident place at nursing station will continue to assess. The next note was made on 1/19/23 at 4:29 PM and read, Called to the room by patients Certified Aide to assess patients left arm. Upon observation her arm was edematous and bruised just below the shoulder to the elbow. Upon lifting her arm laterally with support patient leaned towards the left arm and showed signs of discomfort. Director of Nursing made aware and undersigned paged on call medical service. An order was given for an x-ray of the arm and a progress note dated 1/20/23 at 1:19 AM that read, Undersigned called Dynamic Mobile Imaging for patients results of left shoulder x-ray. It was reported that the patient has an acute fx and that the results will be faxed over first then called to staff. Night shift nurse made aware of pending fax and that imaging service will call when faxing as been processed. The resident was sent per physician's order to the emergency room at a local hospital and returned to the facility the same day with a sling on the arm and an order to follow up with an orthopedist. On 10/2/24 at 10:55 AM this surveyor interviewed the Director of Nursing (DON) who recalled resident #311 and this incident. They stated, I wasn't notified of the fall until 1/19/23 when the nurse came and got me because she was going to do a blood pressure and saw the swelling and bruising. She said to me well, you know she fell the other day. I told her no, there was nothing in the notes about a fall. I went and looked at the resident and did an investigation and that is what I attributed the injury to. She had a history of fragility fractures and osteoporosis. The injury wasn't suspicious because it was in a location that would be vulnerable to fracture from a fall especially considering her osteoporosis. The investigation conducted by the facility was provided. The investigation included a time line, witness statements, a copy of the x-ray report and a summary that read in part, It was determined that the injury was caused by the fall that occurred on 1/15-1/16/23 11-7 shift, this incident was not considered reportable due to that reason. This surveyor reviewed the policy entitled, Fall Management which read in part, Documentation: All falls are documented in the resident record, to include if applicable, the following objective and factual statements regarding: Circumstances at time of fall- For an unwitnessed fall, the record reflects the resident's statement with quotes if the resident is able to state what happened- For an unwitnessed fall, notes indicate the resident's location, position, and condition upon staff arrival-For an unwitnessed fall, notes indicate the resident's activity prior to the fall and other precipitating factors- Results of assessment and condition of the resident- care rendered- Notification of physician, resident representative and emergency room transport company (if utilized)- Physician orders- Interventions implemented to minimize future falls. 10/02/24 02:13 PM this surveyor interviewed Licensed Practical Nurse (LPN) # 1. They stated they were the nurse caring for resident # 311 on the night of 1/16/23. They stated, It was on 11-7 I was at the desk and she came scooting out in the hall on her bottom. We put her in a chair and left her at the desk because she was very active all night. I assessed her there wasn't any bruising or swelling her ROM was good, she was able to lift her arms and her grips were equal. When asked to confirm there were no injuries assessed directly after the fall they stated, no, she wasn't injured that I could tell. Surveyor asked if resident could have indicated if they were in pain and they stated, she could answer yes or no questions and I asked her, she didn't say anything about pain. She didn't show any grimaces or anything and had a nice firm grip. We had to keep repositioning her in the chair all night because she kept trying to get up and she wasn't able to walk or anything. When asked if she notified the RP or MD she stated, It was really late, I waited until morning. If I had known there was an injury, I would have called the on call. When asked about the lack of any notes surrounding the fall, they stated, I was just so preoccupied with keeping her safe, she was really agitated and continuously trying to get up and that took up most of my night. I honestly never even remembered that I didn't put the first note in about the fall. On 10/3/24 at 3:37 PM the survey team met with the [NAME] President of Quality the DON and the [NAME] President of Nursing Services. This concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview and facility document review, the facility staff failed to provide evidence of a minimum of 12 hours of annual training for 1 of 5 sampled Certified Nursing Assistants (CNA), CNA #5. The findings included: The facility staff were unable to provide evidence of at least 12 hours of annual training for CNA #5. On 10/03/24, surveyor requested evidence of CNA #5's staff trainings completed since hire. CNA #5 had been employed with the facility since September 2023. On 10/03/24 at 2:20 PM, surveyor spoke with the [NAME] President (VP) of Quality and VP of Nursing Services regarding CNA #5's training records. VP of Quality stated they could not locate any training records since hire for CNA #5. VP of Nursing Services stated the CNA had been removed from the schedule and could not return to work until all required trainings were completed. Surveyor requested and received the Facility assessment dated [DATE] which read in part .Required in-service training for nurse aides. In-service training must: - Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year . On 10/03/24 at 3:36 PM, the survey team met with the VP of Quality, Director of Clinical Support, VP of Nursing Services, VP of Clinical Affairs, and the Director of Nursing and discussed the concern of CNA #5 failing to receive at least 12 hours of annual training. No further information regarding this concern was presented to the survey team prior to the exit conference on 10/03/24.

Based on staff interview and facility document review, the facility staff failed to provide evidence of staff education regarding activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, abuse prevention, procedures for reporting incidents of abuse and dementia management for 1 of 5 staff members reviewed, Certified Nursing Assistant (CNA) #5. The findings included: The facility staff were unable to provide evidence of staff education regarding prevention, identification, and procedures for reporting resident abuse and dementia management for CNA #5. On 10/03/24, surveyor requested evidence of CNA #5's staff education completed since hire. CNA #5 had been employed with the facility since September 2023. On 10/03/24 at 2:20 PM, surveyor spoke with the [NAME] President (VP) of Quality and VP of Nursing Services regarding CNA #5's education records. VP of Quality stated they could not locate any training records since hire for CNA #5. VP of Nursing Services stated the CNA had been removed from the schedule and could not return to work until all required trainings were completed. Surveyor requested and received the facility policy titled Resident Abuse Prevention with a last reviewed date of 11/07/22 which read in part .Upon hire and at least annually, staff will be trained regarding abuse, neglect, misappropriation of resident property, and exploitation . The Facility assessment dated [DATE] read in part .Required in-service training for nurse aides. In-service training must .Include dementia management training and resident abuse prevention training . On 10/03/24 at 3:36 PM, the survey team met with the VP of Quality, Director of Clinical Support, VP of Nursing Services, VP of Clinical Affairs, and the Director of Nursing and discussed the concern of CNA #5 failing to receive education regarding resident abuse and dementia management. No further information regarding this concern was presented to the survey team prior to the exit conference on 10/03/24.

Based on observation, staff interview, clinical record review and facility document review, it was determined that facility staff failed to revise the care plan for 3 of 28 residents in the survey sample to reflect that Resident #26 was receiving hospice services; Resident #12's Foley catheter had been discontinued; and Resident #4, acquired left heel pressure ulcer The findings included: 1. The facility staff failed to revise the comprehensive care plan for to reflect hospice services for Resident #26. Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #26's most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 3/5/21. Resident #26 was coded as being severely impaired in the ability to make daily decisions on the Staff Interview for Mental Status Exam. Resident #26 was coded in Section O (Special Treatments and Programs) as receiving hospice services. Review of Resident #26's clinical record revealed that she was admitted to hospice services on 3/1/21. The following social services note was documented: Resident effective with hospice services through (Name of Hospice Provider) as of 3/1/21. Review of Resident #26's clinical record revealed a Plan of Care Order dated 3/2/21 from the Hospice provider. Further review of Resident #26's clinical record revealed that Resident #26 was on comfort measures prior to being placed on Hospice services. Her order for comfort measures started on 6/28/18. Review of Resident #26's comprehensive care plan dated 6/28/18 through present showed a comfort measures care plan that documented in part, the following: (Name of Resident #26) and/or family has requested certain treatments be withheld related to residents current medical condition. No IVs, No hospitalization s, No Tube Feeding, No Lab Work, No Weights .(Name of Resident #26) will not receive those measures decided upon in accordance with the resident and/or family request .Educate resident & (and) family about Hospice if desired. There was no evidence that Resident #26's comprehensive care plan had been revised to reflect her new order for Hospice Services. On 4/29/21 at 3:15 p.m., an interview was conducted with Registered Nurse #1, the MDS nurse. When asked if a resident was receiving hospice services if that should be reflected on the comprehensive care plan, RN #1 stated that Hospice Services would be added to the care plan. When asked the timeframe for revising the care plan to reflect Hospice Services; RN #1 stated that she would first complete a significant change MDS assessment and then create a Hospice care plan within 14 days. When asked what interventions would be included on a Hospice care plan, RN #1 stated that the care plan would specify care and services the facility would provide versus what the Hospice provider would do. RN #1 stated that the Hospice provider also provided a care plan of the care and services they provide. When asked if the Resident's comprehensive care plan should still be revised to reflect hospice services even if the Hospice provider sends their own care plan, RN #1 stated, Yes. On 4/29/21 at 3:26 p.m., RN #1 confirmed that Resident #26's comprehensive care plan was not revised to reflect that she was utilizing Hospice Services. RN #1 stated that she was going to update Resident #26's care plan. On 4/29/21 at 5:52 p.m., the facility Administrator and the DON (Director of Nursing) were made aware of the above concerns. 2. The facility staff failed to revise the comprehensive care plan for Resident #12 to include the removal of a Foley catheter. Resident #12 was admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's Minimum Data Set (MDS) an admission assessment with an Assessment Reference Date (ARD) of 02/15/21 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. In addition, the MDS coded Resident #12 total dependence of two with transfer, total dependence of one with bathing, extensive assistance of one with bed mobility, dressing, toilet use and personal hygiene for Activities of Daily Living care. The resident was coded for Indwelling catheter under section (H) Bowel and Bladder. Resident #12's comprehensive care plan created on 02/22/21 documented Resident #12 at risk for infection related to indwelling catheter. The goal: will remain free of urinary tract infection during period of catheterization. Some of the interventions to manage goals include but not limited to: clean around catheter with soap and water/provide catheter care, keep tubing below level of the bladder and free of kinks or twists, record output per shift and change drainage bag pre policy/order. The care plan was not revised to include the removal a Foley catheter. During the initial tour on 04/27/21 at approximately 12:25 p.m., Resident #12 was observed without a Foley catheter in place. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During the review of Resident #12's clinical note dated 03/17/21 read in part: catheter removed without difficulty. After the review of Resident #12's clinical notes from 03/17/21 until 04/29/21 did not reveal Resident #12 had an indwelling Foley catheter in place. A phone interview was conducted with the Director of Nursing (DON) on 04/29/21 at approximately 10:52 a.m. The DON reviewed the care plan and clinical record for Resident #12. After reviewing the clinical record the DON stated, Resident #12's Foley was removed on 03/17/21; the care plan does not reflect the removal of the Foley catheter. When asked who was responsible for updating/revising Resident #12's care plan, she replied, It's a team effort; the MDS Coordinator, Assistant Director of Nursing (ADON) and Myself are responsible for revising Resident #12's care plan. The DON said Resident #12's care plan should not include an indwelling Foley since it was removed on 03/17/21. The facility's Administration team was informed of the finding during a debriefing on 04/29/21 at approximately 6:00 p.m. The facility staff did not present any further information about the findings. The facility's policy titled: Person-centered Baseline and Comprehensive care Plan - last reviewed: 05/17/18. Procedures read in part: The care plan is reviewed and updated as needed. Definition: A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. Reference www.NIH.gov (National Institutes of Health). 3. The facility staff failed to revise Resident #43's comprehensive care plan for pressure ulcers. Resident #43's most recent Minimum Data Set assessment was an admitted d 3/29/21 and coded the resident with a score of 12 out of a total score of 15 which indicated she was moderately impaired in the cognitive skills for daily decision making. Resident #43 was coded always incontinent of bowel and bladder. Resident #43 was assessed to require extensive assistance of 2 for transfers, extensive assistance of 1 for dressing, toilet use, and totally dependent on one staff for bathing. The wheelchair was Resident #43's primary mode of mobility. Resident #43 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #43 was coded at risk for pressure ulcers based on the formal assessment, Braden scale and had a stage 1 or greater over a bony prominence. Resident #43 was coded for unhealed pressure ulcers; one stage 1, 2 stage 2's (admitted ) and 2 unstageable pressure ulcers (admitted ). Resident #43 was assessed for pressure reducing devices, pressure ulcer care, surgical wound care and application of ointments and medications other than feet. The care plan dated 3/31/21 identified there was a stage 1, stage 2 pressure ulcer (PU), but the care plan did not identify the location of the stage 1 or stage 2 PU's. The care plan did not address the unstageable PU's. A preventative pressure ulcer care planning was dated 3/31/21, after Resident #43 acquired a left heel fluid filled blister on 3/30/21. According to the wound documentation forms dated 3/24/21, Resident #43 was admitted with the following pressure ulcers, documentation by the wound care nurse, Registered Nurse (RN) #2: -Left lateral medial foot with *eschar, . -Left medial knee with eschar, 4.5 cm x 3.5 cm. -Stage 2 to sacrum (3.5 cm x 1.0 cm x 0.1) and left buttock (3.5 cm x 1.5 cm x 0.1 cm). None of these areas were identified on the care plan. On 3/30/21 RN #2 documented on the wound documentation form that Resident #43 acquired a left heel fluid filled blister, 3.2 cm x 3.5 cm, to offload and skin prep. On 4/6/21 the wound measures 4.5 cm by 5.0 cm. On 4/14/21 the area is not resolved and requires re-evaluation. The pressure ulcer opens to be assessed as 100% eschar. The documentation indicated that prior to the fluid filled blister, Prevalon boots were in place and pillows to offload as tolerated. It was noted that the resident self-repositions in bed by pushing up and placing pressure on bilateral heels. None of this personalized information was identified on the care plan. The preventative care plan was developed on 3/31/21 after this left heel blister was identified. On 4/29/21 at 2:40 p.m. and interview was conducted with the Director of Nursing (DON). She reviewed Resident #43's care plan, but could not explain the lack or personalization or revisions related to the resident's admitted or acquired pressure ulcer. On 4/29/21 at 6:00 p.m., a debriefing was conducted with the Administrator, Assistant Administrator, DON, Infection Control Preventionist and Corporate, CFO. All of the aforementioned issues were reviewed, and again it could not be explained why the care plan was not personalized to reflect the resident's admitted pressure ulcers and acquired pressure ulcer or that the pressure ulcer preventative plan of care was dated 3/31/21 after Resident #43 acquired the left heel pressure ulcer on 3/30/21. No further information was provided prior to survey exit.

Based on observations, clinical record review, staff and resident interviews, the facility staff failed to ensure interventions were in place and operational for 3 out of 28 residents (Resident #41, #355 and #24) to prevent falls. The facility staff failed to ensure Resident #41's and #355's bed/chair alarms were properly positioned and functional. The facility staff failed to ensure Resident #24's call light was within reach and functional; and that her bed was in the lowest position per fall plan of care. The findings included: 1. The facility staff failed to ensure Resident #41's chair alarm was properly positioned and functional to alert staff that the resident has changed position, increasing the risk for falling. Resident #41 was admitted to the nursing home on 5/28/19 with diagnoses that included history of falls with history of displaced right femur fracture, dementia, muscle weakness and high blood pressure. The most recent Minimum Data Set (MDS) assessment was a significant change in status assessment dated [DATE] and coded the resident with a 14 out of a possible score of 15 which indicated the resident was cognitively intact with the skills needed for daily decision making. The resident was assessed to require extensive assistance from one staff for toilet use and bathing. She was coded to require extensive assistance of 2 for transfers. The resident was not steady during surface to surface transfer from bed and chair or wheelchair. The wheelchair was the primary mode of transportation. The resident was assessed to have 2 or more falls since admission and one with injury. She was assessed to have had recent surgery requiring active skilled care. The resident was coded always incontinent of bowel and bladder. The care plan dated 6/7/19 to present identified Resident #41 had a history of falls since admission, prior admission and had repeated falls, 31 falls were listed on the care plan, 3/19/21 resulted in a fracture to the distal radius. The goal set by the staff was that the resident would maintain current level of mobility with no increase in the incidence of falls/injuries. Interventions to accomplish this goal included apply sensor mat to bed and chair. The resident had physician orders dated 6/10/19 for a sensor mat to bed/chair to alert staff if resident attempts to transfer without assistance. Check placement and function every shift. The following observations of Resident #41 related to the chair alarm positioning and functionality: On 4/28/21 at 9:30 a.m., Resident #41 was in her room sitting in a wheelchair. There was a cast on the resident's right arm and wrist. The cord to the chair alarm was visibly hanging behind the resident, along the back of her wheelchair. There was no alarm box connected to the end, nor was the box attached anywhere on the wheelchair. The resident sat on the Pummel cushion and the sensor pad had been placed directly on the seat of the wheelchair under the Pummel cushion. Certified Nursing Assistant (C.N.A.) #1 was observed circulating around the resident, removed the breakfast meal tray. Licensed Practical Nurse (LPN) #5 was also observed administering medications to the resident without noticing there was no alarm box connected to the end of the cord. On 4/28/21 at 12:35 p.m., the resident was served her lunch meal. The chair alarm remained detached and no visible alarm box. On 4/28/21 at approximately 4:00 p.m., the resident was observed in bed. The sensor pad was under the resident's draw sheet, but no alarm box visible. On 4/29/21 at approximately 8:30 a.m. through 12:17 a.m., Resident #41 was again observed sitting in her wheelchair without the chair alarm connected. The sensor pad was positioned under the pummel cushion as previously observed on 4/28/21. On 4/29/21 at 12:20 p.m., CNA #1 stated she came on at 6:30 a.m. and there was no alarm box, only the sensor pad. She stated the resident always has the sensor pad with alarm, but could not explain where the alarm box was located. After a search of the resident's room, closet and drawers, the alarm box was not located. On 4/29/21 at 12:30 p.m., Resident #41's assigned LPN #1 was asked if there was a place on the Treatment Administration Record (TAR) to sign off placement and functionality of the chair alarm. She stated. I have already checked the resident's sensor pad alarm box and everything is in place and working fine. She showed this surveyor that she signed off on the TAR at 8:49 a.m. for placement and function of the alarm. The LPN was informed the alarm box had been missing and the sensor pad was positioned under the pummel cushion which may hamper the ability to activate the alarm. The LPN went into the resident's room and looked around for the alarm and stated she was so busy and she needed to evaluate how she signed off on the TAR in the future. On 4/29/31 at 12:40 p.m. the Assistant Director of Nursing (ADON) stated she would find an alarm to attach to the cord/sensor pad. Upon return to the resident's room, LPN #2 had found an alarm that she stated was in the stock room, checked the batteries and attached the alarm. She stated any nurse at any time can unlock the stock room and replace the alarm. It was then asked if the sensor pad was properly placed in order to activate the chair alarm, to which she responded, she did not know, but after the resident finished her lunch meal, they would lift the resident up off the wheelchair cushion to determine if the alarm sounded. On 4/29/21 at 1:10 p.m., LPN #2 (charge nurse) and a CNA hooked the resident to the mechanical lift and lifted the resident off the pummel cushion. The alarm did not activate. LPN #2 and the CNA repositioned the sensor pad on top of the pummel cushion, sat the resident back down and lifted her again, at which time the alarm sounded with a very loud shrill. On 4/29/21 at 2:40 p.m., the DON was informed of the aforementioned observations. She stated training would take place immediately for proper placement of sensor pads, functioning of the alarm, as well as ensuring that nurses accurately signed off for the device. On 4/29/21 at 6:00 p.m., a debriefing was conducted with the Administrator, Assistant Administrator, DON, Infection Control Preventionist and Corporate CFO. The Administrator stated staff education would take place regarding the alarms, placement and check off for them. The DON stated staff should not sign off on what they have not done and that would be an essential part of the training. 2. The facility staff failed to ensure Resident #355 chair alarm was properly positioned and functional to alert staff that the resident has changed position, increasing the risk for falling. Resident #355 was admitted to the nursing facility on 11/30/20 with diagnoses that included COVID-19, high blood pressure, [CONDITION(S)] and generalized weakness. The most recent Minimum Data Set (MDS) assessment was a quarterly and coded the resident on the Brief Interview for Mental Status (BIMS) with a 3 out of a possible score of 15 which indicated the resident was severely impaired in the cognitive skills for daily decision making. Resident #355 was not coded to have behavioral or mood problems. The resident was required extensive assistance from one staff for bed mobility, dressing personal hygiene. The resident was coded totally dependent on two staff for transfer and bathing. There was no impairment in upper and lower extremities. The wheelchair was the resident's main mode of transportation. Resident #355 was assessed always incontinent of bowel and bladder. The resident was coded on the assessment with having no falls. The care plan dated 12/11/20 to present identified the resident as having falls and remained at high risk for falls. The goals set by the staff for the resident was that the resident would not sustain injuries from a fall. Among the many approaches to accomplish this fall was the need for a personal or sensor mat alarm. The following observations of Resident #355 related to the chair alarm positioning and functionality: On 4/29/21 at 1:45 p.m., Resident #355 was observed in her room sitting in her wheelchair. She had an alarm box attached to the back of her wheelchair and the sensor pad was observed under her chair cushion by Certified Nursing Assistant (CNA) #1. Licensed Practical Nurse (LPN) #3 assisted the resident to stand, at which time the alarm did not sound. The LPN stated she did not know why the CNA placed the sensor pad under the wheelchair cushion because it would not activate to alert staff of the resident's movement which was the purpose of the chair alarm. LPN #3 repositioned the sensor pad on top of the cushion, at which time the alarm sounded with a loud piercing shrill. The assigned LPN (#1), had signed off for the 7/3 shift on the functionality of the alarm, as well as the proper placement of the sensor pad. On 4/29/21 at 2:40 p.m., the DON was informed of the aforementioned observations. She stated training would take place immediately for proper placement of sensor pads, functioning of the alarm, as well as ensuring that nurses accurately signed off for the device. On 4/29/21 at 6:00 p.m., a debriefing was conducted with the Administrator, Assistant Administrator, DON, Infection Control Preventionist and Corporate CFO. The Administrator stated staff education would take place regarding the alarms, placement and check off for them. The DON stated staff should not sign off on what they have not done and that would be an essential part of the training. The facility's policy and procedure titled Fall Management dated 3/20/19 indicated that it was the facility's goal to promote resident safety, assess each resident for fall risk, design an individualized person-centered plan for care and implement planned interventions to minimize falls and/or injury. The policy indicated that position change alarms were designed devices intended to monitor the resident's movement. The device emits an audible signal when the resident moved in a certain way. Types of position change alarms included chair and bed sensor pads. 3. The facility staff failed to ensure Resident #24's call light was within reach and functional; and that her bed was in the lowest position per fall plan of care. Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to muscle weakness, type two diabetes mellitus, vascular dementia without behavioral disturbance and [CONDITION(S)] of the left nondominant side. Resident #24's most recent MDS (Minimum Data Set) assessment was a significant change assessment with an ARD (Assessment Reference Date) of 3/2/21. Resident #24 was coded as being severely impaired in cognitive function scoring 03 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #24 was coded as being totally dependent on two staff members with transfers. Review of Resident #24's clinical record revealed her most recent fall was on 2/22/21 that resulted in a left fractured shoulder. The following was documented: Resident was lowered to the floor after writer witnessed resident hanging onto the dresser with the right arm leaning forward .Interventions: Bed in lowest position, call bell within reach, Non-skid footwear, engage in activities. Review of Resident #24's fall care plan dated 12/15/20 through present documented the following interventions: Keep nurse call light within reach .Keep personal items within easy reach; bed to be in lowest positron with wheels locked. On 4/29/21 at 10:00 a.m., an observation was made of Resident #24. Resident #24 was laying in bed with her call light within reach. Resident #24's bed did not appear to lowered all the way to the lowest position. On 4/29/21 at 12:15 p.m., an observation was made of Resident #24. Resident #24 was laying awake in bed. Resident #24's call bell was detached from the wall and found to be on the floor. When asked the resident if she was able to use her call bell, Resident #24 stated that uses the call bell and that she wasn't sure what had happened to it. On 4/29/21 at 12:56 p.m., an unidentified nursing aide had brought in Resident #24's lunch. This nursing aide put Resident #24's over bed table over her bed and set up her lunch tray. The CNA left the room at 12:57 p.m. without ensuring Resident #24's call light was within reach. On 4/29/21 at 1:45 p.m., Resident #24 was sitting up in bed with now her over bed table over her bed, finishing up lunch. Resident #24's call bell was still detached from the wall and found to be on the floor. On 4/29/21 at 1:50 p.m., an interview was conducted with Resident #24's assigned nursing aide; CNA (Certified Nursing Assistant) #1. When asked how she knows what each resident needs as far as preventing falls, CNA #1 stated that she will get a verbal report from the nurses. When asked what Resident #24 needed in place to prevent falls, CNA #1 stated the only thing she thought Resident #24 needed was to ensure her call light was within reach. CNA #1 was asked to follow this writer into Resident #24's room. CNA #1 confirmed that Resident #24's call bell was detached from the wall and on the floor. When asked Resident #24 needed her bed in the lowest position, CNA #1 stated that she thought the resident just couldn't have her bed too high. When asked if CNAs had access to the care plan, CNA #1 stated that they did not. When asked if Resident #24's bed was in the lowest position; CNA #1 took the bed controller and was able to lower the bed even further. On 4/29/21 at 3:06 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1, Resident #24's nurse. When asked what fall preventative measures should be in place for Resident #24; LPN #1 stated that her call bell should always be in reach and functioning. When asked if Resident #24 was able to use to call bell, LPN #1 stated that she was. When asked if Resident #24's bed had to be in the lowest position, LPN #1 stated that she wasn't sure if her bed had to be in the lowest position. When asked if nurses had access to the care plan, LPN #1 stated that they did. When asked if nursing aides had access to the care plan, LPN #1 stated that she was not sure. LPN #1 stated that nurses usually verbally communicated Resident needs to the nursing aides. On 4/29/21 at 5:52 p.m., the facility Administrator and the DON (Director of Nursing) were made aware of the above concerns. Facility policy titled, Fall Management documents in part, the following information: The facility strives to promote resident safety and protect resident rights and dignity .the facility assesses each resident for his or risk for falls, designs an individualized person centered care plan for care, and implements interventions to minimize falls and/or injury .Fall mitigation strategies .Maintaining bed in low position, providing call system that is within reach reach and secured .

Based on clinical record reviews, staff interviews and facility documentation, the facility staff failed to do a Gradual Dose Reduction (GDR) for 1 of 28 residents (Resident #35) in the survey sample who were receiving a PRN (as needed) [CONDITION(S)] medication. The findings included: 1. The facility staff failed to ensure a PRN (as needed) [CONDITION(S)] medication ([MEDICATION(S)]) was limited to 14 days for Resident #35. The physician did not do an evaluation of Resident #35 to extend the [CONDITION(S)] medication pass 14 days without documenting the rational and duration in the resident's medical record. Resident #35 was originally admitted to the facility on [DATE]. Diagnosis for Resident #35 included but not limited to Dementia with behavioral disturbances, Anxiety and Major Depressive Disorder. Resident #35's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date of 03/10/21 coded Resident #35 a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe impaired cognitive skills for daily decision-making. In addition, the MDS with an ARD of 03/10/21, under section E (Behaviors), coded Resident #35 for not exhibiting physical and verbal behaviors directed towards others 1-3 days each week. The resident was also coded for not having behaviors symptoms not directed toward others. Under section (E0800), for rejection of care was coded for not having behavior occurred 1-3 days each week. Resident #35's person-centered comprehensive care plan with a revision date 05/10/16 documented Resident #35 at risk for side effects related to use psychoactive medication. The goal: will achieve desired effect from ordered medications and will experience no negative effects. Some of the interventions to manage goals include but not limited to: offer non-pharmalogical interventions prior to increasing medications or giving PRN medications, assess for other causes for mood or behavior disturbances prior to use of PRN medications and consulting Pharmacist Medication Regimen Review (MMR) at least monthly. The physician Order Sheet (POS) for April 2021 included the following order: [MEDICATION(S)] 0.5 mg tablet by mouth as needed every 6 hours starting on 08/19/20 for Major Depressive Disorder. 1. Review of January 2021 Treatment Administration Record (TAR) revealed, PRN [MEDICATION(S)] was administered on the following days: 01/05, 01/06, 01/08, 01/09, 01/26, 01/27 and 01/29/21. 2. Review of March 2021 Treatment Administration Record (TAR) revealed, PRN [MEDICATION(S)] was administered on the following days: 03/03, 03/06, 03/26, 03/28 and 03/30/21. 3. Review of April 2021 Treatment Administration Record (TAR) revealed, PRN [MEDICATION(S)] was administered on the following days: 04/01, 04/08, 04/18, 04/20 and 04/28/21. On 04/29/21 at approximately 10:57 a.m., a phone interviewed was conducted with the Director of Nursing (DON.) The DON reviewed Resident #35's [MEDICATION(S)] order then stated, The PRN [MEDICATION(S)] order should have been written for 14 days then reevaluated by the physician. After the physician had reassess Resident #35 for the use of the PRN [MEDICATION(S)], a new order should have been written to resume the as needed [MEDICATION(S)] with a physician progress note explaining the reason for the continuation of the [MEDICATION(S)]. The facility's Administration team was informed of the finding during a debriefing on 04/29/21 at approximately 6:00 p.m. The facility staff did not present any further information about the findings. A policy for the use of PRN [CONDITION(S)] medication was requested on 04/29/21 at approximately 5:04 p.m., but not received.

Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to ensure 1 of 28 residents (Resident #53) in the survey sample was given the opportunity to formulate an Advance Directive. The findings included: Resident #53 was originally admitted to the nursing facility on 12/16/20. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date of 04/16/21 coded a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. Review of Resident #53's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) The review of Resident #53's clinical record did not show evidence of an Advance Directive. On 04/29/21 at approximately 9:38 a.m., a phone interview was conducted with the Social Worker (SW) and Corporate support. When asked, if Resident #53 had an Advance Directive, the SW replied, Not on paper. Corporate said when Resident #53 transitioned from the hospital, to this facility, to another facility and back here, Resident #53's Advance Directive got lost in the mix. Corporate stated, We did not follow our own process, we should have ensured education was provided, discussing risk vs. benefits for having an Advance Directive. Corporate said an Advance Directive should have been reviewed and discussed within 2-3 days after his first admission. When asked if Resident #53 was given the opportunity to formulate an Advance Directive, they replied, No. The facility provided the following document for Resident #53: Advance Care Planning with an assessment date of 04/27/21, that read in part: Residents and/or their responsible health care decision makers should be provided the opportunity to discuss advance care planning with appropriate staff members and medical providers within the first few days of admission to the facility, at times of change in condition, and periodically for routine updating of care plans. The facility's Administration team was informed of the finding during a debriefing on 04/29/21 at approximately 6:00 p.m. The facility staff did not present any further information about the findings. The facility's policy titled Advance Directives with a review/revised date (04/28/21) included but not limited to: Policy: Advance Directives will be discussed with resident and/or family member upon admission or as soon as clinically appropriate so the resident's wished, with respect to life prolonging treatments, can be documented in the medical record.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store narcotics in a double lock compartment; AND failed to ensure one medication room (The Bethel Unit) was free from expired medication. The findings included: On [DATE] at 9:23 a.m., observation of the Bethel Unit medication room was conducted. An unopened 30 ml (milliliter) bottle of [MEDICATION(S)] (1) was found in the door of the medication refrigerator behind only one lock to get into the refrigerator. The bottle of [MEDICATION(S)] was not stored in a black locked box with the other bottles of [MEDICATION(S)]. On [DATE] at 9:24 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #2. LPN #2 stated that the [MEDICATION(S)] was being stored in the door of the refrigerator because the resident (that the [MEDICATION(S)] belonged to) had recently passed. When asked if the [MEDICATION(S)] should still be stored in the locked black box or behind a double lock; LPN #2 stated that it should. Upon further review of the medication room; an unopened house stock bottle of [MEDICATION(S)] (2) was observed in the medication refrigerator. The expiration date on this bottle documented: [DATE]. When asked LPN #2 if all medications in the refrigerator were available to be used, LPN #2 that they were. When asked if the bottle of Cath Flo should have been removed, LPN #2 looked at the expiration date and stated Yes, Ma'am. On [DATE] at 5:52 p.m., the facility Administrator and the DON (Director of Nursing) were made aware of the above concerns. Facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles documents in part, the following: .Facility should store Scheduled II-V Controlled Substances and other medications deemed by facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device .Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security .Facility should ensure that medications and biologicals that:(1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier. (1) [MEDICATION(S)]-A scheduled IV controlled substance indicated for the management of anxiety disorders or for the short-term relief of the symptoms of anxiety or anxiety associated with depressive symptoms. This information was obtained from The National Institutes of Health. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid= c[DATE]-acec-64e877bd2b4c. (2) [MEDICATION(S)]- is indicated for the restoration of function to central venous access devices as assessed by the ability to withdraw blood. This information was obtained from The National Institutes of Health. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=91ecdef,d+[DATE]ff-42dd-a31c-c8a09cab3ad9.

Based on observations, clinical record reviews, staff and resident interview, the facility staff failed to ensure care was provided to prevent and treat pressure ulcers for 1 of 28 residents ( Resident #43) in the survey sample. The findings included: 1. For Resident #43, the facility failed to prevent the development of a facility acquired left heel pressure ulcer, as well as provide consistent offloading to the left medial knee pressure ulcer to ensure continued healing and comfort. Resident #43 was admitted to the nursing facility on 3/24/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #43's most recent Minimum Data Set assessment was an admitted d 3/29/21 and coded the resident with a score of 12 out of a total score of 15 which indicated she was moderately impaired in the cognitive skills for daily decision making. Resident #43 was coded always incontinent of bowel and bladder. Resident #43 was assessed to require extensive assistance of 2 for transfers, extensive assistance of 1 for dressing, toilet use, and totally dependent on one staff for bathing. The wheelchair was Resident #43's primary mode of mobility. Resident #43 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #43 was coded at risk for pressure ulcers based on the formal assessment, Braden scale dated 3/24/21 (very limited limited in extremity and body position without assistance, bedfast and friction and shearing as a problem) and had a stage 1 or greater over a bony prominence. Resident #43 was coded for unhealed pressure ulcers; one stage 1, 2 stage 2's (admitted ) and 2 unstageable pressure ulcers (admitted ). Resident #43 was assessed for pressure reducing devices, pressure ulcer care, surgical wound care and application of ointments and medications other than feet. The care plan dated 3/31/21 identified there was a stage 1, stage 2 pressure ulcer (PU), but the care plan did not identify the location of the stage 1 or stage 2 PU's. The care plan did not address the unstageable PU's. A preventative pressure ulcer care planning was dated 3/31/21, after the resident acquired a left heel fluid filled blister on 3/30/21. The care plan dated 3/31/21, identified that the resident had the potential for and has altered skin integrity and was at risk for pressure ulcers. The goal set was that Resident #43 would not experience impaired skin integrity and or area of impaired skin integrity would demonstrate wound healing. Some of the approaches to accomplish this goal included use positioning/preventable devices as tolerated by the resident, turn and reposition, and encourage Resident #43 to reposition as able. Use pillows, pads, or wedges to reduce pressure on heels and pressure points. Perform complete skin assessment and record. Specialized mattress: low air loss implemented on 4/16/21. According to the wound documentation forms dated 3/24/21, Resident #43 was admitted with the following pressure ulcers, documentation by the wound care nurse, Registered Nurse (RN) #2: -Left lateral medial foot with *eschar, . -Left medial knee with eschar, 4.5 cm x 3.5 cm. -Stage 2 to sacrum (3.5 cm x 1.0 cm x 0.1) and left buttock (3.5 cm x 1.5 cm x 0.1 cm). None of these areas were identified on the care plan. On 3/30/21 RN #2 documented on the wound documentation form that Resident #43 acquired a left heel fluid filled blister, 3.2 cm x 3.5 cm, to offload and skin prep. On 4/6/21 the wound measures 4.5 cm by 5.0 cm. On 4/14/21 the area is not resolved and requires re-evaluation. The pressure ulcer opens to be assessed as 100% eschar. The documentation indicated that prior to the fluid filled blister, Prevalon boots were in place and pillows to offload as tolerated. It was noted that the resident self-repositions in bed by pushing up and placing pressure on bilateral heels. None of this personalized information was identified on the care plan. The preventative care plan was developed on 3/31/21 after this left heel blister was identified. There was no pressure ulcer noted to the right heel. Low air loss mattress applied on 4/15/21. The wound care physician reviewed all of the aforementioned admitted pressure ulcers with wound care recommendations, as well as the facility acquired pressure ulcer (left heel) that is assessed on her visit 4/14/21 as unstageable with 100% thick devitalized necrotic tissue, The wound care physician debrided the area, treatment with Santyl (topical debrider). Recommendations to float heels in bed, off load the wound, reposition per facility protocol. The wound care physician also recommend the left medial knee unstageable pressure ulcer be offloaded, reposition per facility protocol. The following observations were made of Resident #43. On 4/27/21 at 11:00 a.m., Resident #43 was observed in bed on her air loss mattress, positioned on her right side. There was a pillow at her back and bilateral Prevalon boots in place. There was no pillow positioned between her legs to offload pressure to the left medial knee. On 4/27/21 at 3:00 p.m., the resident was positioned on her right side with pillow at her back, the Prevalon boots were in place to bilateral heels, but no pillow between her legs. On 4/28/21 at 10:00 a.m., 1:30 p.m., there was no pillow positioned between the resident's legs to offload the left lateral knee while resident was in bed. On 4/28/21 at 2:25 p.m., the wound care physician, accompanied by the wound care nurse performed complete assessments, treatments and dressing dressing changes for all pressure ulcers. It was determined that the resident could not lift her left heel off the mattress as she tried and stated, See, I am not able to lift that heel. It is my bad side. The wound care nurse verified the resident's left leg was the weak side. The resident demonstrated she was able to move the right heel without difficulty, and no redness or skin integrity issues. The resident could not demonstrate she was able to push with both heels to pull herself up in bed as the care plan indicated she was able to perform. There was no pillow between the resident's legs to offload the left medial pressure ulcer. After the treatments were completed, the wound care nurse left the resident's room to retrieve a pillow, returned and positioned the pillow between the resident's legs to protect and ensure offloading of pressure and continued healing. The wound care nurse stated she expected the staff to maintain a pillow between the resident's legs to ensure pressure relief of bone to bone pressure from her knees which was how the pressure ulcer originally developed due the resident's inability to independently reposition that left leg. On 4/29/21 at 11:05 a.m., the wound care nurse stated she was making sure the pillow was maintained between Resident #43's legs and staff education was started that would be ongoing. She also stated although she did not document Prevalon boots were in place from the resident's admission that was what she meant when she documented to float heels. She stated Prevalon boots were a nursing order and did not require a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated even if floating heels with pillows were consistently in place, the resident should not have acquired the right heel blister that opened to be a eschar/necrotic area. She could not explain how the resident was able to acquired the left heel pressure ulcer, if Prevalon boots were in place from admission, as she indicated. On 4/29/21 at 2:40 p.m. and interview was conducted with the Director of Nursing (DON). She stated that if pillows are appropriately in place, offloading is effective for residents that are compliant and unable to reposition themselves. It was determined that Resident #43 was compliant, unable to reposition herself and she expected that pillows and or Prevalon boots were in place for ongoing pressure relief. She stated Prevalon boots ensure pressure relief to heels even with resident movement and she thought they were in place from the resident's admission. She confirmed they were a nursing order, and not signed off on the TAR for the accountability purposes to ensure they were in place every shift. On 4/29/21 at 6:00 p.m., a debriefing was conducted with the Administrator, Assistant Administrator, DON, Infection Control Preventionist and Corporate, CFO. All of the aforementioned issues were reviewed, no further information was provided prior to survey exit.

Based on family and resident interview, clinical record review, and facility document review, it was determined that facility staff failed to provide ADL (Activities of Daily Living) services to maintain personal hygiene for 2 of 28 sampled residents, Resident #24 and #35. The findings included: 1. The facility staff failed to ensure Resident #24 was offered and received a scheduled twice-weekly shower to maintain good personal hygiene. Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24's most recent MDS (Minimum Data Set) assessment was a significant change assessment with an ARD (Assessment Reference Date) of 3/2/21. Resident #24 was coded as being severely impaired in cognitive function scoring 03 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #24 was coded as being totally dependent on one staff member with personal hygiene and bathing. On 4/28/21 at 10:15 a.m., in an interview with a family member, a concern was expressed that the resident may not be getting her hair washed due to not receiving showers. This family member also stated that Resident #24 had refused showers on a few occasions. Review of Resident #24's current care plan revealed the following for ADLs: ADL- has reacher (sic) her maximum functional potential and is at risk for decline Effective: 12/15/20 to Present .Have personal hygiene needs met in accordance with resident preference and need .Encourage Resident to take at least two showers/tub a week. Further review of Resident #24's care plan revealed another ADL care plan that documented the following: (Name of Resident #24) has the potential for health and safety concerns related to ADL needs and mobility status .Effective: 12/15/20 to Present .Assist (Name of Resident #24) with bathing as needed. Review of the shower schedule revealed that Resident #24 was to receive showers on Wednesday and Saturday 2:30- 11:00 p.m. Review of Resident #24's bathing and shower log dated 12/2020 through 4/2020 revealed that Resident #24 refused showers on 3/3/21 and on 4/12/21. It was documented that a bed bath was given in place of a shower during those time. Further review of Resident #24's bathing/shower log failed to evidence that Resident #24 ever received a shower from 12/3/20 until 4/27/21. Further review of Resident #24's care plan and clinical record failed to evidence that Resident #24 frequently refused showers. On 4/29/21 at 2:05 p.m. an interview was conducted with Resident #24. Resident #24 stated that she normally receives a bed bath. Resident #24 stated that she does not get offered a shower. When asked if she would like to receive her showers, Resident #24 stated that she would only like her showers so her hair can be washed. Resident #24 stated that when she is given bed baths, her hair is not washed. When asked how long it has been since her hair was washed, Resident #24 stated; It's been months. At the time of this interview and during the course of survey, Resident #24 had been wearing her wig over her hair. On 4/29/21 at 2:15 p.m., an interview was conducted with CNA (Certified Nursing Assistant) #1, a CNA who frequently worked with Resident #24. When asked if Resident #24 refuses showers, CNA #1 stated that Resident #24 refuses occasionally but not all the time. CNA #1 could not recall Resident #24's shower days. When asked if it should be documented on the clinical record if a resident refuses showers, CNA #1 stated that it should. CNA #1 stated that their was an option to document Refused and Received etc. When asked if a resident's hair was washed if a bed bath was given, CNA #1 stated that hair was normally washed in the shower. When asked the last time she personally gave Resident #24 a shower, CNA #1 stated that it has been awhile since she had personally washed the resident in the shower or had washed her hair. CNA #1 stated that she normally worked 6:30 to 2:30 p.m. shift. (Day shift). When asked how would we determine that Resident #24 received a shower if it was not documented on her shower log, CNA #1 stated that she was not sure how to know. On 4/29/21 at 03:06 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1, Resident #24's nurse. When asked who was responsible for giving showers, LPN #1 stated the nursing aides were responsible for giving showers. When asked when Resident #24 was supposed to receive a shower, LPN #1 stated that she wasn't familiar with shower schedules; that the nursing aides would know that information. When asked if nursing aides should be documenting if showers are refused, LPN #1 stated They should be. LPN #1 stated that if a resident refuses a shower, the nursing aides should be alerting the nurse so the nurse can encourage the resident to take a shower. LPN #1 stated some ways to encourage a resident would be saying things like, Hey, lets try this new body wash or Lets go wash your hair. When asked if a resident refuses showers on multiple occasions if that would be documented on the care plan, LPN # 1 stated, Yes. The care plan should be revised. When asked if Resident #24 refuses showers frequently, LPN #1 stated that the nursing aides had not told her that. When asked if nursing aides should be documenting when a resident receives a shower, LPN #1 stated, They should be. When asked if hair can be washed while the resident is laying in the bed, LPN #1 stated, We used to have shower caps that can be warmed up in the microwave that will sit on the resident's head or we use dry shampoo. When asked how we would know if Resident #24 received a shower if there was no evidence on the shower logs, LPN #1 stated that she wasn't sure. On 4/29/21 at 5:52 p.m., the facility Administrator and the DON (Director of Nursing) were made aware of the above concerns. 2. The facility staff failed to ensure Resident #35 was offered and received a scheduled twice-weekly shower to maintain good personal hygiene. Resident #35 was originally admitted to the facility 11/23/05. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date of 03/10/21 coded a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe impaired cognitive skills for daily decision-making. In addition, the MDS coded Resident #35 total dependence of one with bathing, extensive assistance of one with bed mobility, dressing, toilet use and personal hygiene for Activities of Daily Living (ADL) care. Resident #35's comprehensive care plan with a created date of 05/16/16 document Resident #35 refuses her showers when offered at times. The goal: will not experience preventative complications, or decline in condition related to refusal of care as ordered/care planned through next review. Some of the intervention included but not limited to: Resident prefers showers first thing in the morning; staff to attempt to accommodate resident preference in coordinating preferred time and staff to report refusals to charge nurse. The care plan also included to document resident's refusal for care in the medical record and notify the physician of persistent refusal of treatments, medications, and care. On 4/27/21 at approximately 11:30 a.m., Resident #35 was in her room in her wheelchair. A strong urine odor was detected upon entering the room. After exploring around the bed, it was determined the odor emanated around the resident. The resident was also hollering out, but not able to understand the content. When asked the Certified Nursing Assistant (CNA) #2 if she smelled urine around the resident, she responded that the resident did not like to be changed, but did not smell anything. On 4/28/21 at 1:00 p.m., the resident was sitting in her wheelchair in the hallway. The same urine odor was detected from the resident. Resident #35 showers are scheduled to be given twice weekly every Tuesday and Friday (6:30-3p shift.) Review of Resident 35's Data Collection Worksheet for bathing revealed the following: Showers were not given on the following shower days: March 2021 (03/30/21) and April 2021 (04/09, 04/13, 04/16 and 04/27/21.) A phone interview was conducted with the Director of Nursing (DON) on 04/29/21 at approximately 10:52 a.m. The DON said showers are to be given twice a week and bed baths on their non-showers days. She said if the resident refuse their shower or bed bath, the Certified Nursing Assistant (CNA) is to report the refusal to the nurse; the nurse will speak with the resident and if the resident still refuses, the nurse will document their refusal in the clinical record. When asked if the CNA's should also documented Resident #35's refusal of showers or baths, she replied, Yes. During a phone interview with the DON on 04/29/21, a request was made to do a phone interview with CNA #2, CNA #3, and CNA #4, who were assigned to Resident #35 on the missed shower days in March and April 2021. The DON she will have the CNA's contact me away via phone; the staff never called. During the clinial record review from 02/05/21 - 04/23/21 revealed two refusal of care (03/06/21 and 04/23/21.) A phone interview with the DON on 04/29/21, a request was made to do a phone interview with CNA#2, CNA #3, and CNA #4. They were assigned to Resident #35 on her missed shower days in March and April 2021. The DON said she give the 3 CNA's my contact number and have them call you right away; staff never called. The facility's Administration team was informed of the finding during a debriefing on 04/29/21 at approximately 6:00 p.m. The DON was informed the CNA nursing staff never called, she replied, I apologize, I was under the impression they had contacted you. The facility's Administration team was informed of the finding during a debriefing on 04/29/21 at approximately 6:00 p.m. The facility staff did not present any further information about the findings. The facility's policy titled Tub or Shower Bath (Revision date: 03/23/15.) Policy: Residents should receive a tub or shower bath at least twice weekly. Purpose read in part: To provide cleanliness and comfort to the resident and to prevent odors.

Based on record review and staff interview, the facility staff failed to send a notice of discharge to the Ombudsman for 1 resident (Resident #55) in the survey sample of 28 residents. The findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility staff failed to send a notice of discharge to the ombudsman. A Nursing Note dated 02/05/21 indicated: Resident #55 was experiencing low Oxygen Saturations. A review of the nursing notes indicated Resident #55 was transferred to the emergency roiagnom on [DATE] because resident was [CONDITION(S)] with oxygen saturation at 89 percent on 3 liters of oxygen. During an interview on 4/29/21 at 5:44 PM with the administrator she stated, The Ombudsman was not sent a notice of discharge to the hospital for Resident #55. The facility staff failed to send a notice of discharge to the hospital for one resident. No additional information was provided prior to exit of survey.

Based on staff interview and resident interviews the facility staff failed to ensure residents were informed on how to file a grievance. The findings included: On 04/28/2021 at approximately 11:00 a.m., a Resident Group Meeting was held with 5 cognitively intact residents present. When asked if they had been told how to file a grievance, the residents stated, No. An interview was conducted with the Director of Activities on 04/28/2021 at approximately 12:00 p.m. When asked have the residents been informed on how to file a grievance, the Director of Activities stated, No, have not discussed that with them. Planning to ask the ADON (Assistant Director of Nursing) to go over grievance procedure. When asked should the residents have been informed on how to file a grievance, Director of Activities stated, Yes Ma'am. On 04/29/2021 a copy of the facility policy on Resident Rights was requested and received. The Administrator and Director of Nursing was made aware of the finding at the pre-exit meeting on 04/29/2021 at approximately 6:00 p.m. No further information was provided about the finding. Policy: Virginia Health Services Resident Rights Policy F156 Notice of rights. Prior to or upon admission and during the resident's stay, the facility will inform the resident orally and in writing of his/her rights and all rules and regulations governing resident conduct and responsibilities during his/her stay in the facility. This shall be done in a language the resident can understand. The resident's authorized representative or a family member may interpret this information to a resident before he/she signs a receipt acknowledgement that the information has been received. All resident's rights under state law shall be included in this notice. A signed receipt for this information, and any amendments to it, will be filed in the resident's records. Resident rights will be reviewed with residents during resident council, with residents individually, or with resident's responsible party annually. F165 Grievances. Residents may voice grievances without discrimination or reprisal from the facility. F166 A prompt investigation and resolution will be made for all grievances residents may have. Grievances include those related to treatment furnished, treatment that has not been furnished and behavior of other residents. Grievances may be oral or written.

Based on staff interview and resident interviews the facility staff failed to ensure residents were informed of their rights and given information on how to formally complain to the State Agency and informational agencies about the care they are receiving and ensure residents were educated on where the Ombudsman contact information was posted. The findings included: On 04/28/2021 at approximately 11:00 a.m., a Resident Group Meeting was held with 5 cognitively intact residents present. When asked if they knew where the Ombudsman contact information was posted in the facility, the residents responded, No, what is a Ombudsman? When asked if they were informed of their rights, and given information on how to formally complain to the State Agency if they have a concern about the care they are receiving, the residents stated, No. On 04/28/2021 at approximately 12:00 p.m., an interview was conducted with Director of Activities. When asked was contact information for the Ombudsman and location of where it is posted reviewed with the residents, Director of Activities stated, No, I haven't done that. I will do that at the next Resident Council Meeting. When asked have the residents been informed of their rights and given information on how to formally complain to the State Agency if they have a concern about the care they are receiving, Director of Activities stated, No. Director of Activities stated, I did give out Resident Rights to the residents last month. When asked do residents get a copy of Resident Rights on admission, Director of Activities stated, No. The Director of Activities stated, I will type up and pass out to all residents how to contact the State Agency, how to make a complaint to the State Agency and who the Grievance Official is in the facility. I am going to ask (Ombudsman Name) to come in and talk with the residents and explain her role. On 04/29/2021 a copy of the facility policy on Resident Rights was requested and received. The Administrator and Director of Nursing was made aware of the finding at the pre-exit meeting on 04/29/2021 at approximately 6:00 p.m. No further information was provided about the finding. Policy: Virginia Health Services Resident Rights Policy Reviewed/Revised 9/3/03 F156 Notice of rights. Prior to or upon admission and during the resident's stay, the facility will inform the resident orally and in writing of his/her rights and all rules and regulations governing resident conduct and responsibilities during his/her stay in the facility. This shall be done in a language the resident can understand. The resident's authorized representative or a family member may interpret this information to a resident before he/she signs a receipt acknowledgement that the information has been received. All resident's rights under state law shall be included in this notice. A signed receipt for this information, and any amendments to it, will be filed in the resident's records. Resident rights will be reviewed with residents during resident council, with residents individually, or with resident's responsible party annually. F156 Posting of names, addresses and telephone numbers. The names, addresses and telephone numbers of the State survey and certification agency, the State licensure office, the State Ombudsman program, the protection and advocacy network and the Medicaid fraud control unit are posted prominently in the facility. This posting includes a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect or misappropriation of resident property in the facility.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that facility staff failed to thoroughly investigate and allegation of potential neglect for one of four sampled residents, Resident #1, reported on 1/13/20. The findings included; Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 8/24/20. Resident #1 was coded as being cognitively intact in the ability to make daily decisions scoring 14 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #1 was coded as requiring extensive assistance from one staff member with toileting. Review of Resident #1's active (current) incontinence care plan documented in part, the following: (Name of Resident #1) is frequently incontinent. Goals: The number of incontinence episodes will be reduced through next review date. Interventions: Check for incontinence, change if wet/soiled. Clean skin with mild soap and water. Apply moisture barrier. Evaluate incontinence pattern to determine voiding schedule .Remind (Name of Resident #1) to empty bladder before meals, at bedtime, and before activities. Review of a 2019 timeline of Resident #1's complaints, presented by the DON (Director of Nursing) documented in part, the following incident on 1/13/20: CNA left report of resident not receiving care on 3-11 Friday evening shift and Sat (Saturday) eve (sic) (evening) shift. Resident is OOB (out of bed) wheeling in electric chair this morning by 9 a.m. and expressed care concerns that had occurred over the weekend. Writer (DON) interviewed resident around 11 a.m. regarding concerns and resident confirmed what the 11-7 aide had reported. Resident also confirmed that staff had come in to bring medication and meal. Saturday he stated the aide did come in once but did not return after 8 p.m . 11:30 a.m. (Name of Ombudsman) was in facility regarding resident concern from the weekend. There was no evidence that this incident was thoroughly investigated. On 11/13/20 at 11:00 a.m., an interview was attempted with Resident #1. He did not wish to talk about any past incidents. On 11/13/20 at 12:03 p.m., an interview was conducted with ASM (Administrative Staff Member) #2, the DON (Director of Nursing). When asked about the incidents on 1/10/20-1/11/20; with Resident #1 alleging he was not provided care; ASM #2 stated that she wasn't sure what exactly happened and that she wasn't sure if it was confirmed that Resident #1 was really left soiled or if it was just a report made by the resident. When asked why the timeline documents that an aide also reported that Resident #1 was not provided care, ASM #2 stated that the staff may have just reiterated what the Resident had reported. ASM #2 was asked to provide an investigation or the outcome of this report made on 1/13/20. ASM #2 stated that she may have interviewed staff and written it down and would try to find it. On 11/13/20 at 3:26 a.m., an interview was conducted with OSM (Other Staff Member) #1, the LTC Ombudsman. When asked about the above allegations or the incidents on 1/13/20; OSM #1 stated that she could not recall those particular things. OSM #1 stated that most of the complaints came through from the facility. OSM #1 stated that the son would report issues and then the facility would call her (the ombudsman). OSM #1 stated that she recalled the resident and the son's biggest concerns were the call bell response time. OSM #1 stated that when she would go in and speak with the resident, the resident didn't want to talk about anything. OSM #1 stated that the resident would state, I took care of that, it's alright. On 11/16/20 at 2:15 p.m., further interview was conducted with ASM (Administrative Staff Member) #2, the Director of Nursing. When asked if she had found an investigation regarding the incident reported on 1/13/20, that Resident #1 did not receive care on 1/10/20 and 1/11/20; ASM #2 stated that per the timeline that was given to this writer, it appeared that an aide had been in his room on two occasions on Saturday 1/11/20. When asked what was determined about Friday 1/10/20; ASM #2 stated that she would have to check to see if she could find any additional information. When asked who the nursing aide was that was working with Resident #1 on 1/10/20; ASM #2 stated that didn't know and would have to check. When asked what nursing aide had reported this incident on 1/13/20, ASM #2 stated that she would have to check on that also. On 11/16/20 at 3:53 p.m., ASM #2 could not present any additional information. When asked if a resident of staff member report an allegation of lack of care on a shift, if that could be an allegation of potential neglect, ASM #2 stated, If it's verified. When asked how were these allegations verified without a thorough investigation, ASM #2 stated, Yes, I don't have anything else. On 11/16/20 at 3:59 p.m., ASM #1, the Administrator, and ASM #2, the DON were made aware of the above concerns. Facility policy titled, Resident Abuse, documents in part, the following: All alleged violations involving mistreatment, neglect, exploitation or abuse including injuries of unknown source and misappropriation of resident property, must be reported immediately to the Administrator of the facility .the facility must complete a through (sic) written investigation and must prevent further potential abuse while investigation is in progress .During investigation the following represent possible indicators of abuse and should trigger further assessment .Possible Signs of Neglect .Inadequately cleaned or clothed. Poor skin condition or poor skin hygiene. Malnourished or dehydrated without illness.- related cause. Complaint Deficiency.

Based on observations, clinical record review, staff and resident interview, the facility staff failed to ensure appropriate assistive devices and transfer needs were implemented for 1 out of 16 residents (Resident #7) in the survey sample. The facility staff failed to provide Resident #7 with the full mechanical lift and 2 person assist for a transfer per Minimum Data Set Assessment (MDS), plan of care, Resident Profile and facility protocol, which resulted in an acute fracture of the left distal femur resulting in harm. The findings include: Resident #7 was admitted to the nursing facility on 6/16/16 with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded the resident with a score of 8 out of a possible score of 15 on the Brief Interview for Mental Status which indicated the resident was moderately impaired in the skills needed for daily decision making. The resident was coded not safe for surface to surface transfers without staff assistance. Bed mobility and transfers required extensive assistance of two staff. The resident had a history of [REDACTED]. The MDS dated [DATE] was a Significant Change in Status Assessment and coded the resident totally dependent on two staff for transfers and bed mobility. The resident was coded to have fallen with major injury. The care plan dated 10/20/16 identified Resident #7 had a history of [REDACTED]. Some of the goals the staff would use to implement this goal included when staff transferred resident to use 2 person HOYER (full mechanical lift) lift. Resident #7's Fall Risk Assessments dated 6/16/16, 9/30/16 and 3/23/17 indicated the resident had a history of [REDACTED]. The Fall Risk assessment dated [DATE] indicated the resident was bedridden and immobile with an increased score of 40. The Physical Therapy evaluation and plan of care dated 6/18/16 indicated the resident lived with a family member, required assistance with transfers and was walking with walker approximately 6 months ago. The goal was that she would return home with family. Her rehab potential for stated goal was good. It was noted that the resident was an excellent historian. The resident required maximum assistance with transfers in and out of bed; sitting to standing. At the end of therapy, 7/18/16, the resident remained the same for transfers in and out of bed and was unable to perform unsupported standing. The resident Profile for CNAs to follow in the provision of care dated 3/23/17 indicated the resident was transferred utilizing a total lift. The policy of the facility (dated 3/23/15) indicated the total lift required at least 2 nursing staff for transfer. The Nurse's Notes dated 3/27/17 dated 3:37 p.m., indicated the resident had fallen and sustained a skin tear. After the fall she was transferred back to bed via total lift. The Nurse's Notes dated 3/30/17 at 10:01 p.m., noted Resident #7 complained of pain that she thought was from the fall on 3/27/17. The physician was in the building assessed the resident and ordered X-rays of the left leg tibia/fibula/femur and right hip. Resident was medicated for pain. The Nurse's Notes dated 3/31/17 at 9:11 a.m., indicated the X-ray results revealed an acute fracture of the left distal femur and the resident was transported to the local Emergency Department (ED) for further evaluation at 11:45 a.m. The resident was admitted to the hospital. The Nurse's Notes dated 4/3/17 at 10:17 p.m., indicated the resident returned from the local hospital on [DATE] at 6:10 p.m. with a knee immobilizer in place on the left leg. Physician orders [REDACTED].*Norco 5 milligram(mg)/325 *acetaminophen 1 tablet (tab) as needed every four hours. The Medication Administration Record (MAR) from 4/3/17 to current (6/1/2017) recorded the administration of Norco 59 times, in addition to acetaminophen 325 mg (2 tabs) as needed every 6 hours, administered 8 times. *Norco (Hydrocodone bitartrate and acetaminophen) is supplied in tablet form for oral administration. Hydrocodone bitartrate is an opioid analgesic and anti-tussive and occurs as fine, white crystals or as a crystalline powder. It is affected by light. (https://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid= ) *Acetaminophen is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain(https://medlineplus.gov/druginfo/meds/a 4.html) The facility's investigation of the fall incident on 3/27/17 indicated the resident fell while being transferred from bed to chair. As the resident continued to complain of pain in both legs, X-rays were taken of bilateral legs on 3/31/17 that revealed an acute fracture of left distal femur. The resident was evaluated in the hospital on [DATE]. The family opted for no aggressive treatment to include surgical options and the resident was returned to the nursing facility on 4/3/17 with a knee immobilizer in place, as well as orders for Norco pain medication. The Nursing Assistant (NA) # 1's written statement dated 3/27/17 indicated the following: (Resident #7's name) slipped out of the Sit-to-Stand. I saw her falling and assisted her to the floor. Then, I told (nurse's name) and (another nurse's name) and they came to our assistance. The aforementioned NA #1 was interviewed on 5/31/17 at 1:30 p.m. She said she was due to take her test in June to become a Certified Nursing Assistant (CNA), but had orientation that included the use of mechanical lifts. She stated she used the Sit-to-Stand lift to transfer the resident because previously she had another aide help her as they lifted the resident under her arms to place her in and out of bed. She said, I thought the Sit-to-Stand would take the place of a person, since I did not have anyone to help me transfer her to bed like before. I saw her legs buckle as she started to stand and then she fell to the floor. She stated she did not check the Resident Profile to verify how the resident should be transferred and was told if she had, she would have known the resident was a total lift with 2 staff. NA #1 said, I learned my lesson at the expense of the resident falling to the floor and breaking her leg. I should have used the HOYER (full/total) lift with another staff. I always check the Resident Profile now for each resident for all needs to include transfer requirements. NA #1 stated the facility re-educated her to refer to the Resident Profile for transfer needs and ask charge nurse or Director of Nursing (DON) for any concerns. The orientation Checklist for NA #1 dated 3/17/17 identified the Mobility Aid Program that included use of the Total lift and Sit-to-Stand. On 6/1/17 at 11:00 a.m., Resident #7 stated the aide placed a strap under her arms and positioned her legs in a contraption and when she tried to stand; she stated, I fell straight to the floor and hit my head first. The aide was not able to catch me and was not in contact with my body. I have been scared to get out of bed, so I stay in bed. Plus, it hurts a lot along with my arthritis that's all over my body. When specifically asked if she had been transferred the day she fell with two aides and the full mechanical lift; she stated, There was one aide and she tried to transfer me with the thing that you have to stand in. She also said she had been transferred without the full mechanical lift by two aides before the day she fell . On 5/31/17 at 2:15 p.m., an interview was conducted with the DON. She stated the NA should have never used the Sit-to-Stand because the resident was not assessed for that device; instead she was assessed and care planned to require the HOYER Lift (total ) always with two staff. The DON also stated the resident should not be transferred with two staff without the HOYER Lift. She stated she re-educated the NA, as well as all staff regarding checking the Resident Profile and safe transfers, as well as the observations of the use of all lifts. On 5/31/17, the Administrator and the DON presented the following Corrective Action Plan with a start date of 3/27/17: 1. (Resident's medical identification number) has been sent to the hospital for medical review of needed treatment and is anticipated to return to the facility. 2. The DON/Designee will observe the aide performing transfers on residents using the mechanical lifts to ensure adherence to the (Facility name) Mobility Aid Program policy. It will include observation of aide's review of the resident profile prior to initiating transfer. The Assistant Director of Nursing (ADON) will be responsible for ensuring completion of the resident profile assessment according to the (Facility name) Mobility Aid Program policy to ensure transfer method is appropriate. 3. The DON/designee has re-educated the staff on Resident Transfers. The inservice included, but was not limited to review of the (Facility name) Mobility Aid Program, ensuring appropriate transfer method has been determined and captured on the resident profile, importance of reviewing the resident profile by staff member prior to transferring the resident as well as ensuring appropriate method of transfer is used at all times. 4. The DON/designee will observe five random transfers weekly for 6 weeks to ensure transfers are performed according to the residents profile while adhering to the (Facility name) Mobility Aid Program policy. Any variances will be addressed and findings will be reported to the Quality Assurance committee on at least a quarterly basis. 5. The plan of correction is submitted as complete effective 4/18/17. Based on the aforementioned interviews with facility staff, review of the corrective action plan and that the deficient practice did not reoccur after 4/18/17 or exist during the current survey, it was determined the facility met Past Non Compliance for this specific regulatory requirement. The facility's policy and procedure titled Fall Prevention Program dated 5/6/11 indicated .The purpose of the program was to prevent or reduce the number of falls .Care plans should reflect the incident and the approaches .Mobility aides available and properly used . The facility's policy and procedure titled Mechanical Lifts dated 3/23/15 indicated The mechanical lift is used on residents who are unable to safely transfer independently or with a gait belt .The Sit-to-Stand lift can be used for residents who are able to bear weight. If the resident is unable to bear weight, the total lift should be used .At least 2 staff are required for the use of the total lift .

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed for 1 resident (Resident #3) of 16 residents in the survey sample to identify and treat an unstageable pressure ulcer resulting in harm. On 4/1/16, a black, calloused area with defined wound edges was identified on Resident #3's left heel by a floor nurse during a weekly skin check. No treatment was initiated. The area was not assessed again by facility staff until 4/6/16. On 4/6/16, the area was documented by the wound care nurse as unstageable-100% eschar. The findings included: Resident #3, an [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #3's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date of 3/7/16. She was coded with a Brief Interview of Mental Status score of 12 indicating no cognitive impairment. She required extensive assistance with most activities of daily living. She was coded to have no current pressure ulcers. She was not coded to be at risk for the development of a pressure ulcer. Although the MDS did not identify Resident #3 as being at risk for the development of a pressure ulcer, Resident #3 had a previous ulcer to the sacrum when she was first admitted to the facility. In addition, the form Braden Scale for Predicting Pressure Sore Risk was completed for Resident #3 on 1/11/16. The assessment form determined that the resident was At Risk for the development of a pressure sore. The care plan had the following information: Problem, 4/6/16, (Resident) has a history and is at risk for pressure ulcers. The following Interventions were added to the care plan on 4/6/16: -check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown -perform nutritional screening -Use pillows, pads, or wedges to reduce pressure on heels and pressure points. Turn/ reposition. -Do not massage skin over pressure areas -Blue open heeled boots to be worn while resident is in bed. Skin prep to be applied to resident ' s left heel every shift-d/c 4/7/16. 4/7/16 [MEDICATION NAME] to L heel every shift. No shoe to left foot when resident is in wheelchair. Only non-skid socks. Resident #3 ' s care plan also addressed properly fitting shoes. The problem read (Resident) is at risk for falls due to [DIAGNOSES REDACTED]. On 5/25/16 at 3:30 p.m., the wound nurse was interviewed. When asked why the facility did not code Resident #3 to be at risk for the development of a pressure ulcer on the MDS, the wound nurse stated that they did not consider her at risk because she was mobile. She stated that the Interdisciplinary Team (IDT) made this decision. The wound nurse was asked to provide documentation from the IDT. No documentation was provided. Weekly skin checks were completed by the floor nurses. Resident #3's weekly skin checks were completed as follows: 3/4/16- no issue identified 3/11/16- no issue identified 3/13/16- skin check not completed 3/18/16- no issue identified 3/25/16- skin check not completed 4/1/16- hardened area, left heel Licensed Practical Nurse A (LPN A) was the nurse who identified the hardened area to the left heel. She initiated the form titled Nonpressure- Initial Skin Documentation Form for Wounds on 4/1/16. The wound type was hand written in as calloused area. The wound color was checked as black. No drainage was present. The wound edges description was checked as defined, fibrotic, scarred, or hyperkeratonic. The surrounding tissue description was checked as black or hyperpigmented. In the comment section, the description dark stable area (L) heel was written. On 5/26/16 at 11:40 a.m., LPN A was interviewed. LPN A was asked if she remembered doing the skin assessment of Resident #3's heel. LPN A stated that she did remember. During the interview, LPN A was asked to describe the area. She described it as hard, rough and dry. She stated that there was no drainage present. When asked if the heel area had defined edges, LPN A stated that she could feel the edge. When asked what she meant by the description of stable, LPN A stated that the area was not gel like. LPN A was asked if the area felt the same as the surrounding skin. She stated that she did not touch the other skin. LPN A explained that skin areas identified during a weekly skin check were documented either on a Nonpressure form or a Pressure area form. When asked how she determined which form to use, LPN A stated that she chose to use the Nonpressure form because she was not sure what the area on the left heel was. She stated that this skin assessment was completed after hours on a Friday evening. LPN A did not inform any staff that she was unsure of her assessment of Resident #3's left heel. LPN A stated that she did not start a treatment to the area because it was stable and I didn't feel like it needed a treatment. LPN A was asked to explain what happened to the pressure or nonpressure form after it was completed by a floor nurse. She stated that the forms were put into the skin assessment book on the unit. The charge nurse was supposed to review the skin forms. There was no documentation that the charge nurse or any other nurse assessed the left heel area after LPN A put the Nonpressure form in the skin book. The next time the heel was asssessed was on 4/6/16 by the wound care nurse. On 4/6/16, the wound care nurse assessed the left heel area. Documentation was completed on the VHS Pressure Ulcers Initial Skin Documentation/ Assessment Form. It was documented that the wound developed after admission on 4/6/16. The wound was documented as Unstageable- Slough and/ or Eschar, 100% Eschar/ Slough. Length 4, width 3.5 centimeters. Wound color: black. Surrounding tissue: Normal for ethnic group. Wound edges: distinct, even with wound base. The area was not documented to have any pain. Treatment was initiated on 4/6/16, skin prep to left heel every shift. The treatment was changed on 4/7/16 to [MEDICATION NAME] solution daily, apply [MEDICATION NAME] soaked gauze to left heel and dry dressing once daily. On 5/24/16 at 5:25 p.m., the wound care nurse stated that 4/6/16 was the first time she assessed Resident #3's heel wound. The wound care nurse also documented the wound in the clinical notes. Her note read: 4/6/16, 4:11 p.m. It was noted that resident has an area of stable eschar to her left heel. Resident is at risk for skin breakdown due to comorbidities of [MEDICAL CONDITIONS], AFIB ([MEDICAL CONDITION]),[MEDICAL CONDITION](hypertension), [MEDICAL CONDITION], and Vit D deficiency. Resident has decreased mobility and was discharged from PT (physical therapy) on 3/23/16 where she was receiving therapy for bilateral heel cord flexibility to increase safety. Resident likes to get up in the early morning and is able to self propel herself around in the w/c (wheel chair). Resident is incontinent of bladder and has a few documented episodes of bowel incontinence. Resident currently consumes 75-100% of breakfast, lunch, and dinner. She is on a multivitamin for nutritional supplementation. MD (doctor) notified of request to obtain lab work to check for protein malnutrition. Blue open heeled boots to be worn while resident is in bed, skin prep to be applied each shift, and resident and staff aware that resident is only to wear non skid socks of that foot until wound heals. ____ (wound specialist) to see resident on next scheduled visit. MD and RP (responsible party) aware. A wound care specialist evaluated the left heel wound on 4/11/16. The wound was described as pressure, unstageable necrosis. The wound size was documented as 3.5 x 3.1 x 0.1 Thick adherent black necrotic tissue (eschar): 100%. Continue [MEDICATION NAME] treatment. Resident #3's wound was observed in the presence of the wound care nurse and an additional surveyor on 5/25/16 at 9:58 a.m The wound had a necrotic center/ cap and measured 2.5 x 2.5 (centimeters). On 5/25/16, around 2:15 p.m., Resident #3's wound was reviewed with the DON. The DON was asked if the area, which was first identified as a callous and five days later identified as 100% eschar, was identified incorrectly by the floor nurse on 4/1/16. The DON stated that she could see how it could get identified wrong due to the resident's dark, dry skin. The DON also stated that education was provided to staff to help ensure that hyperpigmented skin and pressure areas get identified appropriately. On 5/25/2016, around 2:25 p.m., the facility Wound Care Consultant stated that she reviewed the documentation for all five of the wounds in question by the survey team. She stated that she felt the treatment modalities were accurate. She stated that she agreed that the facility staff had an issue with identification and staging. The DON and wound care nurse were present during the interview. On 5/26/16 at 1:45 p.m., the wound care nurse and Director of Nursing (DON) were interviewed. Both the wound care nurse and the DON stated that they assessed skin areas after they were identified by the floor nurses. When asked why the area to Resident #3's heel was identified on 4/1/16 (Friday) and was not assessed again until 4/6/16 (Wednesday), the wound care nurse stated that the area was identified on a Friday night and that she and the DON were not at the facility over the weekend. When asked why it was not looked at on Monday or Tuesday, the DON stated that she was on vacation from 4/4/16 to 4/8/16. The wound care nurse did not say why she did not look at the area until 4/6/16. At this time, the wound care nurse and DON were notified that LPN A stated that she was unsure of how to assess the area to Resident #3's heel and that LPN A had not notified any staff that she questioned her own assessment of the left heel. The wound care nurse stated that she was not aware that LPN A questioned the area. During this time, the wound care nurse and DON stated again that they did not feel that Resident #3 was at risk for the development of a pressure ulcer (Although the 4/6/16 note written by the wound care nurse read that the resident is at risk due to comorbidities). They stated that the resident would tell them if she had pain or any type of issue. It was reviewed with the wound care nurse and DON that the facility's initial assessment of the area did not indicate that pain was present. It was also reviewed that Resident #3 stated to this surveyor that the wound did not hurt, she did not know that she had a wound, and that she did not know how the heel wound happened. Resident #3 stated that since the development of the wound, she does not wear shoes, only gripper socks (interview 5/26/16 at 10:05 a.m.). The wound care nurse mentioned that the wound could have been caused by the resident's shoe. When asked if the resident could put her shoes and socks on by herself, the DON stated no. It was reviewed that Resident #3 required assistance with dressing, bathing and hygiene. According to the bathing and shower record, Resident #3 received a bed bath on 4/1/16, 4/2/16, 4/4/16, and 4/5/16. No documentation was provided that showed that the staff who had administered the bed baths had identified or reported the left heel issue. During an interview on 5/24/16 at 5:25 p.m., the wound care nurse stated that certified nursing assistants were expected to report skin areas identified during daily care. Resident #3's care plan was reviewed. The care plan read ____ is at risk for and/or has altered skin integrity. The Interventions read 4/6/16- impaired skin integrity to left heel- tx (treatment) as ordered- encourage offloading as tolerated. Other interventions included assist with turning/ repositioning, complete Braden scale per policy, educate on risks, preventions, and treatments, inspect skin and report bruises, open areas or discoloration, use positioning/ preventative devices as tolerated. The facility policy titled Pressure Area Prevention Program was reviewed. Identification of residents at risk for development of pressure ulcers included the use of the Braden Scale to be completed with each RAI (resident assessment instrument) quarterly or comprehensive assessment. Monitoring for effectiveness of the interventions included at least daily, staff should remain alert to potential changes in the skin condition of the resident and should evaluate and document the identified change. The section Pressure Points and Tissue Tolerance read Tissues closest to the bone may be the first tissue to undergo necrosis. Pressure ulcers are usually located on bony prominence, such as sacrum, heel, the greater troncanter, ischial tuberosity, fibular head, scapula and ankle. The following may need to be evaluated for at risk residents: support surfaces, positioning- postural alignment, distribution of weight, balance and stability, shoes, determine if medical device is in use (tubes, casts, orthoses, braces, cervical collars, etc., contractures. The facility policy titled Pressure Ulcer Treatment Program was reviewed. Under the Procedure section read CNAs (Certified Nursing Assistants) and other direct care staff should report any signs or symptoms of a potential pressure related impairment of skin integrity to the head/ charge nurse immediately. The section titled Stage Determination Guidelines read Pressure ulcers in which the base is covered by slough are unstageable. The section Stage Classifications read Unstageable Related to Slough and/ or Eschar- Pressure ulcers that are covered with slough and/ or eschar and the true depth (and therefore stage) cannot be determined. The policy defined Eschar Tissue as dead or devitalized tissue that is hard or soft in texture; usually black , brown or tan in color and may appear scab-like; necrotic tissue and eschar are usually firmly adherent to the base of the wound and often to the sides/ edges of the wound. The following definitions regarding pressure injuries and staging were accessed from the National Pressure Ulcer Advisory Panel website on 5/31/16 at 1:25 p.m. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ Pressure Injury:A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Unstageable Pressure Injury: Obscured full-thickness skin and tissue lossFull-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on an ischemic limb or the heel(s) should not be removed. The Administrator, DON and corporate staff were notified of the harm level deficiency on 5/26/16 at 12:15 p.m.