Every finding on record at Larkspur

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Residents #34, #66 and #71) and 2 of 7 staff (CNA A and CNA B) reviewed for infection control. 1. The facility failed to ensure CNA A followed EBP and proper infection control measures when providing direct care and handling soiled linens for Resident #66 on 6/08/2026. 2. The facility failed to ensure EBP was initiated and followed for Residents #34 and #66 on 6/08/2026 and 6/09/2026. 3. The facility failed to ensure CNA B followed EBP when providing direct care to Resident #71 on 6/09/2026. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings include: 1. Record review of Resident #66's facility face sheet, dated 6/10/2026, indicated Resident #66 was a [AGE] year-old male, readmitted [DATE], with diagnosis of atrial fibrillation (irregular heart rate). Record review of Resident #66's quarterly MDS assessment, dated 5/12/2026, revealed a BIMS of 07 that indicated Resident #66 had severely impaired cognition. He was dependent on staff for all ADLs, was always incontinent of bowel and bladder and had a pressure ulcer. Record review of Resident #66's comprehensive care plan, revision date 3/06/2026, indicated Resident #66 had a pressure ulcer to his right heel and required EBP for a chronic wound and to implement enhanced barrier precautions. Record review of Resident #66's order summary report, dated 6/10/2026, indicated Resident #66 did not have an order for EBP until 6/09/2026. During an observation on 6/08/2026 at 10:57 am Resident #66 was in bed and had dressings to his feet. There was no signage or PPE at the door indicating EBP. He could not answer questions about his wound or staff wearing PPE. During an observation on 6/08/2026 at 12:34 pm CNA A was in Resident #66's room providing incontinent care. She was not wearing any PPE and had placed soiled linens on the floor next to the bed. During an interview on 6/08/2026 at 12:41 pm CNA A said she did not know Resident #66 needed EBP because there was not a sign but he did have a wound so he should have EBP precautions in place. She said she should have worn a gown and gloves when giving care and placed the soiled linens in a bag not on the floor to prevent spreading infections. 2. Record review of Resident #34's facility face sheet, dated 6/10/2026, indicated Resident #34 was a [AGE] year-old male, readmitted [DATE], with diagnosis of infection of surgical site. Record review of Resident #34's electronic health record indicated Resident #34's MDS assessment was not yet due and had not been completed. Record review of Resident #34's initial care plan, dated 6/03/2026, indicated Resident #34 had a surgical wound and implement enhanced barrier precautions. Record review of Resident #34's order summary report, dated 6/10/2026, indicated Resident #34 had an order for treatment for a surgical wound dated 6/04/2026 and did not have an order for EBP until 6/09/2026. During an observation on 6/08/2026 at 11:56 am Resident #34 was in a wheelchair in his room and he had a dressing to his left leg amputation. There was no sign or PPE outside the room indicating need for EBP. During an observation and interview on 6/09/2026 at 8:44 am Resident #34 was in bed and had a wound vacuum dressing system in place to his left leg amputation. There were no signs or PPE at the door identifying need for EBP for his wound. He could not recall if the staff were wearing PPE or not. 3. Record review of Resident #71's facility face sheet, dated 6/10/2026, indicated Resident #71 was an [AGE] year-old female, admitted [DATE], with diagnosis of diabetes with chronic skin ulcer. Record review of Resident #71's quarterly MDS assessment, dated 4/22/2026, revealed a BIMS of 09 that indicated Resident #71 had moderately impaired cognition. She was dependent on staff for most ADLs, was always incontinent of bowel and bladder and had a diabetic foot ulcer. Record review of Resident #71's comprehensive care plan, revision date 4/22/2026, indicated Resident #71 had a diabetic ulcer to her left ankle, required EBP for a midline catheter and implement enhanced barrier precautions. Record review of Resident #71's order summary report, dated 6/10/2026, indicated Resident #71 had an order for EBP dated 5/31/2026. During an observation and interview on 6/08/2026 at 10:45 am Resident #71 had an EBP sign and PPE at her door. She was in bed with a midline catheter (a type of intravenous catheter) in her left upper arm and had a dressing to her left ankle. She could not recall if staff wore PPE when providing care. During an observation on 6/09/2026 at 8:58 am Resident #71 had an EBP sign at her door. CNA B and CNA C entered Resident #71's room to transfer her. CNA B provided direct care by positioning her and adjusting her linen with no PPE in place. Resident #66 was not ready to get up and they did not proceed with transferring her. During an interview on 6/09/2026 at 9:10 am CNA B said she was assigned to different halls and that EBP signs were used to identify residents that required PPE for care. She said she had overlooked that Resident #71 had an EBP sign and PPE at the door. She said she had been trained in EBP and for residents with wounds and tubes, a gown and gloves had to be worn to provide care. She said she forgot Resident #71 was on EBP when she went to get her up. She said Resident #34 did not have a sign posted outside his room. She said she had given care to Resident #34 without wearing PPE because she had forgotten he had a wound and PPE had to be worn. She said not following EBP could cause infections to spread. During an interview on 6/09/2026 at 9:41 am the Unit Manager said she was the unit manager for hall 600 and was responsible for the oversight of the EBP program. She said that she used the 24-hour report and order report to review and put EBP signs and PPE out for staff use. She said that Residents #34, #66 and #71 had wounds and there should have been EBP signs and PPE outside their rooms. She said the signs were the staff's way of knowing precautions were required. She said she was not sure how those residents were overlooked. She said soiled linen were never to be placed on the floor and all staff were trained on infection control for handling soiled linen. She said she helped train staff on EBP and infection control and staff were knowledgeable on the facility's infection control program. She said if staff did not follow EBP and proper linen handling infections could spread. During an interview on 6/09/2026 at 9:56 am the ADON said she was the infection prevention nurse and she and the unit managers oversaw that infection control measures were in place throughout the facility. She said she performed an audit a few times a month to help catch any missing precautions in place. She said that the posted signs and PPE were the staff's aid to recognize residents requiring EBP. She said that soiled linens were to be bagged and never placed on the floor to prevent cross contamination and spread of infections. During an interview on 6/10/2026 at 11:45 am the DON said the ADON was the infection prevention nurse and she along with the charge nurses and unit managers were responsible for initiating the EBP procedures. She said a resident with a wound or implanted devices should have an order for EBP, a sign and PPE outside their room. She said that the sign was the tool used for the staff to know EBP was required. She said that orders were reviewed weekly and Residents #66 and #34's EBP requirements were missed. She said that staff were trained in EBP and following the guidelines on hire and as needed. She said soiled linens were to be placed in a bag and never on the floor. She said that staff not following the facility's infection control program could lead to the spread of infections. During an interview on 6/10/2026 at 1:45 pm the Administrator said the DON and Infection Prevention nurse were responsible for the infection control program. He said that orders should be reviewed daily and if the residents needed EBP in place then it should be initiated and facility policy followed. He said all staff were trained on hire and at least quarterly on infection control measures. He said that the staff should be following infection control measures and wear their PPE and appropriately handle soiled linen to prevent the spread of infections. He said he planned to re-inservice all staff and ensure measures were in place for daily monitoring for compliance. Record review of a facility policy titled Enhanced Barrier Precautions, dated 12/01/2025, indicated, .it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following:i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.) 3. Implementation of Enhanced Barrier Precautions:a. Make gowns and gloves available immediately near or outside of the resident's room.4. High-contact resident care activities include:a. Dressingb. Bathingc. Transferringd. Providing hygienee. Changing linensf. Changing briefs or assisting with toiletingg. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline cathetersh. Wound care: any skin opening requiring a dressing. Record review of a facility policy titled Handling Soiled Linen, dated 12/30/2025, indicated, .It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. This policy pertains to soiled linen. 3. Linen should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons.4. Used or soiled linen shall be collected at the bedside (or point of use, such as dining room) and placed in a linen bag or designated lined receptacle. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom.

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #52) reviewed for enteral nutrition. The facility failed to ensure staff followed facility policy to label the formula label with date, time and initials of nurse when formula bag was started. This failure could affect residents by placing them at risk of dehydration and weight loss. Findings include: Record review of the face sheet, dated 6/09/26, reflected Resident #52 was a [AGE] year-old male who initially admitted to the facility on [DATE]. His diagnoses include severe protein-calorie malnutrition, paraplegia and dysphagia (difficulty swallowing). Record review of the nursing home MDS assessment, dated 3/13/26, reflected Resident #52 had a BIMS score of 09, which indicated moderate cognitive impairment. Resident #52 required total assistance from staff with ADLs. Resident #52 received 51% or more of total calories through tube feeding. Record review of Resident #52 comprehensive care plan revised on 5/28/2026 included resident was to have nothing by mouth due to medical condition and requires tube feeding due to swallowing problems. Record review of Resident #52 order summary report for June 2026 reflected nothing by mouth diet. Enternal feed order of Isosource 1.5 at 65 ml/hr via feeding tube with auto flushes of 50 ml every hour, start date 5/24/2026. During an observation on 6/08/2026 at 10:30 AM, noted that feeding bag of Isosource 1.5 hanging on feeding pump and infusing at 65 ml/hr via g-tube. Noted that label had no date, time or initials on the label. Approximately 30% of bag contained formula. During an interview on 6/10/2026 at 10:30 AM with LVN D, she stated she was the unit manager for Resident #52's unit and has been employed at the facility for 2 years. She stated nurses that hang a new bag of tube feeding should label the bag with date and time the bag is placed on the pump. She stated that feeding bags are safe to use for 48 hours after inserting tubing in feeding tube and labeling with date and time allow the charge nurse to monitor that the appropriate amount of feeding is being infused by the pump. She stated not labeling the feeding bag with the date, time and nurses initials could place residents at risk for receiving formula that has been opened over the recommended time of 48 hours and impede the nurses ability to ensure that the feeding is infusing at the proper rate. During an interview on 6/10/2026 at 10:45 AM with the Director of Nurses, she indicated the charge nurse was responsible for labeling all feeding bags with date, time and initials prior to administering the feeding. She stated labeling with date and time ensures that formula is not hanging longer than required and that the formula is infusing at the proper rate. She stated she expected the charge nurse to label all feeding bags according to the facility policy and if any unlabeled bags are noted by the charge nurse, the bag is to be removed and replaced with a new bag that is labeled appropriately.During an interview on 6/10/2026 at 11:30 AM with the Administrator, he stated the charge nurse is responsible for labeling any feeding bags administered to the residents. He stated the feeding bags should be labeled with date, time and initials of the nurse prior to administering the feeding. He said that proper labeling ensures the feeding is infusing over the appropriate time and not opened for longer than recommended. He stated that he expects the charge nurse to label all feeding bags according to facility policy. He said not labeling the feeding bags with the date, time and nurses initials could lead to feedings that are opened longer than recommended and the inability of the nurse to monitor feeding is infusing at the proper rate. Record review of a facility policy titled Enternal Feedings- Safety Precautions revised November 2018 indicated On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.

Based on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 3 of 3 days reviewed for 3 of 3 days reviewed (06/08/2026, 06/09/2026 and 06/10/2026) for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 06/08/2026, 06/09/2026 and 06/10/2026.This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included:During an observation on 06/08/2026 at 11:01 AM, the daily staff posting was not in or around the front entrance lobby accessible to all visitors or residents. The daily staff posting was dated 06/08/2026 and located in a case on a wall in front of the Therapy department and down the hallway leading to 500/600 and 700/800 hallways. The posting was not visible to residents or visitors traveling toward the 100/200 and 300/400 hallways.During an observation on 06/09/2026 at 3:33 PM, the daily staff posting was not in or around the front entrance accessible to all visitors or residents. The daily staff posting was dated 06/08/2026 and located in a case on a wall in front of the Therapy department and down the hallway leading to 500/600 and 700/800 hallways. The posting was not visible to residents or visitors traveling toward the 100/200 and 300/400 hallways.During an observation on 06/10/2026 at 10:55 AM, the daily staff posting was not in or around the front entrance accessible to all visitors or residents. The daily staff posting was dated 06/08/2026 and located in a case on a wall in front of the Therapy department and down the hallway leading to 500/600 and 700/800 hallways. The posting was not visible to residents or visitors traveling toward the 100/200 and 300/400 hallways.During an interview on 06/10/2026 at 1:00 PM, the DON said ADON was responsible for staffing in the facility for the nurses and nurse aides. She said the daily staff posting was the responsibility of the ADON. She said the posting was on the wall near the Therapy department and also posted near the dining room. She said the location was previously at the receptionist desk at the main entrance, but they had moved it at some point in the past few years. During an interview on 06/10/2026 at 1:30 PM, the Administrator said the ADON and DON were responsible for putting out the daily staff posting. He said the posting would not be visible to visitors or residents if they turned to the left at the lobby and traveled to the 100/200 and 300/400 hallways. The Administrator said the purpose of the staff posting was so anyone would be able to see the census and how many staff were working that day. Record review of a facility policy titled Nurse Staffing Posting Information dated 12/30/2025 indicated, .It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff and visitors at any given time.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #2) reviewed for infection control.The facility failed to ensure CNA C changed her gloves, washed or sanitized her hands, and placed clean items on dirty linens when providing care to Resident #2 on 10/29/2025.This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #2 dated 10/29/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), type 2 diabetes, major depressive disorder (persistent sadness and loss of interest in doing things), and hypertension (high blood pressure).Record review of a Quarterly MDS Assessment for Resident #2 dated 9/1/2025 indicated she did not have any cognitive impairment with a BIMS score of 13. She was dependent on staff for toileting hygiene. She was always incontinent with urinary/bowel.Record review of a care plan for Resident #2 dated 3/10/2025 indicated she had bladder/bowel incontinence related to CVA. Interventions included to check the resident every two hours and assist with toileting as needed and clean peri-area with each incontinence episode.During an observation on 10/29/2025 at 9:26 AM, CNA C and CNA D were at the doorway of Resident #2 to perform incontinent care. There was a sign on the door that read Enhanced Barrier Precautions (staff were required to wear a gown and gloves when care was provided). CNA C and CNA D both donned (put on) a gown in the hallway and entered the resident's room. Both staff washed their hands and put on gloves. CNA C opened Resident #2's brief and pulled it down between her thighs. CNA C removed wipes from the package and wiped both inner thighs and her lower abdomen and placed the wipes in the trash. CNA C removed wipes from the package and wiped down the middle of her vagina from front to back. CNA D rolled the resident onto her right side. CNA C removed wipes from the package and wiped Resident #2's rectal area from front to back and placed the wipe in the trash and applied a barrier cream to the resident's buttocks. CNA C placed a clean brief under the resident's buttocks on the wet sheet and then rolled the linens under the resident. Resident #2 was rolled onto her back and the brief was secured. Resident #2 was rolled onto her left side, and the dirty brief and linens were removed from the bed by CNA D and placed in a plastic bag. Resident #2's gown was removed and placed in a plastic bag. CNA C removed her gloves and gown and placed them in the trash. CNA C washed her hands and exited the room to get clean linens. CNA C reentered the room with clean bed linens in a plastic bag. CNA C was wearing a gown and she washed her hands in the bathroom and applied gloves. CNA D removed her gloves and placed them in the trash and washed her hands. CNA D placed a clean gown on Resident #2. Both CNA C and CNA D placed clean linens on the bed and repositioned Resident #2 in the bed.During an interview on 10/29/2025 at 9:56 AM, CNA C said during the incontinent care provided to Resident #2, she should have changed her gloves when she changed task from dirty to clean. She said she should have sanitized or washed her hands after she removed gloves. She said she did not realize she never changed her gloves during the care. She said she was nervous because she was being observed. She said she should not have placed the clean brief on the dirty linens. She said there could be a risk for residents getting germs or cross contamination. She said she had a skills check-off not long ago on incontinent care.During an interview on 10/29/2025 at 11:37 AM, the ADON said hand hygiene should be performed before care, when hands were visibly soiled, during care, after barrier cream was applied, and when care was complete. She said staff could wash or use hand sanitizer to perform hand hygiene. She said gloves should be changed when tasks changed from dirty to clean and clean items should not be placed on dirty items. She said staff received training on skills on hire, yearly and as needed if concerns were noted. She said the nurse managers were all responsible for training staff on skills. She said if staff did not perform hand hygiene or follow infection control there could be a risk to the residents for infections or cross contamination.During an interview on 10/29/2025 at 12:57 PM, the DON said hand hygiene should be done before care, every time gloves were changed, when changing from dirty to clean, and at the end of care. She said hand hygiene included washing hands with soap and water or use of hand sanitizer. She said residents could be at risk for infections and she planned to in-service the staff.During an interview on 10/29/2025 at 1:18 PM, the Administrator said hand hygiene should be done before care, between dirty and clean tasks, between glove changes and after care. He said staff should wash or sanitize their hands. He said nursing administration were responsible for training staff on infection control that included hand washing and they received training often. He said there could be a risk of cross contamination or spreading infection if staff did not follow hand hygiene.Record review of a perineal care skills checklist for CNA C dated 8/29/2025 indicated she was successful with female perineal care.Record review of the facility policy titled Hand Hygiene revised August 2019 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: h. before moving from a contaminated body site to a clean body site during resident care; j. After contact with blood or bodily fluids; 9. The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observations, interviews, and record reviews, the facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls for 1 of 7 residents (Resident #3) reviewed for pharmacy services.The facility failed to ensure a tube of diclofenac sodium topical gel 1% (primary use for pain relief) was not in the room of Resident #3 on 10/28/2025.This failure could place residents at risk for adverse effects and reduced therapeutic effects of medication.Findings included:Record review of an admission Record for Resident #3 dated 10/28/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of benign neoplasm of cerebral meninges (non-cancer tumor in the brain), rheumatoid arthritis (chronic disorder that affects the joints), and chronic kidney disease (loss of kidney function).Record review of an admission MDS Assessment for Resident #3 dated 9/15/2025 indicated she had moderate cognitive impairment with a BIMS score of 11. During the 5-day look back period, the resident did not receive any scheduled pain medication regimen.Record review of a care plan for Resident #3 dated 10/20/2025 indicated she was on pain medication therapy with interventions to administer analgesic medications as ordered by physician.Record review of active physician orders for Resident #3 dated 10/28/2025 indicated there were no orders for diclofenac sodium topical gel 1%.During an observation and interview on 10/28/2025 at 9:20 AM, Resident #3 was in her room sitting in a recliner. She was alert to person, place, and time. She said she had been at the facility for a few days. A tube of diclofenac sodium topical gel 1% was on a desk in the room. She said she did not remember where she had received the topical gel.During an interview on 10/28/2025 at 9:28 AM, MA A said she had been employed at the facility for 10 years. She said there were not any residents in the facility that were able to self-administer medications, and the nursing staff gave the residents all their medications. She said she had given Resident #3 her medications that morning, but had not given her any topical gels.During an observation and interview on 10/28/2025 at 9:39 AM, MA A entered the room of Resident #3. She said the diclofenac was a medication out of the nurse's carts. She said she was not aware Resident #3 had a tube of diclofenac and would give it to the nurse.During an interview on 10/28/2025 at 2:39 PM, RN B said there were not any residents in the facility that were able to self-administer medications themselves. She said the nurses and medications administered the medications. She said MA A told her about the diclofenac sodium topical gel that was found in Resident #3's room. She said family would bring medications to the facility without notifying the nursing staff. She said all medications should be stored in the medication cart or in the medication room.During an interview on 10/29/2025 at 10:29 AM, the RP of Resident #3 said they were not aware the resident had a tube of diclofenac topical gel and had not taken any medications to the facility. The RP said the resident had been in rehab at a local hospital and may have gotten the prescription while she was a patient. The RP said Resident #3 did have a cream that was prescribed that could be applied to her knees and back, but did not know the name of the medication.During an interview on 10/29/2025 at 11:37 AM, the ADON said there were no residents in the facility that had been deemed safe to self-administer medications. She said medications should be stored in the medication carts or in the medication rooms. She said she was aware of the tube of diclofenac that was found in the room of Resident #3 on yesterday 10/28/2025. She said someone else could take the medications if they were left in the rooms or the resident could take too much of the medicine.During an interview on 10/29/2025 at 12:57 PM, the DON said medications should be stored in the medication room or in the medication cart. She was made aware of the diclofenac gel of Resident #3 that was found in her room. She said there could be a risk of improper administration. She said there were not any residents in the facility that were able to self-administer.During an interview on 10/29/2025 at 1:18 PM, the Administrator said medications should be stored in the medication room or in the medication cart. He said there were no residents in the facility who had been deemed safe to self-administer medications. He said if medications were not stored properly it could lead to getting the wrong dose of medicine, and it would not be administered as ordered by the physician. He said the nursing staff were responsible for ensuring medications were stored properly.Record review of the facility's policy titled Storage of Medications revised April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 2. The nursing staff shall be responsible for maintaining medication storage.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 1 of 8 residents reviewed for ADLs (Resident #2)The facility failed to ensure Resident #2 received timely incontinent care on 10/29/2025.This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs, which could result in poor care.Findings included:Record review of an admission Record for Resident #2 dated 10/29/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), type 2 diabetes, major depressive disorder (persistent sadness and loss of interest in doing things) and hypertension (high blood pressure).Record review of a Quarterly MDS Assessment for Resident #2 dated 9/1/2025 indicated she did not have any cognitive impairment with a BIMS score of 13. She was dependent on staff for toileting hygiene. She was always incontinent with urinary/bowel.Record review of a care plan for Resident #2 dated 3/10/2025 indicated she had bladder/bowel incontinence related to CVA. Interventions included to check the resident every two hours and assist with toileting as needed and clean peri-area with each incontinence episode.During an observation on 10/29/2025 at 9:26 AM, CNA C and CNA D were at the doorway of Resident #2 to perform incontinent care. CNA C and CNA D both donned (put on) a gown in the hallway and entered the resident's room. Both staff washed their hands and put on gloves. CNA C opened Resident #2's brief and pulled it down between her thighs and performed incontinent care. CNA D rolled the resident onto her right side. The linens were soaked in urine with a light-yellow ring on the flat sheet. The brief was saturated with urine and her gown was wet. Resident #2's buttocks were macerated (skin overly saturated with moisture). After the care was complete, CNA C applied a barrier cream to the resident's buttocks. CNA C placed a clean brief under the resident's buttocks and placed a clean gown on Resident #2. Both CNA C and CNA D placed clean linens on the bed and repositioned Resident #2 in the bed.During an interview on 10/29/2025 at 9:56 AM, CNA C said she was the transportation driver for the facility, but also was a CNA. She said she was notified the night of 10/28/2025 that she would need to work on the hall where Resident #2 resided. She said her shift started at 6 am that morning (10/29/2025). She said that the care that was observed with Resident #2 was her first round for the morning with the resident. She said Resident #2 was soaking wet from urine and Resident #2 informed her that she had not been changed since the night of 10/28/2025. She said the nurse aides were supposed to round and check the residents every 2 hours. She said that morning (10/29/2025) she was busy and had other things to do for residents on the hall that included giving a resident a shower and passed out the breakfast trays and picked them back up. She said Resident #2's bed was soaked, and should not have been that way if she was changed timely. She said residents could be at risk for skin breakdown if they were not changed timely.During an observation and interview on 10/29/2025 at 10:05 AM, Resident #2 was in her bed. She said the nursing staff checked on her once on the night of 10/28/2025, and changed her and it was after supper time. She said she was not checked and changed until a few minutes ago.During an interview on 10/29/2025 at 10:07 AM, CNA D said Resident #2's brief was saturated with urine and her gown was wet along with her linens on the bed. She said the nurse aides were supposed to round on the residents every 2 hours to make sure they were clean and dry. She said Resident #2 was a heavy wetter. She said residents could be at risk for skin breakdown if they were not checked and changed every 2 hours.During an interview on 10/29/2025 at 12:57 PM, the DON said incontinent care should be performed every 2 hours and as needed. She said she was not aware Resident #2 had not received care in a timely manner and the resident had not mentioned any concerns to her. She said residents could be at risk for skin issues if care was not done in a timely manner.During an interview on 10/29/2025 at 1:18 PM, the Administrator said incontinent care should be performed every 2 hours. He said he was not aware Resident #2 had not received care in a timely manner. He said he planned to in-service the nurse aides on rounding and incontinent care. He said there was a risk for skin issues if care was not done timely.Record review of the facility's policy titled Perineal Care Protocol dated September 2023 indicated, .To provide care of the external genitalia and anal area which promotes cleanliness and prevents infections.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 2 of 6 residents reviewed for ADLs (Residents #23 and Resident #24) 1.The facility failed to clean/groom Resident #23's fingernails. Resident #23 had long fingernails that were about an inch in length with a yellow-brown substance underneath them on 4/21/2025 and 4/22/2025. 2.The facility failed to clean/groom Resident #24's fingernails that had a black substance underneath them on 4/21/2025 to 4/23/2025. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care. Findings included: 1. Record review of an Admission Record for Resident #23 dated 4/22/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of parkinsonism (nervous system disorder that causes tremors and loss of motor function), hypertensive heart disease with heart failure (heart problems caused from high blood pressure), and major depressive disorder (persistent sadness or loss of interest). Record review of a Quarterly MDS Assessment for Resident #23 dated 4/3/2025 indicated she did not have any impairment in thinking with a BIMS score of 15. She required supervision or touching assistance with personal hygiene. Record review of a care plan for Resident #23 dated 3/11/2025 indicated she had an ADL self-care performance deficit related to muscle wasting and atrophy. Interventions included bathing/showering: check nail length and trim and clean on bath day and as necessary. During an observation and interview on 4/21/2025 at 9:47 AM, Resident #23 was in her room in bed awake. She said she had been at the facility since February 2025. Her fingernails were long, about an inch in length and had a yellow-brown substance underneath them. She said they needed to be cleaned. During an observation on 4/21/2025 at 2:31 PM, Resident #23 was in bed resting. Her fingernails were still long and had a yellow-brown substance underneath them. During an observation and interview on 4/22/2025 at 11:10 AM, Resident #23 was in bed awake. She said she received a bed bath earlier that day on 4/22/2025 but the nurse aide did not trim her nails. She was picking at her nails. She said she would like to have them trimmed. During an observation and interview on 4/22/2025 at 11:42 AM, CNA A said she gave Resident #23 a bed bath earlier on 4/22/2025. She said Resident #23 was not diabetic. She said the nurse aides were responsible for cleaning and trimming nails of residents if they were not diabetic. She said she did not notice Resident #23's nails that day. She said the nurse aides were to clean and trim the resident's nails every shower/bath day. She said she would be upset if she had to depend on staff to trim or clean her nails. 2. Record review of an Admission Record for Resident #24 dated 4/22/2 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), hemiplegia affecting left dominant side (paralyzed on left side), major depressive disorder (persistent sadness or loss of interest) and PTSD (a condition caused by an extremely stressful or terrifying event). Record review of a Quarterly MDS Assessment for Resident #24 dated 2/26/2025 indicated she had moderate impairment in thinking with a BIMS score of 9. She was dependent on staff with personal hygiene. Record review of a care plan for Resident #24 dated 3/11/2025 indicated she had an ADL self-care performance deficit related to hemiplegia affecting left dominant side. Interventions included for bathing/showering-she was totally dependent on staff for bathing/showers. There was not a care plan to indicate that she resisted nail care. During an observation and interview on 4/21/2025 at 2:19 PM, Resident #24 was in her bed awake. Her fingernails were dirty with a black a substance underneath them. She said the staff did clean her nails, but she did not like them to clean them. She said she cleaned them herself and did not want the staff to clean them. During an observation and interview on 4/22/2025 at 3:03 PM, Resident #24 was in bed awake eating food with her fingers that consisted of a banana that was cut up into pieces, an avocado cut into slices, two pieces of cheese, and 5 Vienna sausage links. Her nails had a black substance underneath them. She said she received a bed bath earlier that day on 4/22/2025 and the staff did not clean her nails. She said she did not remember who gave her a bath. During an observation on 4/23/2025 at 8:44 AM, Resident #24 was in bed awake eating breakfast with her hands instead of using utensils that were on her tray. She said she liked to eat with her hands instead of using her utensils. Her nails had a black substance underneath them. She said she used her hands all the time when she ate, and her nails stayed dirty. She said she would not care if the staff cleaned her nails. During an interview on 4/23/2025 at 8:50 AM, the ADON said she had been employed at the facility for 2 years. She said nail care was to be performed by the nurse or nurse aides. She said the nurse would take care of the diabetic residents with cutting and cleaning their nails. She said nail care should be done on shower days. She said Resident #23 was not diabetic, but Resident #24 was. She said if she were dependent on staff to clean and care for her nails and they did not, it would make her feel dirty. During an interview on 4/23/2025 at 8:58 AM, RN B said she had been employed at the facility since September 2024 She said the nurses were responsible for nail care if the residents were diabetic and the nurse aides were responsible for nail care for the other residents. She said Resident #24 would often refuse nail care but was not sure the last time Resident #24 refused care. She said they usually checked nails weekly to see if they needed to be trimmed and cleaned them daily. She said if her nails were not clean, it would make her feel dirty. During an interview on 4/23/2025 at 9:03 AM, the DON said nail care was the responsibility of the nurse and nurse aides. She said if a resident was diabetic, then the nurse would be responsible for nail care. She said nail care should be done when needed with cutting and cleaning. She said she was not aware of any residents in the facility with dirty or long nails. She said they would take care of Resident #23 and Resident #24's nails. She said if her nails were dirty or long, it would make her feel gross. During an interview on 4/23/2025 at 2:02 PM, the Administrator said nail care was to be done every Sunday by the nurse aides and they should be cleaned and trimmed, unless they were diabetic then the nurse would be responsible. He said if he were dependent on staff to clean his nails, he would tell someone because he would not like it. Record review of a facility policy titled Care of Fingernails/Toenails revised October 2010 indicated, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General guidelines: 1. Nail care included daily cleaning and regular trimming .

46436 Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls for 1 of 18 rooms (room [ROOM NUMBER]) reviewed for pharmacy services. The facility failed to ensure a syringe of normal saline 0.9% (a solution used to maintain hydration) and 1 syringe of heparin 500 units per 5 ml (blood thinner) was were not on a bedside table in an unoccupied room (room [ROOM NUMBER]) on 4/21/2025. These failures could place residents at risk for adverse effects and reduced therapeutic effects of medication. Findings include: During an observation on 4/21/25 at 9:21 AM, an unoccupied room (room [ROOM NUMBER]) had 1 syringe of Normal Saline 0.9% and 1 syringe of heparin 500 units per 5 ml lying on a side table. During an interview on 4/21/25 at 9:33 am, LVN E said that the resident in room [ROOM NUMBER] was discharged to the hospital last week. She said she had only worked on 300 hall for a short time and was not sure why or how the medication was left in the room. She said that the normal saline and heparin syringes came as a house stock and should never be left at the bedside. She said all medications should be stored and secured appropriately either in the medication room or medication cart. She said that improper storage of medication could affect resident health. During an interview on 4/23/2025 at 8:50 AM, ADON said medications should be stored in the medication room and in medication carts and never left at the bedside. She said there could a risk of other residents going in the room and taking the medication if they were left. During an interview on 4/23/2025 at 9:03 AM, the DON saidmedications should never be left in the resident's room unless they are being administered. She said she was made aware of the medications of heparin and normal saline being left in a room of a resident who had discharged to the hospital. She said another resident could go in the room and get the medications if they were left unattended. During an interview on 4/23/2025 at 2:02 PM, the Administrator said the medication aides and unit managers should be checking daily to make sure medications were stored appropriately and should not be left in any resident rooms. He said residents could get the medications if they were left in rooms. Record review of a facility policy titled Storage of Medications revised April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 6 residents (Resident #32) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service from 04/21/2025 through 04/23/2025. This failure could place residents at risk of a loss of quality of life due to injuries. Findings included: 1. Record review of a facility face sheet dated 4/21/2025 for Resident #32 indicated that she was a 65 -year-old female admitted to the facility on [DATE] with diagnoses including morbid obesity due to excessive calorie intake and essential hypertension (uncontrolled blood pressure). Record review of a Quarterly MDS assessment dated [DATE] for Resident #32 indicated that she had a BIMS score of 15, which indicated she was cognitively intact. She was dependent for all transfers and most ADLs. Record review of a comprehensive care plan dated 3/11/2025 for Resident #32 indicated she had an ADL Self-Care Performance Deficit and required a mechanical lift for all transfers with staff assistance x 2 for transfers. During an observation and interview on 04/21/2025 at 9:30 AM, Resident #32 said the staff use the lift sling sitting on the table in her room to get her up. The straps on the Medline lift pad were faded light in color and the care tag was illegible. During an observation and interview on 04/22/2025 at 11:52 AM the Laundry Supervisor, said she had worked at the facility for two years and had not received any training regarding specific laundry requirements for the lift slings. She said she was aware if the slings have holes or are coming unsewn they should not be used. She said she had never removed a sling from service since she has worked at the facility. A Med-Line lift sling was in the dryer ready to be removed. The care tag was illegible, crinkled and the straps were faded in color light pink, light blue and light teal green. The straps were not vivid blue, bright green and bright red as other slings in the dryer. The Laundry Supervisor said she does not bleach the slings and she does place them in the dryer to dry on medium heat with other colored items. She said if a sling that was unsafe was used for residents, it could tear causing the resident to fall and get hurt. During an observation and interview on 4/23/25 at 10:00 AM the Laundry Aide said that he had worked at the facility since January 2025 and had received training to remove mechanical lift slings if the slings had rips and holes. The Laundry Aide said he washed the slings alone, in the bleach cycle and dried them in the dryer. A sling was laid in a wheelchair next to a mechanical lift on hallway 100, ready for use. The sling was dated with a marker 4/15/2022 and the care tag was crinkled, illegible and the straps were faded in color, light pink, light blue and light teal green. The Laundry Aide said it had no rips or holes, so it looked good for use to him. During an interview on 04/23/25 at 10:43 AM the Regional Nurse Consultant said staff had just performed a sweep to remove old slings and had ordered new slings. She said they will remove the faded slings and replace them. The Regional Consultant said staff would be in serviced on when to remove slings from service including old, bleached or faded slings. She said that using a sling that was no longer safe for use as indicated by manufacturers recommendations could result in a fall with injuries. During an interview on 4/23/2025 at 1:30 PM, the DON said the lift slings should be checked about every 6 months and checked every time they were washed. She said she was not aware of the manufacturer's guidelines for the lift slings that the slings should not be in use if they had been bleached and were faded. She said they planned to conduct an audit and the facility had ordered new slings for the facility. She said there could be risk for injury if the faded and unraveling slings were being used. During an interview on 4/23/2025 at 1:45 PM, the Administrator said staff knew to report any torn or ripped mechanical lift slings and to throw them away. He said it was the responsibility of the DON or ADON to make sure they were not using worn or damaged lift slings. He said he was not aware that the laundry aide was bleaching the slings. He said the faded slings could not be in use and there would be a potential risk for falls or injuries. Record review of a facility policy titled Lifting Machine, using a Mechanical, revised 07/20/2017 indicated: . Sling Care: 2. Wash and Sanitize according to manufacturer's instructions. 3. Discard any worn, frayed, or ripped slings . Record review of the manufacturer instruction for Medline full body slings undated indicated, .Full body slings are made of durable materials and are ideal for patient transferring and toileting activities. Always inspect slings prior to each use. Signs of color fading, bleached areas, indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use . Record review of the manufacturer instructions for Proactive full body slings accessed https://proactivemedical.com/products/lifts-slings/patient-slings/full-body-sling/ accessed 03/18/2025 indicated, .Proactive medical products . Guideline for Identifying Deteriorated Slings Accelerated Deterioration from Bleach, High Temperature Wash or Drying Slings, especially loop straps that have been damaged from being laundered in unsuitable conditions (bleach, high heat wash or dry) may appear to be in good condition but the actual tensile strength of the material may be compromised and pose a safety risk and should not be used for lifting a patient or resident. This Guide is intended to help staff and caregivers better identify slings that have been exposed to above laundry conditions and subsequent loss of tensile strength. We encourage any sling identified with the following characteristics to be removed from service immediately as a preventive measure. Proactive Medical slings have been designed and tested for laundry wash conditions of 170F degrees and air dry or dry at low temperature. The slings should never be bleached. Commercial washer and dryers are not recommended. Care instructions on the sling label should always be followed. Laundry equipment should be properly maintained and repaired when necessary. Completely Faded / Missing / Illegible Tag while the main body of the sling fabric is still intact and in relatively good condition. Colors are not faded or show very little fading .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #20) and 1 of 5 staff (CNA D) reviewed for infection control. CNA D failed to wear appropriate PPE for contact isolation precautions when providing care to Resident #20 on 4/21/2025. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of Resident # 20's facility face sheet revealed Resident #20 was a [AGE] year-old female and admitted on [DATE] with diagnosis of memory deficit following cerebrovascular disease. Record review of Resident #20's Quarterly MDS assessment dated [DATE] revealed a BIMS of 13 indicating intact cognition and required supervision with activities of daily living. Record review of Resident #20's comprehensive care plan dated 3/27/2025 revealed Resident #20 had a urinary tract infection and monitor for signs and symptoms. Record review of Resident #20's consolidated physician's order dated 4/15/2025 revealed an order for contact isolation. During an observation on 04/21/25 at 12:40 pm CNA D was in Resident 20's room setting up her meal tray. CNA D did not have on PPE and Resident #20 required contact isolation per the signs on the outside of the room. CNA D was observed handling Resident #20's over bed table and bed remote control without any gloves or gown in place and CNA D left the room without performing hand hygiene. During an interview on 4/21/25 at 12:46 pm CNA D said she knew Resident # 20 was on contact isolation and was in a hurry to pass trays and forgot to put on her PPE. She said she had been trained on contact isolation precautions and by not following isolation precautions she could spread infections. During an interview on 4/23/25 at 9:59 am the ADON said she was the infection prevention nurse and was responsible for the infection control program and training all staff. She said if a resident was in contact isolation staff should be applying PPE before entering the room. She said if CNA D entered Resident #20's room and handled any belongings she should have had on her PPE. She said staff were trained on hire and frequently throughout the year on infection control and isolation precautions. She said if staff were not following the isolation precautions, infections could spread. During an interview on 4/23/25 at 10:12 am the DON said the ADON was responsible for the infection control program, but she was responsible for the oversight of all nursing staff. She said that staff were trained on isolation precautions and expected staff to follow the isolation precautions. She said if precautions for infections were not followed infections could spread. During an interview on 4/23/25 at 1:50 pm the Administrator said the DON was responsible for oversight of the infection control program and every staff member was trained on infection control on hire and throughout the year. He said he expected staff to follow the facility infection control program to prevent spread of infections. Record review of skills checklist dated 2/27/25 indicated CNA D had been trained on isolation, proper PPE use and handwashing. Record review of a facility policy titled Contact Precautions dated August 2012 indicated, .contact precautions are designed to reduce the risk of transmission of important microorganisms by direct or indirect contact. Direct-contact transmission also can occur between two Patients (e.g., by hand contact), with one serving as the source of infectious microorganisms and the other as a susceptible host. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the Patient's environment. In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non sterile gloves are adequate) when entering the room. In addition to wearing a gown as outlined under Standard Precautions, wear a gown (a clean, non sterile gown is adequate) when entering the room if you anticipate that your clothing will have substantial contact with the Patient, environmental surfaces, or items in the Patient's room .

Based on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 2 medication rooms (Bluebonnet) reviewed for pharmacy services. The facility failed to dispose of expired medications from the medication room for Bluebonnet on 4/22/2025 which included: *Resident #35 had a foil package of albuterol 0.083% (nebulized medication that helps with breathing) that expired February 2025. *Resident #24 had a box of albuterol 0.083% that expired February 2025. *Resident #191 had 1 box of ipratropium/albuterol 0.5 mg/3 mg (nebulized medication that helps with breathing) that expired October 2024 and 3 boxes of ipratropium/albuterol 0.5 mg/3 mg that expired February 2025. These failures could place residents at risk for adverse effects and reduced therapeutic effects of medication. 1. Record review of an Admission Record for Resident #35 dated 4/22/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), hemiplegia (paralyzed on one side of the body), COPD (a group of lung diseases that affect breathing) and aphasia (difficulty speaking). Record review of active physician orders for Resident #35 dated 4/22/25 did not indicate an order for albuterol 0.083% 3 ml. Record review of a Quarterly MDS Assessment for Resident #35 dated 2/5/2025 indicated a BIMS score of 0 as she was rarely/never understood. She had shortness of breath or trouble breathing when lying flat and used oxygen while a resident during the 14 day look back period. Record review of a care plan for Resident #35 dated 1/23/2025 indicated she had oxygen therapy related to ineffective gas exchange. Interventions indicated to monitor for signs and symptoms of respiratory distress and report to MD prn. 2. Record review of an Admission Record for Resident #24 dated 4/22/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), hemiplegia affecting left dominant side (paralyzed on left side), and other pneumonia (lung infection). Record review of active physician orders for Resident #24 dated 4/22/25 did not indicate an order for albuterol 0.083%. Record review of a care plan for Resident #24 dated 3/11/2025 indicated she had an ADL self-care performance deficit related to hemiplegia affecting left dominant side. Record review of a Quarterly MDS Assessment for Resident #24 dated 2/26/2025 indicated she had moderate impairment in thinking with a BIMS score of 9. She had shortness of breath or trouble breathing with exertion and when lying flat. She used oxygen therapy during the 14 day look back period. 3. Record review of an Admission Record for Resident #191 dated 4/22/2025 indicated she admitted to the facility on [DATE] and discharged on [DATE]. She was [AGE] years old with diagnoses of sepsis (infection in the blood), UTI (infection in the urinary tract) and age-related osteoporosis (brittle bones). Record review of active physician orders for Resident #191 dated 4/22/2025 indicated an order for ipratropium/albuterol 3 ml inhale orally every 8 hours as needed for shortness of breath with a start date of 12/20/2023. Record review of a Quarterly MDS Assessment for Resident #191 dated 11/1/2024 indicated she did not have any impairment in thinking with a BIMS score of 14. During the 14 day look back period she did not require oxygen therapy. Observation on 4/22/2025 at 8:38 am, in the Bluebonnet medication room for halls 500, 600, 700, and 800 with LVN C revealed: 1. Resident # 35 had a foil package of albuterol 0.083% 3 ml inhale orally via nebulizer every 4 hours as needed for wheezing that expired February 2025. 2. Resident #24 had a box of albuterol that expired February 2025. 3. Resident #191 had four boxes of ipratropium/albuterol. Three boxes expired February 2025 and the other box expired October 2024. During an interview on 4/22/2025 at 8:51 AM, LVN C said she had been employed at the facility for 2 years. She said the nurses, medication aides, DON, ADON and unit managers were responsible for checking the medication rooms for expired medications. She said the medication boxes of nebulizer treatments were placed in the bottom cabinet for overflow. She said the medications should have been discarded when the residents discharged . She said the medication rooms should be checked daily. She said residents could have adverse reactions if they were given medications that were expired. During an interview on 4/23/2025 at 8:50 AM, ADON said the nurses were responsible for checking the medication room daily and the nurse managers were to check them weekly. She said they checked for expired and discontinued medications. She said she was made aware of the nebulizer medications being found in the medication room on yesterday 4/22/2025. She said there could be a risk of the medications not being effective if given past the expiration date. During an interview on 4/23/2025 at 9:03 AM, the DON said the medication rooms were the responsibility of all nursing staff and they should be checked weekly by the nurse managers and daily by medication aides and nurses. She said they should check for expired, damaged, or discontinued medications. She said she was not aware of any expired medications in the medication room and said it was overlooked. She said if residents were given medications that were outdated, they would not get the therapeutic effect intended. During an interview on 4/23/2025 at 2:02 PM, the Administrator said the medication aides and unit managers should be checking daily to make sure medications were stored appropriately. He said medications that were outdated should be destroyed. Record review of a facility policy titled Storage of Medications revised April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on interview and record review, the facility failed to ensure residents had the right to be free from misappropriation of resident property for 1 of 2 residents (Resident #1) reviewed for misappropriation. The facility failed to prevent misappropriation of property when CNA A took money via cash app from Resident #1 in the amount of $106.00 dollars. The noncompliance was identified as PNC. The noncompliance began on 05/10/2024 and ended on 05/10/2024. The facility had corrected the noncompliance before the survey began. This failure could affect residents by putting them at risk for not being able to meet financial needs and diminished quality of life. Findings included: Record review of Resident #1's electronic face sheet, dated 01/06/2025, indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged from the facility to home on 05/18/2024 with two additional shorts stays (the latest stay admitted [DATE] and discharged to home 10/03/2024). Resident #1 had diagnoses of sepsis (systemic infection), atherosclerosis of bilateral lower extremities (decreased circulation with blockage by arteries and vessels of the lower legs), pain, and nausea. Record review of Resident #1's MDS assessment, dated 09/25/2024, indicated Resident #1 was understood by others and understood others. Resident #1 had a BIMS score of 14, which indicated the resident's cognition was intact. Record Review of an incident report created on 5/10/2024 at 6:00 p.m. by LVN C, This nurse notified by CNA B that Resident #1 had reported CNA A had access to resident's phone during the same time money was stolen, $106.00 was sent from resident's cash app to an account named Nessaaaa. Reported to DON and ADON. Requested statement from CNA and nurse went to resident's room to take a statement from resident. While in room, resident received an email that the $106.00 had been refunded. A cash app tag was attached to the refund. When this nurse searched the cash app, the account came up with the first name CNA A. Notified ADON and DON. Contacted Police Department and requested officer to facility. Officer to facility and took report and gave case #. All info reported to DON ADON, MD and Administrator. Record review of facility investigation report dated 05/11/24, included copies of documentation that the Administrator reported the misappropriation of $106.00 from Resident #1's cash app account to appropriate state agency, immediately suspended CNA A pending investigation, notified police department. The facility investigation included copies of completed employee- Abuse, Neglect & Exploitation in-service 05/11/24 and 5/12/24 with emphasis on misappropriation, documentation of completed resident interviews, documentation of completed resident safety surveys that indicated no reports of misappropriation by other residents and the residents interviewed felt safe at the facility, and a copy of employee disciplinary action form for suspension of CNA A on 05/10/24 completed per phone call. During a phone interview on 01/06/25 at 2:20 p.m., Resident #1 said she was a resident at the facility last May but was currently living at home. Resident #1 said last May she was planning to be discharged , when she asked CNA A to help her look at rent houses on her phone. After they viewed a few properties, CNA A proceeded with incontinent care, and she placed Resident #1's cell phone on the bedside table behind her. Resident # 1 said that it seemed like the care was taking too long and she became suspicious of what CNA A was doing. Resident #1 said after the care was completed, she looked at her phone and she had received a notification from her cash app that a $106.00 withdrawal/ scam alert. She said the money was returned to her account in less than an hour, after she confronted CNA A and alerted facility staff CNA B and LVN C. Resident #1 said she was very pleased how the facility handled the incident. She said that she received no harm due to the incident and she has had two additional short term stays at the facility since this incident. During interview with the DON on 01/07/25 at 2:30 p.m., the DON confirmed that CNA A never acknowledged she had taken the money, never returned to work, and was terminated via a phone call 05/16/24. The DON confirmed that police were notified (case # 24-00014617). During an observation and interview on 01/07/25 at 2:30 pm, LVN C said that the incident occurred as she reported in the incident and accident report. LVC C said she was immediately summoned to Resident #1's bedside and started notification and an investigation. LVN C said CNA A become nervous when Resident #1 confronted CNA A about the cash app being accessed and CNA A left the facility when the investigation started. LVN C shared screen shots of the cash transaction of $106.00 and refund that indicated a person by the first name of CNA A had made the transaction. Administrator not available for interview at time of investigation. Phone call attempted, no return call. Interviewed attempted by phone for CNA A with messages left with no return phone call. Record Review of a police report #2400014617 indicated: Public narrative, Nurse cash app's herself money from residents cash app without consent . Officer was at facility on 05/10/24 at 7:16 p.m. Officer obtained consent from Resident #1 to view cash app statements. The officer observed Resident #1 to receive a refund for $106.00 from CNA A. Resident #1 said that when she found the money missing, she confronted CNA A. Resident #1 said that CNA A became nervous and advised she had to leave. Resident #1 said that she received a refund from CNA A through her cash app. CNA A had already left the scene prior to arrival. Resident #1 wished to pursue charges on scene while speaking with officer. Case referred for processing. Review of Employee file revealed CNA A held a current Texas Nurse Aide Certification, was hired on 04/23/24 completed orientation to include abuse, neglect, exploitation, and misappropriation, maintaining resident rights including dignity, mail, visitors, personal property and telephone. Background Profile 04/09/24 reflected clear public records; Misconduct Registry 04/11/24 reflected no results found; Criminal History Conviction search reflected no search results found and a copy of the employee termination, completed with CNA A per phone call and signed by DON post complete investigation on 05/16/2024. During interviews with staff present on morning and evening shifts from 01/07/2025 10:00 am to 5:00 p.m. to 01/08/2025 9:00 a.m. to 3:00 p.m. revealed the staff were able to identify that the abuse coordinator was the Administrator. The staff said that they would report any abuse, neglect, exploitation, or misappropriation immediately, and had been trained on exploitation and misappropriation. A record review of the facility's Abuse, Neglect and Exploitation Policy revised April 2021 reflected that was the policy of the facility to 1. Protect resident from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to .a. facility staff. 2. Develop and implement policies and protocols to prevent and identify . c. theft, exploitation, or misappropriation of resident property.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 16 residents (Resident #2) reviewed for infection control. The facility failed to ensure CNA D and CNA E wore appropriate PPE for enhanced barrier precautions when providing catheter care to Resident #2 on 1/6/25. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings include: Record review of a facility face sheet dated 1/6/25 for Resident #2 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of myocardial infarction (heart attack). Record review of a 5-day MDS assessment dated [DATE] for Resident #2 indicated that she had a BIMS score of 13, which indicated that she had intact cognition. She required partial/moderate assistance with toileting hygiene. She had an indwelling catheter and was occasionally incontinent of bowels. Record review of a comprehensive care plan dated 10/3/24 for Resident #2 indicated that she required enhanced barrier precautions due to having a urinary catheter and a chronic wound. Record review of a physician's order summary report dated 1/6/25 for Resident #2 indicated that she had an order to implement enhanced barrier precautions. During an observation and interview on 1/6/25 at 1:30 pm Resident #2 was observed in her room sitting up in a wheelchair. She was observed to have a foley catheter (an indwelling urinary drainage tube to drain urine from the bladder to a bag on the outside of the body). She said that staff do not wear gowns when providing personal care to her. She said she did not know they were supposed to do that. No signage indicating EBP was observed. No PPE box was observed inside or outside the room. During an observation on 1/6/25 at 3:40 pm CNA D and CNA E were observed to provide catheter care to Resident #2 in her room without donning gowns as required for enhanced barrier precautions. During a joint interview on 1/6/25 at 4:00 pm CNA D and CNA E both said they were not aware that Resident #2 required enhanced barrier precautions. They both said they had not received training on enhanced barrier precautions or when to use it. During an interview on 1/6/25 at 4:20 pm Regional Nurse Consultant said enhanced barrier precautions should be used on any resident that had an indwelling medical device such as a foley catheter, a chronic wound, and certain infectious organisms. She said Resident #2 required enhanced barrier precautions due to having a foley catheter and a chronic wound. During a joint interview on 1/6/25 at 1:45 pm IP, Regional Nurse Consultant, and DON all said they expected staff to follow proper infection control protocol with regards to enhanced barrier precautions. DON said they had already begun to in-service staff and would continue to do so to ensure compliance. DON said Resident #2 must have just gotten missed being placed on EBP when she returned from the hospital in December. All said residents who require enhanced barrier precautions could be at risk for increased infections if protocol is not followed. Record review of a facility Annual In-Service Packet dated 9/30/24 for CNA D indicated that she had received training on enhanced barrier precautions on 9/30/24. Record review of a facility Annual In-Service Packet dated 9/30/24 for CNA E indicated that she had received training on enhanced barrier precautions on 9/30/24. Record review of a facility policy titled Enhanced Barrier Precautions dated March 2024 read: .EBP is indicated for residents with any of the following: .Chronic wounds (pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers) and/or indwelling medical devices (devices fully embedded in the body, i.e., central lines, hemodialysis catheters, urinary catheters, feeding tubes and tracheostomy tubes) even if the resident is not known to be infected or colonized with a CDC-targeted MDRO . .EBP will be used when performing the following high-contact resident care activities: .providing hygiene .changing briefs or assisting with toileting .device care or use: central line, urinary catheter, feeding tube, tracheostomy . .Residents who are on EBP will have signage placed outside their room to alert staff of those residents who require the use of EBP prior to providing high-contact care activities . and; .The PPE cart will be placed directly inside the resident's room or immediately outside the room with gown and gloves .

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from sexual abuse for 2 of 15 residents (Resident #1 and Resident #2) reviewed for abuse. 1. The facility failed to prevent sexual abuse for Resident #1 witnessed by CNA A on 06/08/2024 at approximately 2:00 p.m. to be in her room covered with a sheet and lying in bed with the Floor Tech. 2. The facility failed to prevent sexual abuse for Resident #2 that reported to CNA B on 06/08/2024 at 2:15 p.m. that the Floor Tech approximately two weeks prior had touched her hip, rubbed his penis against her while clothed, and asked if she was interested while making sexual body gestures. The noncompliance was identified as PNC. The IJ began on 06/08/2024 and ended on 06/08/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm, impaired quality of life in unsafe environment, and further abuse. Findings included: 1. Review of a face sheet for Resident #1, dated 06/25/2024, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses including: cerebral infarction (stroke), dysphagia (difficulty swallowing), UTI, mononeuropathy (nerve damage outside of brain and spinal cord), and anorexia (eating disorder). Review of Resident #1's quarterly MDS, dated [DATE], indicated she had a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate impairment, and a short-term memory score of 1 indicating she had a memory problem. Resident #1's functional status indicated she was non-ambulatory and required substantial/maximal assistance with ADL's. Review of Resident #1's care plan, dated 06/25/2024, indicated she rejects care such as skin assessments and evaluation with a suspected history of personal trauma with interventions to include identifying staff that result in least resistance, talk to resident/family about reasons for refusal of care, and ensure physical and emotional safety. Review of written interview statement by Social Worker with Resident #1, dated 06/08/2024, reflected the following: .Social Worker attempted to interview patient regarding reported sexual assault. Patient was unable to provide appropriate responses to questions asked. Patient is alert oriented with confusion, able to make her needs known. She requires total assistance of staff for ADL care and transfers. Review of hospital records for Resident #1, dated 06/08/2024, indicated she was sent to the ER after being found in bed with male staff member. Hospital records indicated Resident #1 reported she was sleeping and does not remember a staff member being in bed with her. Hospital records indicated Resident #1 denied pain or discomfort, and GU and skin exam were negative for abnormalities, pelvic pain, or vaginal bleeding. Review of progress notes signed by the ADON, dated 06/09/2024, indicated a head to toe assessment was completed 06/08/2024 on Resident #1 with no adverse findings. Review of progress notes signed by LVN C, dated 06/09/2024, indicated CNA A reported that staff member was found in the bed under the covers with Resident #1 at 2:10 p.m. Progress notes indicated staff member was fully dressed and immediately rolled out of the bed to his knees stating, it's not what it looks like. Progress notes indicated LVN C ensured patient safety by removing staff member from room, police interviewed resident, and resident was sent to the hospital. Review of Psychosocial Well-Being signed by the Social Worker, dated 06/12/2024, indicated Resident #1 was alert and oriented with confusion, no signs and symptoms of distress noted or verbalized, was sent to the ER for evaluation and treatment, and referral was warranted to psychology and psychiatry services. 2. Review of a face sheet for Resident #2, dated 06/25/2024, indicated she was a [AGE] year-old female, admitted on [DATE] and transferred to another nursing facility on 06/24/2024. Resident #2's face sheet indicated she had diagnoses including vascular dementia (impaired thought process due to brain damage from impaired blood flow to the brain), major depressive disorder, heart failure, and UTI. Review of Resident #2's discharge MDS, dated [DATE], indicated she had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impairment. Resident #2's mood indicated she had felt down, depressed, hopeless, with little interest in doing things for several days. Review of Resident #2's care plan, dated 06/25/2024, indicated she had interventions for suspected trauma to include ensure physical and emotional safety. Review of employee statement by CNA B, dated 06/08/2024, indicated the following: To whom it may concern I went to change [Resident #2] and she told me [Floor Tech], the housekeeper had got in the bed with her and was rubbing on her body with his hand and body. The resident told me that this has been going (on) 2 weeks on the weekends. Review of hospital records for Resident #2, dated 06/08/2024, reflected she was sent to the ER for complaints of being molested for 2 weeks and stated he rubbed his penis on the outside of her clothes two weeks ago. Resident #2's GU was negative for injury, bleeding, or discharge, and skin was negative for abnormalities. Review of progress notes signed by LVN C, dated 06/09/2024, indicated CNA B reported Resident #2 needed to talk to the nurse at 2:13 p.m. and Resident #2 told LVN C that a short black man with thick rimmed glasses with a lazy eye went into her room two weeks ago and rubbed his stuff on her, kissed her neck, and touched her breasts and hips. Progress Notes indicated LVN C notified the DON and ED was aware at 2:17 p.m., head to toe assessment was completed with no adverse findings, police interview resident, and was sent to the hospital. Review of progress notes signed by the ADON, dated 06/09/2024, indicated a head to toe assessment was completed 06/08/2024 on Resident #2 with no adverse findings. Review of employee statement by CNA A, dated 06/08/2024, indicated the following: I [CNA A] walked in [Resident #1's] room and (saw) the housekeeper [Floor Tech] in the bed with her (and) [Resident #2] told me and [CNA B] that [Floor Tech] had been in the bed with her and rubbing on her body. Review of written interview statement by Social Worker with Resident #2, dated 06/12/2024, reflected the following: Patient stated that two weeks ago, a short black guy, who wore maroon clothing, wearing big and bulky glasses with a soft voice meandered into her room and said hi. Patient stated that she did not remember his name. She wasn't sure if he told her his name. The patient says she was lying down in bed, and he was standing by bedside moving his body suggestively. Patient told him that she was not interested. He then made a sarcastic statement voicing his opinion that it was ok. Patient stated that he touched her left hip and started moving his body so she would get the idea. He was moving suggestively his thing back and forth in front of her. Patient stated that this same type of incident has happened twice. Patient says he never got in bed or touched her in any other places. Review of provider investigation report, dated 06/13/2024, reflected the following: . Facility Investigation Findings: Confirmed . Investigation Summary Incident: Per staff member [CNA A] staff member [Floor Tech] was found in the bed with [Resident #1]. [Resident #2] reported that a man that wears thick glasses and a lazy eye rubbed his stuff on her and touched her . Summary of Assessments: Both resident[s] received a head-to-toe assessment with no adverse findings. Timeline 06/08/2024 1410 (2:10 p.m.) [CNA A] Nurse Aide reported to charge nurse [LVN C], that during rounds she noted [Floor Tech] lying in bed under the covers with [Resident #1]. Per [CNA A], [Floor Tech] was fully dressed and immediately rolled out of bed to his knees stating, It's not what it looks like. Nurse assessed patient with no adverse findings. 1412 (2:12 p.m.) [LVN C] reported events to [DON]. DON called [ED] to report what was reported to her. Per our [CNA A] [Floor Tech] was following her around the building repeatedly telling her it's not what you think, and it's not what it looks like. [LVN A] was instructed to get the staff together and search the building for [Floor Tech] and get him to the front of the building and away from the resident care areas. 1415 (2:15 p.m.) [CNA B], nurse aide, reported to [LVN A], that resident [Resident #2] needed to talk to her. Stating it is the same thing going on as the other one. Per [LVN A] she went directly to the room and spoke with [Resident #2] in room [Resident #2's room] while staff searched for [Floor Tech]. 1417 (2:17 p.m.) [LVN A] reported to [DON], that resident [Resident #2] reported that a shirt black man with thick rimmed glasses with a lazy eye went into her room two weeks ago and rubbed his stuff on her, kissed her neck, and touched her breasts and hips. [DON] made [ED] aware of what was reported. [Police Department] called for an officer to come to the building. 1424 (2:24 p.m.) [LVN A] escorted [Floor Tech] to the front of the building. He was not in the resident care areas and [LVN A] stayed with him one to one until police arrived. [6:00 a.m. to 2:00 p.m.] staff were phoned to come back to the facility to give statements and provide an interview with the police. 1434 (2:34 p.m.) [Police Department] arrived and took [Floor Tech] into the conference room for questioning and instructed [LVN A] to await questioning in the chapel. 1440 (2:40 p.m.) MD made aware of incident with noted new orders to send both residents to the ER for evaluation and treatment. 1447 (2:47 p.m.) [CNA B], nurse aide arrived back to the facility for interview and statement retrieval and was asked to await questioning in the admissions office. 1449 (2:49 p.m.) Resident families notified per [Social Worker]. Family voice understanding of information given. 1450 (2:50 p.m.) Two police officers joined [CNA B] in the admissions office for questioning and statement collection. 1455 (2:55 p.m.) [CNA A], nurse aid, arrived back to facility for statement and interview and was asked to stay at the receptionist desk area and await interviewing. Four police officers question [LVN C], as to where the residents live and she escorted them to the residents rooms. Two police officers entered the room of [Resident #1] and two others entered the room of [Resident #2] to question and take statements. [Social Worker] made aware of the situation, and she reported that she was headed to the building to start life safety rounds. 1507 (3:07 p.m.) [CNA B]' interview completed, and she was asked by police to wait in the lobby until the detective arrived. 1508 (3:08 p.m.) [LVN A] was taken into the Chapel and [CNA A] was taken into the admissions office for interview and questioning by [Police Department]. Statements retrieved and staff were asked to wait for the investigator to arrive for additional questioning. Police kept all staff separate from each other. [Social Worker] at building performing life safety rounds. 1515 (3:15 p.m.) Police reported to [LVN A] that the interview was completed at this, and she was free to go back to the floor and finish her tasks. 1526 (3:26 p.m.) [DON] and [ADON] arrived at the building and spoke to police and were escorted to the admission office. An officer came into the office and gave a summary of events and allegations. In-service education started on abuse, neglect, exploitation, reportable incident protocol, accident and incidents, abuse prevention program, abuse prohibition protocol, HIPPA and privacy laws, and media policy. 1618 (4:18 p.m.) The detective arrived at the building and entered the conference room with [Floor tech]. Noted questioning started at that time. Background checks [of] 100% of employees to be completed. The detective and two police officers approached CNA A and CNA B and asked if they would be willing to testify in court as to what they saw and what happened. Noted both said yes, that they would. 1723 (5:23 p.m.) [Floor Tech] was taken out of the building in handcuffs and transported to a police SUV. DON spoke with the detective to see if there was any other needed information or details that he could share with us. Perfect detective, [Floor Tech] will be charged with a state grade felony and taken to jail. 1733 (5:33 p.m.) Residents [Resident #1] and [Resident #2] transportation was set up via (by) [transportation service] to [hospital] for evaluation and treatment as well as SANE evaluation. 1745 (5:45 p.m.) [transportation service] arrived with two ambulances and transferred each resident x2 people to the stretcher, tolerated well. No complaints of pain/discomfort. VS stable. 1800 (6:00 p.m.) 100% audit completed on skin assessment her LVN D, LVN E, LVN F, LVN G. No new adverse findings. 2100 (9:00 p.m.) [Resident #2] return from the hospital with no new orders. SANE Visit unable to be performed due to reported event being over 180 hours ago. New suggestion for the resident to be seen at [an intermediate care facility] for counseling. Per [MD] resident can use in-house psych services instead. 0400 (4:00 a.m.) Resident [Resident #1] return from the hospital. Her hospital no new diagnosis. Wrote order for Macrobid but house MD reported that current treatment is better for UTI and not to change the treatment at this time. Resident in stable condition. 06/10/2024 0830 (8:30 a.m.) Emergency QAPI performed and in-servicing continued. Investigation continued and employee questionnaires and acknowledgements. 06/12/204 1100 (11:00 a.m.) DON called and spoke with dispatch with [Police Department] to inquire about the police report. Per dispatch the detective was out of the office and a message must be left. Message left for [Detective] at [phone number] and awaiting a call back for case number 24-18035. 06/13/2024 1030 (10:30 a.m.) [Medical records] requested hospital records for both patients' ER visit on 06/08/2024 be sent to facility. Awaiting records. 1400 (2:00 p.m.) Received records from hospital. 1500 (3:00 p.m.) DON placed follow up call to psych services regarding psychological evaluation on both patients 1515 (3:15 p.m.) DON placed follow up call to police department to request report. 06/14/2024 0840 (8:40 a.m.) [Psychologist] on site to evaluate both patients. Notes to be sent. Actions taken by facility: Reported to HHSC. Employee was immediately removed from the patient care area until police arrived. Police department notified. Both patients were sent to the ER for evaluation and treatment as indicated. 100% Abuse Questionnaires/safe surveys of interviewable patients. 100% head to toe assessments of non-interviewable patients. 100% rounds of all patients to ensure their safety. Request video footage from family to review incident, if available. Psychosocial assessments completed. Referrals to [psych service]. Abuse Questionnaire for 100% of staff. 100% audit of employee background checks. 100% of interview/statements from staff members. Note any history of unusual behaviors with the suspected employee. Sex registry check on suspect. Grievances. Completion of Accident/Incident Reports. Review of employee's schedule and time punch detail. Review of employee file and prior BGC (background check}. In-service on abuse and identify sexual abuse. In-service Abuse Prohibition Protocol. In-service on Media Police and HIPPA. Notification to RPs. Physician Notification. Notification to the Ombudsman. Conclusion: After questioning the staff and alleged perpetrator, [Floor Tech] was taken to jail by police. He was terminated from [the facility] and a criminal trespass would be issued per police officer. Review of psychiatric consult by Psychologist, dated 06/14/2024, reflected the following: .[Resident #1] Diagnostic assessment was completed with (patient) indicating informed consent. (Patient) required intermittent support to remain adequately engaged. She gestured indicating she feels depressed and anxious. Patient demonstrated poor eye contact and actively turned away at one point. When psychoeducation related to sexual assault was provided. (Patient) made eye contact and asked how anyone could possibly understand how she feels. She went on to provide she worked as a nurse in the past. Patient cried and ceased to speak in an easily understandable manner, but repeated the word 'fear' and referred to difficulty with urination. Collateral information indicates patient's communication function, as demonstrated in assessment, is typical. Additionally, (patient) reportedly demonstrates periods of agitation at times. (Patient) indicated emotions including anger, fear, depression, and anxiety difficulty with reliable and consistent communication complicates assessment and treatment. Available data indicates evidence of depression, anxiety, and PTSD. Diagnostic clarity may improve over time and (diagnosis) should be updated accordingly. As {patient} demonstrates ability to communicate effectively at times, it is recommended psychotherapy services be provided to determine whether she may benefit . Review of psychiatric consult by Psychologist, dated 06/14/2024, reflected the following: .[Resident #2] Diagnostic assessment was completed with (patient) providing informed consent and participating fully in session. She responded to rating scales in a manner consistent with interview and collateral data. (Patient) acknowledged she was sexually assaulted recently and feels angry about the violation(s). (Patient declined to discuss details of the assault(s). (Patient) commented on feeling overwhelmed by the combination of recent sexual assault with existing somatic and dependence-related stressors. (Patient_ was in favor of pursuing psychotherapy services to address affective and behavioral symptoms. Initial impressions suggest (patient) is demonstration sx (symptoms) consistent with moderate anxiety disorder, mild depression, and acute PTSD. (Patient) made no requests for changes or supports at present. She reported feeling safe in the NF (Nursing Facility) . During an interview on 06/21/2024 at 3:21 p.m., the Administrator and DON said the Administrator was the abuse coordinator and that he had been employed for one week at the facility and the DON had been employed since December 2023. The Administrator said he was aware of a sexual abuse allegation that was self reported but that it occurred prior to his employment at the facility. The DON said she was aware of the sexual abuse allegation that was a self reported incident concerning the Floor Tech. The DON said there was an allegation of sexual abuse on 06/08/2024 when CNA A was making rounds in the hallway she had noticed a residents door was shut and when she opened the door the Floor Tech was in the bed with Resident #1. The DON said there was no harm to the resident noted and she was sent to the ER for an evaluation and she came back to the facility with a suggestion for UTI and no other orders. The DON said Resident #1 was evaluated by a SANE nurse and the DON had been calling the Investigator daily to get those results because the hospital would not release them since they were under investigation. The DON said there were no concerns with the Floor Tech's background history and that he had a clear record. The DON said the Floor Tech was brought to the front of the building immediately to ensure resident safety and two staff members sat with him until the police came and he was escorted off the property. The DON said he was arrested, did not know he was currently in jail but that he got bonded out on Sunday, 06/09/2024. The DON said the family was notified and was not sure if they decided to press charges. The DON said it was important residents were free from sexual abuse to ensure their well-being and safety and in response to the incident the facility completed 100% of skin assessments on residents, social life safety rounds,and in-servicing on abuse. The DON said there was one other resident, Resident #2, identified with related concerns. The DON said Resident #2 reported about 2 weeks prior the Floor Tech had came into her room and was rubbing his private area on her body and had touched and kissed her neck. The DON said Resident #2 did not mention any other times and said it only happened once. During an interview on 06/21/2024 at 4:09 p.m., the Ombudsman said she had a concern that she received a self report that a staff member was found in the bed with a resident. During an observation on 06/21/2024 at 4:28 PM, Resident #1 was laying in bed on her left side covered with sheet, bed in low position, and the door to room was open with her television on. Resident #1 did not respond to greeting or questions and appeared in no apparent distress. During an interview on 06/25/2024 at 9:30 a.m., CNA A said she had been employed at the facility since April 2024. CNA A said on 06/08/2024 around or after 1:00 p.m., she walked in the room and saw the Floor Tech lying behind Resident #1. CNA A said Resident #1 had her eyes closed facing the door, lying on her side and the Floor Tech was lying on his side behind her under the covers. CNA A said the Floor Tech appeared to have his clothes on and when he rose up he spinned the covers around and started to act like he was cleaning her bed. CNA A said she did not notice any facial grimacing on Resident #1 at the time of the incident and could see her brief was on and it appeared to be on appropriately and there were no other individuals in the room. CNA A said Resident #1's door was closed and she was a fall risk so staff leave the door open. CNA A said when the Floor Tech rose up from the bed he put his hand across her wiping the bed off and said the bed was wet and grabbed the covers off of her and went to put it in the laundry. CNA A said it was important to protect residents from abuse to ensure their safety and told CNA B that she had to report something to the nurse and when she saw LVN C she reported to her immediately. CNA A said CNA B was a witness that saw the Floor Tech come out of the room. CNA A said LVN C checked on Resident #1 and was calling and notifying management when the Floor Tech was following CNA A around trying to persuade her she did not see anything. CNA A said after she reported to LVN C, she entered Resident #2's room with CNA B and Resident #2 began to report a related concern of staff being inappropriate with her and described the Floor tech's appearance. CNA A said after they reported Resident #2's concern to LVN C it was the end of her shift and she had to return to the facility the same day to write a statement and the police ended up taking the Floor Tech to jail. CNA A said Resident #2 reported they had the wrong people working in this facility and that the little dark man had been rubbing on her. CNA A said Resident #2 reported to CNA B that the Floor Tech had been coming in her room touching and rubbing on her. CNA A said the Floor Tech may have done it to more but no other residents have reported any related concerns that she was aware of and had not noticed any scratches or changes in behavior such as resident being withdrawn. CNA A said Resident #1 is sometimes confused and had been acting normal with no apparent changes. CNA A said Resident #2's family came to get her. CNA A said the facility put interventions in place to prevent sexual abuse by removing the Floor Tech from resident care areas, providing in-services on abuse, and completing assessments on all residents. During an interview on 06/25/2024 at 10:09 a.m., CNA B said she had been employed since November 2015 and had received training on abuse by in-services within the last month and did not suspect abuse at this facility other than the concern with the Floor Tech. CNA B said it was important for residents to be free from abuse to ensure residents safety. CNA B said she noticed the Floor Tech seemed different that day (06/08/2024) and he had his housekeeping cart on her hall and was not cleaning. CNA B said she works with CNA A and felt that the Floor tech was watching what hall they were working on because they had just finished checking on Resident #1's hall. CNA B said they decided to check on the same hall again before ending their shift and realized Resident #1's door was shut. CNA B said they never shut Resident #1's door because she was a fall risk. CNA B said CNA A came out of the room directly across from Resident #1 and when she came out of the room she saw the door was closed and thought CNA B was in there because she was a two person assist. CNA B said CNA A went in the room, came out, and told her what she saw then notified LVN C. CNA B said she finished the room she was in and went to Resident #2's room. CNA B said at that time, Resident #2 said she needed to talk and needed her help. CNA B said she reassured Resident #2 and that she could tell her anything and Resident #2 asked if CNA B could keep a man out of her room that met Floor Tech's description as a short, bald man that wears big glasses and has one eye that is lazy. CNA B said Resident #2 told her the man keeps getting in the bed with her and he was rubbing his hand and body all over her. CNA B said Resident #2 reported the Floor Tech incident always happened on the weekend when he was working and had been going on for two weeks. CNA B said she left out of the door to confront the Floor Tech and CNA A reminded her not to get angry with him and she calmed down. CNA B said the Floor Tech was following them trying to persuade CNA B and CNA A it wasn't what they saw and they told him to leave them alone. CNA B said LVN C got him in the conference room immediately following report of the incident and was instructed she could not leave until the DON and police came. CNA B said she wrote out her statement and the police cuffed him and took him out of the door. CNA B said there was one resident, Resident #3, that reported a week before that the Floor Tech had went in her room and was standing over her bed. CNA B said the facility was thinking Resident #3 was not herself because she is sometimes confused. CNA B said she felt the facility handled the situation appropriately and that there was a sweep of the facility to check on all the residents. During an interview on 06/25/2024 at 11:00 a.m., LVN C said she had been employed since January 2024. LVN C said at that the moment she did not suspect abuse and had received training on abuse by in-services with the most recent this week. LVN C said she was the charge nurse notified when the Floor Tech was found in the room with Resident #1. LVN C said CNA A notified her and she immediately went down to check on the resident and report while she had another nurse aide stay with Resident #1. LVN C said while she was reporting that incident, another aide notified her of Resident #2's similar concern. LVN C said she had that aide stay with Resident #2 and obtained the Floor Tech and notified police. LVN C said when she checked on Resident #1 she was fine and was her normal self, normally confused and disoriented with no new injuries. LVN C said Resident #1 did not know what was going on and she did not remember the Floor Tech had gotten in the bed with her. LVN C said her peri area was checked with no concerns and her diaper was fastened on all 4 contact points appropriately. LVN C said she was wearing clothes that were not disoriented at all. LVN C said Resident #2 reported that about two weeks ago, a short man with thick glasses and a lazy eye came into her room and was rubbing his junk on her and touching on her. LVN C said Resident #2 did not tell anyone and when asked why she said she was out of her mind and was not eating or drinking and had altered mental status due to a fall. LVN C said she assessed Resident #2 and she had no injuries. LVN C said Resident #2 reported she had her clothes on but he was kissing her neck and touching on her and denied that he made penetration. LVN C said Resident #2 told her he had not taken his clothes off around her and she did not say anything about her roommate. LVN C said to ensure residents were safe and free from abuse the facility did in-service training, a facility wide skin sweep, and interviews with the social worker. During an interview on 06/25/2024 at 11:38 a.m., the Social Worker said she got the report that one of the CNA's walked in the room and Floor Tech was in bed with Resident #1. The Social Worker said she interviewed the entire building that was interviewable. The Social Worker said she did have one resident, Resident #2, that stated the Floor Tech had came in her room and he was standing in front of her gesturing and saying it would be okay and rubbed her leg that occurred on two occasions and he touched her and posturing himself in front of her to put his body in her face moving his body around. The Social Worker said the facility completes background checks and checks employee history prior to hire. During an interview on 06/25/2024 at 12:00 p.m., LVN E said she had been employed off and on since 2022 and did not suspect abuse at the facility. LVN E said she received in-services on abuse and when they should report to state concerning some reportables that happened within the past couple of weeks. LVN E said it was important to ensure residents were free from abuse to ensure their safety. LVN E said she was not here when the Floor Tech was found in Resident #1's room and that no residents have reported to her of any inappropriate behavior from male staff. During an interview on 06/25/2024 at 1:54 PM, the RP said he was in the process of getting Resident #1 transferred closer to him. RP said the facility reports any problem with Resident #1 and had received a report of staff being inappropriate with Resident #1. RP said he was aware that the facility put him on administrative leave and he did not decided to press charges but has decided to move her to another facility closer to him in the central Texas area. During an interview and observation on 06/25/2024 at 4:35 p.m., Resident #2 was interviewed at her new nursing home facility. Resident #2 was laying in her bed. Resident #2 said she liked being in the new facility. Resident #2 said when she was at her old [facility] a short stocky black man molested her. Resident #2 said she reported the incident, and the facility fired him. Resident #2 said the man put his hands on her sides and rubbed himself on her stomach while she laid in her bed. When asked what she meant by he rubbed himself she said his penis. Resident #2 said he did not take his penis out and he did not take off her clothing. Resident #2 said when the man rubbed himself on her it made her feel sick and terribly dirty. Resident #2 said she was not physically hurt because she did not fight back. Resident #2 said she did not fight back because she wanted to get it over with. When asked if the man said anything to her, she said you mustn't tell anyone. When asked if he said anything else Resident #2 replied a bunch of stupid love stuff. Resident #2 said after the incident she stayed close to her roommate because if her roommate was around, he wouldn't bother her. Resident #2 said her roommate was usually in her room so she would stay in her room. Resident #2 said her roommate was not in her room at the time of the incident. Review of in-service signed by the Floor Tech, dated between 05/13/2024 through 05/16/2024, reflected education was provided to staff Abuse, Neglect, Reporting - Employee Investigation Questionnaires, and Employee Abuse Acknowledgement. Review of in-services dated 06/08/2024, and emp [TRUNCATED]

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility failed to date six packages of white cake mix and two packages of gelatin mix that were in the dry storage area on 3/4/2024. The facility failed to ensure the DM and Cook wore a hairnet effectively to cover all of their hair on 3/5/2024. These failures could place residents at risk for food-borne illnesses. Findings included: During an observation on 3/4/2024 at 9:10 AM in the kitchen, the dry storage area had six packages of white cake mix and two packages of gelatin mix that were removed from the original box that was not dated. During an interview on 3/4/2024 at 9:30 AM, the DM said everyone that worked in the kitchen were responsible for dating and labeling items and staff were aware not to put anything up without dating and labeling. During an observation and interview on 3/5/2024 at 11:15 AM, the Cook was pureeing food for lunch and the DM was present in the kitchen assisting as needed and both did not have their hair completely covered with the hairnet. They both had hair sticking out from underneath the hair net on the sides of both of their ears and at the back of their necks . The cook said all hair should be covered by the hairnet prior to entering the kitchen and by not doing so could cause cross contamination. During an interview on 3/5/2024 at 2:45 PM, the DM said all staff as soon as they entered the kitchen must put on a hairnet and make sure it completely covered their hair. She said they in-serviced staff on hairnets and labeling of foods on 3/5/2024. She said there could be a risk of hair falling into the food if hair was not completely covered while in the kitchen. Record review of in-service training report dated 3/5/2024 conducted by the DM indicated the kitchen staff were trained on dating and labeling: all items must have date and label before storing. Training also included hair nets: hair nets must be worn while in the kitchen. All hair must be covered. During an interview on 3/6/2024 at 11:50 AM, the Administrator said he was made aware of the items in the kitchen that were not dated and the staff not wearing hairnets appropriately. He said it was the responsibility of the DM for ensuring the foods were dated or whoever put up the food in the kitchen. He said all staff in the kitchen should be wearing hairnets when in the kitchen area. He said hair could fall into food while preparing. He said not dating items depended on the expiration dates of the items. He said going forward they would educate the staff and conduct audit checks between him, the DM, and the RD. Record review of a facility policy titled Food Storage revised 3/2019 indicated, .4. All food items should be dated with the received dated, unless labeled with a readable label from the food vendor . Record review of a facility policy titled Employee Sanitary Practices dated November 3, 2004, indicated, .All employees shall: 1. Wear hair restraints .

Based on interviews and record review, the facility failed to ensure the resident and the resident's representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 6 residents (Resident #4) reviewed for care plans. The facility failed to invite and include the input of the resident responsible party as members of the interdisciplinary team after the completion of the comprehensive assessment for Resident #4. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings included: Record review of a facility face sheet dated 3/6/24 for Resident #4 indicated that she was a [AGE] year-old woman admitted to the facility on [DATE] with a diagnosis of dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #4 indicated that she had a BIMS score of 5, which indicated that she had severe cognitive impairment. Record review of a Quarterly Care Plan Conference invitation letter sent to Resident #4's responsible party indicated that it was sent for the meeting scheduled on April 20, 2023. No invitations were found after this date. During a telephone interview on 3/4/24 at 4:05 pm Resident #4's responsible party said that she had not been invited to or involved in a care plan meeting in almost a year. During an interview on 3/6/24 at 11:10 am the RNC provided the letter for the April 20, 2023 conference. She said that was the last letter sent out. During an interview on 3/6/24 at 2:10 pm the SW said that they had been without an MDS nurse for nearly a year. She stated someone offsite was doing it and she was not receiving the calendar for sending the letters out. She said that she was now making her own calendar to keep up with it and would make sure that she did not miss anymore letters. She said that the facility had been holding the meetings, she just had been failing to send the letters out. She said that she could see where some residents could be at risk of not having personalized care without family input. Record review of a facility policy titled Care Planning - Interdisciplinary Team dated 2001, revised September 2013, read .The resident, the resident's family, and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan .

Based on interview and record review, the facility failed to assess each resident quarterly (every 3 months or 92 days) using the MDS (minimum data set) form specified by the state and approved by CMS (Centers for Medicare & Medicaid Services) for 1 of 6 residents (Resident # 271) reviewed for quarterly assessments. The facility failed to ensure Resident # 271 had a quarterly MDS assessment completed within 3 months or 92 days from the previous assessment that was completed on 07/26/2023. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions. Findings included: Record review of a facility face sheet dated 3/06/2024 indicated Resident #271 was a [AGE] year-old male and admitted to the facility on [DATE] with a diagnosis of cervical disc disorder (disorder of the bones in the neck). Record review of the MDS assessment list indicated Resident #271 had an admission MDS assessment completed on 7/26/2023 however did not receive a quarterly assessment until 12/22/2023. A quarterly MDS assessment was due on or before 10/26/2023. During an interview on 03/06/2024 at 2:29 PM the MDS coordinator stated that she started at the facility at the end of October 2023 and was not sure why Resident #271 did not have a quarterly MDS assessment completed. She stated Resident #271 was on managed care and may have been the reason it was missed. She stated that all residents should get a MDS Assessment within 14 days of admission, quarterly every 92 days and as needed for any significant change in condition, despite payor source. She stated if MDS assessments were not done accurately it could affect resident care. During an interview on 03/06/2024 at 2:42 PM the RCC (regional care coordinator) stated he oversaw the MDS nurse at the facility. He stated the previous MDS nurse missed the quarterly MDS assessment on Resident #271. He stated Resident #271 should have had an assessment within 92 days of the completion of the admission assessment. He stated the facility had not had a full time MDS nurse until October 2023 and assessments were being completed offsite. He stated when the MDS system changed in October 2023 they had software issues and that could have been the cause for it being missed. He stated if assessments were not done the care plan would not be accurate and could affect resident care. He stated he expected the MDS nurse to follow and track the assessments to ensure they were done per the regulations. During an interview on 03/06/2024 at 4:55 PM the administrator stated that the MDS coordinator was responsible but at that time the MDS assessments were done off site and he was not sure how MDS assessments were monitored. He stated the RCC assisted the MDS nurse with the assessment schedules and if a MDS assessment was not done per timeframes the care plan would not be up to date. He stated he expected the MDS nurse to follow the timeframe for all MDS assessments. He stated the facility did not have a policy for MDS timeframes and submission and followed the RAI (resident assessment instrument) manual for MDS assessment completion and submission.

Based on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #63) reviewed for indwelling catheters. The facility failed to prevent Resident #63's urinary catheter drainage bag from touching the floor. These failures could place residents at risk for inappropriate placement of indwelling catheters, discomfort or injury, and urinary tract infections. Findings included: Record review of a facility face sheet dated 3/6/24 for Resident #63 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of essential hypertension (high blood pressure). Record review of a Comprehensive MDS Assessment for Resident #63 dated 1/8/24 reflected that he had a BIMS score of 7, which indicated that he had severe cognitive impairment. Section H indicated that he used a urinary catheter. Record review of a Comprehensive Care Plan dated 3/6/24 for Resident #63 indicated that it did not address the use of a urinary catheter. During an observation on 3/4/24 at 12:20 pm Resident #63 was observed sitting at a table in the dining room with his drainage bag underneath his wheelchair, touching the floor. A restorative aide was observed to remove the resident from the dining room and push him down the hallway with the drainage bag dragging on the floor. During an observation on 3/4/24 at 2:47 pm, Resident #63 was observed lying in bed asleep with his bed in low position. Urinary drainage bag was observed to be hanging from the bed with the bottom of the bag on the floor. During an observation on 3/5/24 at 9:04 am, Resident #63's drainage bag was noted to be hanging from the bed and the drainage bag touching the floor. During an interview on 3/5/24 at 9:20 am, LVN C said that she would get with the DON to see what to do about the bag being on the floor. She said that his bed needed to stay in the low position. She said that the bag should not be placed on the floor and by being on the floor, it could increase the risk for infections. During an interview on 3/5/24 at 9:25 am the DON said that she would figure out some way to keep his bag off the floor. She said that she understood that the bag being on the floor increased the risk for infection. She said that she expected her staff to follow policy of keeping the bag off the floor. During an interview on 3/6/24 at 11:00 am the DON said that they had ordered some low bed specific drainage bags and would be using a basin or a tub until they came in to keep the bag off the floor. She said that she would also be providing in-services for education for nursing staff regarding this. During an interview on 3/6/24 at 2:53 pm the Administrator said that the catheter bag should not be on the floor because it could cause infection, or the bag could tear or leak. He said that he would plan on doing observations and implementing education to help prevent this. Record review of a facility policy titled Catheter Care, Urinary dated 2001, revised September 2014 read .be sure the catheter tubing and drainage bag are kept off the floor .

Based on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided care, consistent with professional standards of practices for 2 of 13 residents reviewed for respiratory care (Residents #7 and #122). 1.The facility failed to ensure Resident #7's nebulizer mask was changed per the facility's policy. 2.The facility failed to ensure Resident #122's humidifier bottle and tubing for the oxygen concentrator were changed per the facility's policy and Physician orders. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress. Findings included: 1.Record review of a facility face sheet dated 3/6/24 for Resident #7 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of hemiplegia following cerebral infarction (weakness/paralysis due to a stroke). Record review of a Quarterly MDS assessment dated [DATE] for Resident #7 indicated that she had a BIMS score of 9, which indicated that she had moderately impaired cognition. Section O indicated that she had received nebulizer treatments for at least 15 minutes for 7 of the previous 7 days of the assessment reference date (2/6/24). Record review of Medication Administration Records for Resident #7 for February 2024 and March 2024 indicated that she received twice daily nebulizer medications. During an observation and interview on 3/4/24 at 10:44 am, Resident #7 was observed lying in bed. A nebulizer mask was observed on her bedside table in a bag which was dated 1/7/24. Resident #7 was unable to say if she used it often. She said that she could not remember. 2.Record review of a facility face sheet indicated Resident #122 was an [AGE] year-old female and admitted to the facility on [DATE] with a diagnosis of COPD (group of lung disease that make it difficult to breathe). Record review of a quarterly MDS assessment dated [DATE] indicted Resident #122 had an impairment in thinking with a BIMS score of 12 - and had special treatments, procedures, and programs that included oxygen therapy as a resident within the last 14 days. Record review of comprehensive care plan with revision date of 12/18/24 indicated Resident #3 had COPD (chronic obstructive pulmonary disease that affects breathing). Record review of a consolidated physician's order list for Resident #122 indicated an order dated 01/17/2024 to administer oxygen 2-4 liters per minute by nasal cannula and change/date oxygen tubing one time weekly. During an observation and interview on 03/04/24 at 10:19 am revealed Resident #122 had oxygen on at 4 liters via nasal cannula. The oxygen tubing was not dated and humidified water bottle was dated 02/18/24 and dry. Resident #3 stated she wore her oxygen all the time and did not know when the bottle or tubing had been changed. During an observation 03/04/24 2:00 PM humidifier bottle remained dry and dated 02/18/24. During an observation on 03/06/24 10:30 AM the humidifier bottle was full of water and bubbling. The bottle and O2 tubing were dated 03/05/24 and O2 on at 4 liters per nasal cannula . During an interview on 3/06/2024 at 2:20 pm, the DON stated the charge nurses were responsible for changing the oxygen tubing and humidifier bottles weekly. She stated by not doing so could cause oxygen delivery issues or infections . The DON said she was responsible for ensuring processes are in place. During an interview on 3/06/2024 at 3:00 pm, the Administrator said nursing was responsible for cleaning the oxygen concentrators, changing the tubing and bottles every Sunday, and as needed. He said the DON was to oversee that the nursing staff were following the respiratory care policy and expected respiratory equipment to be cleaned and changed weekly. He said she would have the DON or designee do an audit to check that they were done. He said the residents could be at risk for inadequate air flow if the concentrators were not cleaned and infections. Record review of a facility policy titled Administering Medications through a Small Volume (handheld) Nebulizer dated 2001, revised October 2010, read .Change equipment and tubing every 7 days . Record review of a facility policy dated October 2010 and titled Oxygen Administration indicated, . Purpose the purpose of this procedure is to provide guidelines for safe oxygen administration .12. Check the mask, tank, humidifying jar etc., to be sure they are in good working order, and securely fastened. Be sure water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. 46273

Based on observations, interviews, and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 4 residents reviewed for misappropriation of property. (Resident #124). The facility failed to prevent a diversion (misappropriation) of Resident #124's Zofran tablets (used to treat nausea and vomiting) a total of 4 tablets. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity. Findings included: Record review of a facility face sheet dated 3/6/24 for Resident #124 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of acute posthemorrhagic anemia (a condition that develops when you lose a large amount of blood quickly and it causes a low number of red blood cells or a low amount of hemoglobin in your red blood cells). Record review of a Comprehensive MDS assessment dated [DATE] indicated that Resident #124 had a BIMS score of 15 which indicated that she was cognitively intact. Record review of a physician order report dated 3/6/24 for Resident #124 indicated that she had a physician order for ondansetron (Zofran) 4mg disintegrating tablets, 1 tablet as needed every 6 hours for nausea with a starting date of 2/27/24. Record review of Medication Administration Records for Resident #124 for the months of February 2024 and March 2024 indicated that she did not receive any doses of Zofran. During an observation on 3/5/24 at 3:54 pm the state surveyor randomly chose 3 narcotic cards to compare to count book on nurse's medication cart. No discrepancies were found. During an observation on 3/6/24 at 2:00 pm 7 tablets of Zofran in individual blister packs were observed in the DON's office. These were found in LVN B's personal belongings on 3/4/24 by the DON and the Administrator. A label with Resident #124's identifying information was stuck to 2 of the tablets. Also observed was an empty package with Resident #124's prescription information indicating that it had been filled on 2/27/24 with a quantity of 4 tablets. This packaging had been found in the trash after finding the tablets in LVN B's possession. A telephone interview was attempted on 3/6/24 at 9:55 am with LVN B. No answer was received, a voicemail was left requesting a return phone call. Another attempt was made at 2:18 pm on 3/6/24, the phone rang twice, then disconnected. The state surveyor was unable to leave a voicemail at this time. No return phone call was received before exit. During a telephone interview on 3/6/24 at 2:18 pm, CNA A said that on 3/4/24 she had witnessed LVN B at the medication cart and heard a pop .pop .pop . like she was removing medications. She then witnessed LVN B go to the nurse's station and sit down. CNA A said that LVN B always kept her purse at the nurse's station. She said that she then heard what sounded like LVN B putting medications in a bottle. She said that she immediately went to the DON to report the allegation. During an interview on 3/6/24 at 2:30 pm the DON said that she had immediately went to LVN B with the RNC and the Administrator. She said that they asked her about the allegation, which LVN B denied. She said that LVN B agreed to let them look in her purse. She said that she found LVN B's personal medications along with 7 tablets of Zofran in separate blister packs along with Resident #124's identifying prescription information. She said that LVN B said that she did not know how the medication got there. The DON said that LVN B was counseled, and drug tested with permission. She said that LVN B was suspended pending investigation, but LVN B voluntarily terminated at that time. The DON said that she also found an empty package with Resident #124's prescription information in the trash on LVN B's medication cart. She said that the package was empty and had been filled with 4 tablets. She was unsure where the other 3 tablets of Zofran came from. She said that they had looked through the narcotics and did not find anything else missing. She also said that they had called the pharmacy consultant to come in and do a review. During an interview on 3/6/24 at 2:53 pm the Administrator said that the CNA had reported the allegation to the DON. He said that he went with the DON to the nurse and LVN B denied the allegations. He said that they asked to look in her purse. He said that they went into an empty resident room and emptied her bag out. He said that all of LVN B's personal medications were in there along with the Zofran tablets for Resident #124. He said that LVN B said that they weren't hers. He said that they then did a cart count with the DON, LVN B, and himself and all counts were accurate. He said that the incident was reported to the police, and they started education and in-services. He said that they will be doing random spot-checks to hopefully prevent incident from occurring again. During an interview on 3/6/24 at 3:00 pm the RNC said that she had called the consultant pharmacist regarding the incident and that he would be coming next week to do a review. Record review of a facility policy titled Identifying Exploitation, Theft ,and Misappropriation of Resident Property dated 2001, revised April 2021 read .'Misappropriation of resident property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent . and .Examples of misappropriation of resident property includes: .drug diversion (taking the resident's medication) .

Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 7 residents reviewed for accidents/supervision (Resident #1). The facility failed to ensure Resident #1's wheelchair was locked during a transfer causing the resident to slide out of the wheelchair and fall. Resident #1 sustained an acute comminuted fracture (when a bone breaks into 3 or more pieces) of the right femur (bone above the knee). The noncompliance was identified as PNC. The Immediate Jeopardy began on 10/24/23 and ended on 10/26/23. The facility had corrected the noncompliance before the survey began. This failure could place all residents at risk of severe injuries or death. Findings included: Record review of Resident #1's face sheet dated 10/31/23 indicated she was a [AGE] year old female admitted to the facility 11/3/22, with diagnoses including Type 2 Diabetes with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes), morbid obesity, acute kidney failure, hypertension (high blood pressure), heart disease , and absence of right leg below the knee. Record review of Resident #1's most recent MDS assessment dated [DATE] indicated she had a Brief Interview for Mental Status of 12, which indicated moderate cognitive impairment. The MDS further revealed Resident #1 required total dependence for transfers, needed 2 person assist, and extensive assist for personal hygiene and dressing with 1 person assist, and no history of falls. Record review of Resident #1's undated care plan indicated Resident #1 was at risk for falls/injury due to amputation of right lower extremity. Interventions included: monitor for proper body alignment and balance-assist with repositioning as needed. Assist with ADL's and transfers using positioning devices as needed. Record review of Resident #1's nurses notes dated 10/24/23 at 12:33 p.m., and signed by LVN A indicated the following, 10:00 CNAs report that resident was being transferred via hoyer lift x 2 nurse aides, wheels on wheelchair were not locked, and as aide was lowering her down in wheelchair resident slid out of the chair, as the aide went to catch her the aide and resident both went to the ground and that resident wanted medication, she felt nauseas. Upon entering room, resident was noted to be sitting upright in wheelchair, hoyer pad underneath her, with a clear trash bag on chest. VS assessed. No new skin injuries noted. Patient complained of pain in right leg, requested nausea medication and pain medication. PRN (2) Tylenol 325mg as ordered and Ondansetron (medication used for nausea) 4mg. administered. MD notified, new order to obtain x-ray STAT. Mobile x-ray contacted. RP, DON, and unit manager notified. Record review of a mobile x-ray radiology interpretation report dated 10/24/23 indicated Resident #1 received an x-ray of the right femur. Impression of the x-ray indicated an acute comminuted fracture. During an interview on 2/7/24 at 10:40 a.m. the DON stated she was not employed in the facility at the time of Resident #1's incident. The DON stated that staff were trained on hoyer lifts, and transfers using gait belts on hire. The DON said her expectations for staff utilizing the hoyer lift were to have 2 persons present, follow the procedures on the skilled checklist and make sure the wheelchair was in a locked position. During an interview on 2/7/24 at 10:48 am. LVN D said she had worked in the facility since August 2023. LVN D stated she was not working when Resident #1 had a fall, but all staff received mandatory training from the therapist on using the hoyer. LVN D stated all wheelchairs needed to be in a locked position prior to transferring a resident. During an interview on 2/7/24 at 11:20 a.m. the DOR stated that Resident #1 had been on therapy services 5/24/23-6/22/23. The DOR stated that after Resident #1 had her fall in October of 23, he did trainings and in-services on using the hoyer, and transfers. The DOR stated that the training was mandatory for all CNAs, MAs, nurses, and prn staff. The DOR stated that demonstrations were done on using the hoyer, as well as transfers, and staff did return demonstrations. The DOR stated he had 3 different training sessions, and checkoff sheets were reviewed and signed by him, and the employee. During an interview on 2/8/24 at 10:35 a.m. the SW stated that she was acting as interim ED at the time of Resident #1's fall. The SW stated that both CNA B and CNA C were asked to reenact what they did during the transfer of Resident #1. The SW stated she did not remember at what point they were asked to do this. The SW stated both CNA B and CNA C said they did not lock the wheelchair. The SW stated that the brakes should have been locked on the wheelchair at the time of the transfer. The SW stated neither CNA B nor CNA C said why the brakes were not on at the time. The SW stated both CNA B and CNA C were terminated. The SW stated a QA meeting was called the afternoon of the incident and training was initiated. During an interview on 2/8/24 at 11:03 a.m. GVN E stated she had worked in the facility since January of this year. GVN E stated she had received training on hoyer lifts and transfers when she hired on. GVN E stated 2 people were required for all hoyer transfers. The resident is placed on the hoyer pad while in bed, the pad is then secured to the hoyer. I always make sure the pad is intact and secured appropriately to the hoyer. One employee operates the lift and the other staff guide the resident to the wheelchair, which is to be locked and the footrests open before transfer. During an interview on 2/8/24 at 11:20 a.m. the Maintenance Supervisor stated he had worked in the facility for 14 months. The Supervisor stated he had been asked to observe all the wheelchairs in the facility in October 2023. The Supervisor stated on 10/25/23 he checked wheelchairs for any loose brakes and adjusted/tightened any that were loose, and all brakes were found to be in working order. The Supervisor stated there were 6 hoyer lifts in the facility, and there was a company that came out quarterly to do any maintenance needed. During an observation and interview on 2/8/24 at 1:05 p.m. MA/CNA F, and CNA G were observed during a hoyer transfer on Resident #2 from wheelchair to bed. There were no issues identified. Both MA/CNA F, and CNA G stated they were hired in December of 2023. Both MA/CNA F, and CNA G stated they had received training when hired on hoyer lifts and transfers. Both MA/CNA F, and CNA G stated that the wheelchair should have brakes locked when transferring a resident in the hoyer. During an observation and interview on 2/12/24 at 8:45 a.m. CNA H said she had worked in the facility 1 1/2 years. During the same interview, Restorative aide M said she had worked in the facility for [AGE] years. CNA H and Restorative aide M were observed during a wheelchair transfer on Resident #3. Resident #3 was transferred from her wheelchair to her bed. CNA H explained what they were doing, and both washed their hands prior to transfer. The footrests were removed from the wheelchair and a gait belt was placed on Resident #3. The wheelchair was locked on both sides. Resident #3 was safely transferred to the bed with no issues. The bed was placed in a low position and call light placed near Resident #3. Both CNA H and Restorative aide M stated they had received training on transfers and using the hoyer lift and had to do hands on demonstrations and signed skills check off form. Restorative aide M stated that all staff were provided a gait belt. Resident #3 stated she felt safe during her transfer, and they do a good job. During an observation and interview on 2/12/24 at 9:05 a.m. CNA H and Restorative aide M were observed during a hoyer lift on Resident #2 from her wheelchair to her bed. No issues were identified. Resident #2 was unable to answer any questions appropriately. During an observation and interview on 2/12/24 at 9:25 a.m. CNA J said she had worked in the facility for 1 1/2 months. CNA K said she had worked in the facility for 1 year. Both aides stated they had received training on using the hoyer lift and doing transfers when they were hired. CNA J and CNA K were observed doing a hoyer transfer on Resident #4. CNA J stated Resident #4 had agreed to get up in the wheelchair, and then be placed back to bed so observation could be done. The transfer to wheelchair and back to bed were observed with no findings. Resident #4 stated she always got nervous when being transferred with the hoyer but had not had any recent problems. Resident #4 stated a long time ago, I can't remember when, the pad broke while I was in the shower. Resident #4 stated she was not hurt, and the staff was good about explaining everything they did. During an observation and interview on 2/12/24 at 9:57 a.m. CNA J was observed doing a bed to wheelchair transfer, and wheelchair to bed transfer on Resident #5. There were no issues identified. Resident #5 stated he felt comfortable with staff transferring him, as he could not do it by himself. Resident #5 stated, this aide is good! Watch her, you will learn a lot from her. During an observation and interview on 2/12/24 at 10:08 a.m. CNA H and CNA L were observed doing a hoyer transfer on Resident #6. There were no issues identified. Resident #6 was non-interviewable. During an observation and interview on 2/12/24 at 10:27 a.m. CNA L was observed doing a bed to wheelchair transfer using a sliding board on Resident #7. There were no issues identified. Resident #7 stated he was receiving therapy but was not able to transfer to his wheelchair by himself at this time. Resident #7 stated he did not like using the hoyer lift as it made him nervous, and using the transfer board made it a lot easier and made him feel more comfortable. During a phone interview on 2/12/24 at 11:24 a.m. CNA B stated she remembered the incident with Resident #1. CNA B stated Resident #1 fell on CNA C and both of us were terminated. CNA B stated, the other girl admitted she did it. CNA B stated the other aide was setting Resident #1 down, and the wheelchair started to tilt and Resident #1 landed on the other CNA. CNA B stated after Resident #1 was on the floor, they grabbed Resident #1 and put her in the wheelchair. She stated Resident #1 did not complain of any pain. CNA B stated Resident #1 could feed herself but was total care. CNA B stated when she was hired, she had received training on the hoyer lift, and transfers. CNA B stated the brakes on the wheelchair were unlocked, and that the brakes to the hoyer were on. CNA B stated the wheelchair brakes should have been on. One side was locked; the other side of the chair was not. The other aide said it was her fault. CNA B stated the wheelchair moved out behind Resident #1 as they were lowering her into the wheelchair. I don't remember what caused it to move. The chair was locked on my side, but not the other side. CNA B stated, if the wheelchair was locked, this probably would not have happened. CNA B stated she knew the wheelchair should have been locked, and not sure why the other side wasn't. During a phone interview on 2/12/24 at 11:34 a.m. CNA C was contacted and voicemail was left. On 2/12/24 at 11:35 a.m. CNA C returned the call. CNA C said she remembered the incident, and stated this happened months ago, and you are just now calling me? CNA C stated she was at work and would return call when she got off around 3:30 p.m. on this date. CNA C did not return call. Record review of a Grievance Report dated 10/24/23 and signed by the SW indicated .Resident #1's RP was notified of a fall that Resident #1 had that was witnessed by the staff transferring her. Family member stated that she was on her way at that time. Upon arrival to the facility, family stated that the Resident told them that she fell during transfer and that they believe she was not transferred with the hoyer. Family then stated that they did not want the aides that did transfer in Resident #1's room. Family member went on to state that she had bail money and I am going to jail today. Both CNAs state that a hoyer transfer was completed and that the resident slipped out of the wheelchair during the transfer. Both aides provided written statements regarding the transfer Record review of an Accident/Incident Report dated 10/24/23 and signed by LVN A indicated the following: .Account of Occurrence- CNAs report that Resident was being transferred via hoyer lift x2 nurse aides, wheels on wheelchair were not locked, and as aide was lowering Resident down in wheelchair, Resident #1 slid out of the chair. As the aide went to catch her, the aide and Resident #1 both went to the ground. Upon assessment, resident complained of pain to the RLE above her amputation site. Resident denies any other pain. Resident was assisted back to wheelchair. PRN pain medicine administered. Received order from MD for STAT x-ray . Record review of a witness statement dated 10/24/23 signed by CNA B revealed the following, I was in the room with Resident #1 and CNA C and I were getting Resident #1 up to put her in the chair and as CNA C was lowering Resident #1 down, she slid out of the chair and CNA C grabbed Resident #1, and Resident #1 fell on top of CNA C, and they both fell on the floor. Record review of an undated witness statement signed by CNA C revealed the following, I CNA C was getting Resident #1 up to put her in her chair. As I was lowering Resident #1 down, she slid out of the chair and I was there to grab her, and me and Resident #1 both fell to the ground. Record review of a Personal Action Form indicated CNA B was terminated with last day worked listed as 10/24/23. Record review of a Personal Action Form indicated CNA C was terminated with last day worked listed as 10/24/23. Record review of a Mechanical Lift Competency Skills Checklist dated 2/27/07 indicated When transferring from or to a wheelchair, shower chair or bed, make sure that wheelchair, shower chair or bed is locked . Record review of the hoyer service provider Certification of Calibration forms indicated visits were made on 10/10/23, and 1/2/24. Record review of a Quality Assurance and Performance Improvement Meeting Minutes form indicated a meeting was held on 10/24/23 at 4:30 p.m. with the following members were present; DON, activity director, care plan/MDS nurse, nutritional services director, HR, interim ED, unit manager, and financial manager. Report also indicated the incident was discussed with the Medical Director over the phone. The following interventions were put in place: Steps taken regarding the incident with completion dates included: Resident assessed immediately- completed 10/24/23 Physician contacted and orders received-completed 10/24/23 PRN pain medication administered-completed 10/24/23 In-services initiated on abuse/neglect- started 10/24/23, completed 10/26/23 In-services initiated on Hoyer transfers- started 10/24/23, completed 10/26/23 In-services initiated on stand-pivot transfers and gait belts- started 10/24/23, completed 10/26/23 In-services initiated on assessment- started 10/24/23, completed 10/26/23 100% audit conducted by maintenance on wheelchair brakes-completed 10/25/23 Audit of Hoyer pads-started 10/24/23, completed 10/25/23 Audit of Hoyers in the facility- started 10/24/23, completed 10/25/23 Grievance completed-completed 10/24/23 Reported to HHSC-completed 10/24/23 Ombudsman notified-completed 10/24/23(message left) spoke to her 10/25/23 Resident sent to hospital-completed 10/24/23 Both aides suspended pending investigation-completed 10/24/23-both terminated Safe surveys initiated-completed 10/25/23 Resident interviews initiated (part of safe surveys) Psychosocial assessment completed prior to resident leaving facility-completed 10/24/23 Inservice on daily care guide- started 10/24/23, completed 10/26/23 Record Review of In-service Training Reports indicated training was done on safe transfers, Abuse/Neglect, Assessment, Activities of Daily Living-Daily Care Guide, and Accidents/Incidents. Trainings were initiated on 10/24/23 and were completed on 10/26/23. A review of Mechanical Lift Competency Skills Checklist, and Transfer Skills Checklist indicated training was initiated on 10/25/23 and completed on 10/26/23. Training records indicated 50 employees received training. The noncompliance was identified as PNC. The Immediate Jeopardy began on 10/24/23 and ended on 10/26/23. The facility had corrected the noncompliance before the survey began.

Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 7 residents (Resident #1) reviewed for quality of care. The facility did not implement interventions to provide bathing and hygiene care for Resident #1. The resident developed irritated and inflamed areas, diagnosed as a yeast infection by the hospital, in and around the skin folds of his body that caused him to yell out in pain when moved. This resulted in the resident not receiving incontinent care, treatments, or bathing after refusing due to being in pain, which contributed to further deterioration of the skin and quality of life. The facility did not notify the physician of the residents pain, refusal of care, or that his skin conditions were not improving. Resident #1 who required total assistance from staff for bathing was unkept, had an odor, and had a buildup of old ointment, powder, and flaking skin in the crevices of his body. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:20 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving treatment and care in accordance with professional standards of practice. Findings included: Record review of Record of Death, dated [DATE] indicated Resident #1 died on [DATE] at 2:27 p.m. The immediate cause of death was cardiopulmonary arrest. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year-old male initially admitted on [DATE] with the most current admission on [DATE]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS assessment, dated [DATE], indicated Resident #1 had unclear speech, was rarely or never understood, and sometimes understood others. Resident #1 had severe cognitive impairment. The assessment indicated he had no behaviors and did not reject evaluation or care during the assessment period. Resident #1 required extensive physical assistance of one person for bed mobility, moving between surfaces, dressing, toileting, and personal hygiene. He required supervision and setup help only to eat or drink. Resident #1 was totally dependent on physical assistance of one staff for bathing. The assessment indicated Resident #1 had impaired range of motion in upper and lower extremities on one side. Resident #1 was always incontinent of bowel and bladder. The assessment indicated Resident #1 was at risk of developing pressure injuries but had no unhealed pressure injuries. The pain assessment instructions indicated if the resident was rarely/never understood the pain assessment interview should be skipped and pain should be assessed via staff assessment of indicators of possible pain which included: a] non-verbal sounds such as crying, whining, gasping, moaning or groaning; b] vocal complaints of pain such as that hursts, ouch, stop; c] facial expressions such as grimaces, winces, wrinkled forehead, furrowed, brow, clenched teeth or jaw; or d] protective body movements or postures such as bracing, guarding, clutching or holding a body part during movement. Although Resident #1 was rarely/never understood, the assessment indicated a pain assessment interview was conducted and indicated Resident #1 had no pain during the last five days. Record review of Resident #1's current care plan, reviewed [DATE], indicated he needed extensive assistance with most ADLs. The care plan indicated a focus area for incontinence of bowel and bladder with interventions including 1] monitor for incontinence every 2 hours and as needed. Change promptly and apply a protective skin barrier to skin; 2] monitor for signs and symptoms of skin breakdown and report to physician and responsible party; 3] assess for causes of incontinence; 4] lab as ordered by physician; 5] encourage fluid intake within dietary limits; 6] monitor for signs and symptoms of infection and report to physician. The care plan indicated a focus area for pain management with interventions including 1] monitor for signs and symptoms of increased pain or discomfort and assess resident for possible causes; 2] provide pressure relieving and positioning devices as needed; 3] assist with ADLs and comfort measures as needed; 4] assess and document pain; 5] monitor for constipating effects of pain medication. The care plan indicated Resident #1 was at risk of skin breakdown related to incontinence, bedfast, impaired bed mobility, fragile skin, cognitive impairment, and refusal of showers, incontinent care, and to have lotion applied to his dry skin, with interventions including 1] monitor for incontinence every two hours and change promptly, 2] apply moisturizing lotion, as he allows; 3] encourage PO and fluid intake; 4] monitor for skin breakdown, report to physician and responsible party; 5] assess skin weekly and record findings. The care plan indicated an undated focus area related to skin/tissue integrity status - chronic redness to right arm fold with interventions including 1] assess and monitor skin integrity and signs/symptoms of complications; 2] assess and monitor nutritional status to prevent skin breakdown and signs of complications; 3] assess and monitor incontinence/moisture risk for skin breakdown. The goal date for this focus area was [DATE]. The care plan indicated an undated focus area related to a history of stroke, and included the intervention develop alternate methods of communication. The care plan did not indicate staff interventions for care refusal, nor did it address the contracture of Resident #1's right hand. Record review of Resident #1's weekly head to toe skin assessments dated [DATE], [DATE], [DATE], [DATE], and [DATE] indicated he had clear skin. There were no completed wound assessments for Resident #1 for the month of [DATE] nor for [DATE]-8, 2021. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *order dated [DATE] pain assessments by shift. There were no medication orders to treat pain. *order dated [DATE] dry dressings by shift. Keep wedge or towel under arm (unspecified) to prevent skin to skin contact unless resident is bathing or receiving incontinent care. May cover with dry dressing as needed for drainage. *order dated [DATE] weekly head to toe skin assessment *order dated [DATE] barrier cream one time daily. Cleanse bilateral buttocks with normal saline or skin cleanser. Pat dry. Apply barrier cream. *order dated [DATE] Hibaclens 4% topical liquid one time daily for rash and other nonspecific skin eruption. The order did not specify what area of the body was to be treated or how. Record review of Resident #1's ADL documentation for [DATE] indicated: *[DATE] incontinent care occurred at 3:43 a.m., 11:22 a.m., and 16:24 p.m. *[DATE] personal hygiene occurred at 3:44 a.m., 11:23 a.m., and 16:26 p.m. *[DATE] incontinent care occurred 5:20 a.m. and 10:28 a.m. There was no incontinent care documented for the ,d+[DATE] shift. *[DATE] personal hygiene occurred at 5:21 a.m. and 10:29 a.m. There was no personal hygiene documented for the ,d+[DATE] shift. *[DATE] incontinent care occurred at 10:40 a.m. There was no other incontinent care documented. *[DATE] personal hygiene occurred at 10:40 a.m. There was no other personal hygiene documented. *[DATE] incontinent care occurred at 2:30 a.m. There was no other incontinent care documented. *[DATE] personal hygiene occurred at 2:31 a.m. and 12:48 p.m. There was no other personal hygiene documented. *[DATE] incontinent care occurred at 1:19 a.m. and 12:36 p.m. There was no other incontinent care documented. *[DATE] personal hygiene was documented as did not occur at 1:19 a.m. and as having occurred at 12:37 p.m. There was no documentation of personal hygiene for the ,d+[DATE] shift. *[DATE] incontinent care occurred at 3:04 am, 10:20 a.m., and 21:02 p.m. *[DATE] personal hygiene occurred at 3:05 a.m., 10:21 a.m., and 21:02 p.m. *[DATE] incontinent care occurred at 12:40 p.m., and 15:28 p.m. There was no documentation of incontinent care on the night shift. *[DATE] personal hygiene occurred at 12:43 p.m., and 15:29 p.m. There was no documentation of personal hygiene on the night shift. *[DATE] incontinent care occurred at 1:48 a.m. There was no other incontinent care documented. *[DATE] personal hygiene occurred at 1:49 a.m. There was no other personal hygiene documented. Record review of treatment notes (TAR) dated [DATE], written by LVN S, indicated Resident #1 refused the dry dressing, and the provider was notified. During an interview on [DATE] at 11:20 a.m., LVN S said the treatment notes for [DATE] indicated she had notified the physician, but she did not. LVN S said the electronic record automatically indicated the physician had been notified anytime you document that a resident has refused something. Record review of treatment notes (TAR) dated [DATE], [DATE], [DATE], [DATE], and [DATE] indicated Resident #1 had a pain scale rating of 0 on all shifts, with the location described as not applicable. Record review of treatment notes (TAR) dated [DATE] and [DATE] on the night shift, entered by LVN A, indicated Resident #1 had generalized pain rated as 3. There was no physician notification, nor any interventions implemented to address pain. There were no nursing notes regarding these pain scale ratings. Record review of a Clinical Note written by LVN B, dated [DATE] at 1:43 p.m., indicated Resident #1 was noted to have labored breathing and a cough at the beginning of the shift (6a-6p). The note indicated LVN B was later (time unspecified) alerted by CNA C that Resident #1 was breathing hard and had not eaten his breakfast which was not normal for him. The note indicated LVN B returned to Resident #1's room to find him short of breath with very labored breathing, an oxygen level of 88% (less than 90% is considered low), and respirations were 48 per minute (Normal range for respirations are ,d+[DATE] per minute) with diminished lung sounds. The note indicated LVN B had called to notify PA D of Resident #1's status when she was alerted by CNA C that Resident #1 was declining, and she called 911 for emergency transport. The note indicated Resident #1's nails were trimmed prior to being transferred to the hospital for emergency care. Record review of an EMS report dated [DATE] written by EMT E indicated EMS arrived at the facility at 9:11 a.m. The report indicated Resident #1 had difficulty speaking related to a previous stroke and his primary problem was shortness of breath. The report indicated .this patient is found to be lying in facility hospital bed, attended by multiple staff members, who are quickly wiping down is hands and feet, clipping his fingernails, scrubbing the layers of caked skin off of him. On the ground, in the bed, in the blankets, are seen an excessive amount of thick ships of skin detritus and debris from the cleaning that is happening, that came off of his body. There appear to this crew, to be much more skin debris than should be on a person, IF a person is being cleaned regularly or appropriately. It appears that the staff have not been regularly washing or caring for him, neglecting his hygiene. The patient is an elderly male, attached to a room air concentrator running at 4 L (liters) per minute via nasal cannula, he had a rapid respiratory rate, 30 BPM, but breaths show to be clear, he is breathing well. He answers questions well, if they are worded in yes/no form, and staff advised this is his common mental status presentation, normal to himself, for [CONDITION(S)] deficits. Staff advise that the reason for the call is that they measured his pulse oximetry at the mid-80s, and he had a rapid respiratory rate. Patient advises he is not short of breath any longer, on the device they have placed him on, nor is he in any pain .As we prepare to move him over he shows to wince when his right arm is moved, staff advise us that he has a current yeast rash in his right armpit, say he is affected to have deficits on that side from the old [CONDITION(S)], so he does not move it often, and when the area is exposed, it shows to be rashy, irritated, inflamed, with thickly caked yellow debris in it, unsure if it is old skin or layered ointment, but it is dried and matted, and not freshly applied ointment consistency. He shows bleeding from the tip of his just-now clipped right thumbnail, his nails are over-thick, irregular and rough in texture, and abnormal in growth, possible from a fungal infection or other nailbed issue. The nail was not clipped too close, not carelessly trimmed, it just shows to have abnormal size and increased blood flow in the cent of the nail matrix, and blood flow all the way distal and even past the tip of his thumb. Using staff's assistance, he is lifted/carried, and moved over into the stretcher .Further examination in the ambulance shows that he has a contracture in his right hand, which holds his fist together, but multiple area of his finger skin appear to have pressure sores in the joints and knuckles from hot having padding between the hard spots. Upon arrival at the emergency room his pulse oximetry has remained at ,d+[DATE]% on 3 LPM NC. Throughout the duration of contact he has had no complaints, other than the transfers from bed and cot which are painful to him. As we give a report, we are assisting the nurses in transfer of care. We mention the state of the patient's room and the state of the patient when we first got him, and as the RNs strip his clothes off, they remove his adult diaper, in order to get him washed and in a clean gown, and they find more rashes, skin breakdown in the creases and crevices of his groin, uncleaned feces in his cracks and in the skin below his penis. We advised to the nurses that we will be putting a report in for adult protective services Contact with EMT E was attempted on [DATE] at 10:30 a.m. A message with left with the fire department dispatcher providing the surveyor's contact information and request to return call. EMT E did not return the call. Record review of ED physician documentation dated [DATE] indicated Resident #1 arrived on [DATE] at 9:28 a.m. The record indicated: *patient has cutaneous candidiasis (fungal infection of the skin, caused by yeast) and his axilla and groin creases with [CONDITION(S)] (redness) to the skin. *patient is contracted in the bed responsive to pain only. Record review of ED nurse documentation dated [DATE]-[DATE] indicated: *triage assessment indicated denies pain, appears uncomfortable, behavior is cooperative. Has moderate shortness of breath. *[DATE] at 10:05 a.m. - skin is fragile, dry with flakes to arms, legs, face. Yellow crusty substance to right scalp. Right armpit with redness, swelling, skin scaly. Peri area with redness, dried white powdery crusty substance. Fingernails unkempt, long and curling over fingertips. Right arm with [CONDITION(S)] (paralyzed). *[DATE] at 10:10 a.m. - when asked if he knows where he is, he states eenie, meenie, minie, mo. *[DATE] at 10:48 a.m. - bath given, linen changed. Barrier cream applied to under arm, peri area, buttocks. *[DATE] at 8:39 a.m. - pt grimaces with movement Record review of a hospital discharge summary dated [DATE] indicated: *date of discharge [DATE] *septic shock with Gram negative rod bacteremia (blood borne infection) secondary to acute pyelonephritis (type of urinary tract infection) with obstructive [CONDITION(S)] (obstructed urinary flow) *left sided hydroureteronephrosis (swelling of a kidney due to buildup of urine) with 8 mm ureteric calculus (kidney stone); patient had emergent cystoscopy (procedure used to look inside the bladder) with possible left-sided ureteric stent (tube to allow urine to flow) placement, attempted left-sided ureteric stent placement was unsuccessful. Unable to transfer to higher level of care for left-sided nephrostomy tube placement as the patient was denied. Family had decided on withdrawal of care. *acute hypoxic respiratory failure (respiratory failure related to low levels of oxygen in the blood, possible life threatening) following cystoscopy. Patient have underlying pulmonary [CONDITION(S)] (excess fluid in the blood vessels of the lungs). Withdrawal of care was done today *acute kidney injury with baseline chronic kidney disease stage III; likely precipitated by obstructive [CONDITION(S)]. Patient also had concurrent metabolic acidosis (chemical imbalance of the blood making it more acidic) which has resolved. DC to hospice. *scrotal excoriation/wound/possible laceration (redness and possible wound of the scrotum), continue wound care as appropriate. Record review of Record of Death, dated [DATE] indicated Resident #1 died on [DATE] at 2:27 p.m. The immediate cause of death was cardiopulmonary arrest (heart and lungs stop working). Record review of a Performance Improvement Plan, dated [DATE] indicated problem areas identified included: *skin concerns not addressed according to policy for skin *assessments not completed to represent current skin issues Changes Implemented to reach Baseline: *In-service all nursing staff on PCMS1 (skin policy) *CNA in-service on reporting any skin condition immediately to charge nurse or unit manager and utilizing unity skin alert *Skin sweep of all patients to be completed by managers *Treatment nurse to start completing all weekly head to toe skin assessments *Wound care doctor comes to facility weekly for evaluation and procedures if needed *Treatment nurse to attend stand-up meeting every day with full report on all wounds and interventions in place and any new skin concerns *DON/ADON audit skin report to ensure all area of concern are captured on skin report *UM/ADON/DON/Tx Nurse to round daily to ensure patients with positioning devices are in place and off-loading correctly. Provide individual in-services as warranted *Care plans updated to show any skin concerns chronic and acute, and refusals of care *CNA are to report any shower refusals to charge nurse for follow up and documentation *ensure pre/post pain assessment to all treatment orders During an interview on [DATE] at 12:54 p.m., CNA C said she took care of Resident #1 on [DATE], the day he was transferred to the hospital. CNA C said she told LVN B that he was breathing funny, and that he did not look to be his normal self. CNA C said LVN B checked Resident #1's oxygen levels and then gave him oxygen. CNA C said she had provided incontinent care for Resident #1 earlier that day. CNA C said Resident #1 had an area on his back with red flaky skin. She said the area in between his legs was red as well. She said Resident #1 had an odor and she thought it was from his skin. During an interview on [DATE] at 1:20 p.m., CNA F said Resident #1's right arm did not work and that he could not move it. She said his right hand was contracted into a fist. CNA F said it was hard to get the contracted hand open to clean it, and she had never been told to place anything in the contracted hand to help with the contracture. CNA F said the day Resident #1 was sent to the hospital she pointed out to the nurse (unspecified) how bad his hands and nails looked. She said Resident #1 had an odor as if they did not wash his hand. CNA F said Resident #1's nails were really long and digging into his skin. She said his skin was always red and raw and the CNAs applied barrier cream when providing incontinent care. CNA F said Resident #1 had broken skin around his sacrum, pelvis, testicles, and all of that area from front to back. CNA F said Resident #1 would refuse incontinent care at times. CNA F said Resident #1 needed more care than he got because of his skin issues and his hand contracture, and that when a resident has hand contractures you have to pay more attention to his nails. During an interview on [DATE] at 1:42 p.m., LVN G said she went into Resident #1's room on [DATE] at the end. She said Resident #1 was having difficulty breathing and was receiving supplemental oxygen. LVN G said she did not recall any discussion about Resident #1's nails. She said his hand was contracted, but she was not sure if his hand was so contracted that his nails were into his hand. LVN G said Resident #1 had chronic irritation under his right arm, buttocks, and groin. LVN G said he always had flaky skin. She said the irritated areas were painful and sensitive. During an interview at the receiving hospital on [DATE] at 2:45 p.m., Emergency Department (ED) RN H said Resident #1 was admitted to the ED on [DATE]. RN H said he was not involved in Resident #1's care, but that the nurses assigned to Resident #1 were so concerned about his hygiene that they gave him a bath in the ED. RN H said we don't normally bathe patients in the ED. During an interview at the receiving hospital on [DATE] at 3:00 p.m., ED RN I said she helped care for Resident #1 when he was transferred to the ED on [DATE].RN I said when Resident #1 was undressed he had a smell like rotting flesh she detected through an N95 mask. RN I said Resident #1's right axilla (armpit) had red macerated (skin which may be soft, wet or soggy from being in contact with moisture for too long) skin and was covered in a layer of powder and gunk. She said his nails were unclipped and were growing into the palm of his hand, and there was more macerated tissue underneath his contracted fingers. RN I said the reddened area of his groin extended outside of his briefs and he had macerated skin on both sides. RN I said Resident #1's pubic area was covered in powder and cream and old fecal matter. RN I said once his left groin was separated and cleaned, he had some bleeding, and the creases under his buttocks were bloody and macerated. RN I said Resident #1 was red from below his buttocks to about halfway up his back. She said Resident #1's scalp had yellow dried skin and was caked to the side of his head. RN I said we stopped our ER duties to help clean him up. No one deserves that lack of care; this didn't happen overnight. During a telephone interview on [DATE] at 3:57 p.m., LVN B said she was Resident #1's nurse on [DATE], the day he went to the hospital. LVN B said Resident #1 was not in distress when she made her first round (time unspecified), but that CNA C later alerted her that Resident #1 did not eat his breakfast and did not seem normal. LVN B said when she assessed Resident #1, he had labored breathing and she administered supplemental oxygen. LVN B said while she was calling PA D to notify him of Resident #1's condition and CNA C reported Resident #1's condition was declining, and she called 911 for emergency transport. LVN B said when she went back in the room LVN J was trimming Resident #1's nails and two CNAs (unspecified) were giving him a bed bath. LVN B said it was not normal to give a resident a bed bath or trim their nails before sending them to the hospital for emergency care, and she did not know why it happened. LVN B said Resident #1 had some type of skin condition. LVN B said she did not know what the skin condition was, but that Resident #1 had had it for some time. LVN B said Resident #1''s verbal response for everything is yes, no, maybe but he was not talking at that point. LVN B said Resident #1 had an odor she described as musty. During an interview at the receiving hospital on [DATE] at 11:30 a.m., ED RN K said she was assigned to care for Resident #1 when he was admitted to the ED on [DATE]. RN K described the following areas and conditions of Resident #1's skin: *right thumbnail was overgrown. It had been cut and was bleeding; *fingernails on his contracted hand (right) were overgrown and curling under. They had caused some broken skin in his palm; *right fingers were red from being together; *right axilla - excoriated skin, caked on powder and an odor like a yeast infection. Red scaly skin that was very tender to the touch. He cried out in pain when that arm was moved. The reddened area extended to mid bicep area on the right arm and approximately five inched down the side of his body.; *genital area - caked on powder, redness in groin area past the area of the brief and extending down the inner thighs approximately one hand width. There was a foul smell, and extreme pain on movement. The powder was crusted and there were multiple layers. It was not loose and did not aerate as fresh powder would; *left inguinal fold/crease had crusted caked ointment and powder. The area was red and painful; *buttocks/sacral area - redness and layers of powder. No broken skin but excoriated areas on buttocks and dried fecal matter around the anus. The redness extended from the buttocks to midback on the right side; *scrotum and inner thighs red, inflamed, and tender, covered with layers of powder/ointment; and *right side of head - had food particles, yellow matter and dead skin on the side of his head and in his hair. RN K said Resident #1 would respond to his name, but to most other questions his response was eenie, meenie, miney, mo. During an interview on [DATE] at 1:25 p.m., CNA F said the last time she had bathed Resident #1 was at the beginning of the year. She said Resident #1 hollered all the time. She said Resident #1 was real raw in his pelvic area, and that she had told the nurses. CNA F said there was a cream (unspecified) applied daily. CNA F said she had changed Resident #1 during the week when he was transferred to the hospital. CNA F said she did not see a difference that time from the first of the year. CNA F said his pelvic area had been raw since she started in 2018. CNA F said Resident #1 did not like hygiene care, and that most of the time when he got a bed bath, he would be mad. CNA F said some days he would let you provide care and other days he would not. CNA F said sometimes you could get him cleaner than others, but most of the time he would say no, and we could not get him clean. We would tell the nurses and they would tell us to document that he refused care. During an interview on [DATE] at 1:48 p.m., CNA L said she had not been assigned to care for Resident #1 for the last 2 months. CNA L said Resident #1 did not like to get changed and didn't like to be messed with at all. CNA L said it hurt Resident #1 to move. CNA L said the only skin areas of concern was the redness under his right arm and down his side. CNA L said you could not get all the old cream and powder off before Resident #1 would start yelling at you. CNA L said she told the nurses and they would just document it. CNA L said she did not know specifically what the nurses documented. During an interview on [DATE] at 2:08 p.m., LVN J said Resident #1 refused baths and incontinent care. LVN J said Resident #1 had a chronic skin condition that was normal for him. LVN J said, we keep him creamed and powdered. LVN J said Resident #1 had excoriation really bad under that armpit. LVN J staff tried to put a rolled-up washrag in his contracted hand but Resident #1 refuses. LVN J said Resident #1 cusses at you and refuses care a lot. LVN J said she cut Resident #1's fingernails before he went to the hospital on [DATE] because they needed to be cut. LVN J said she did not nick him or anything. LVN J said Resident #1 was not bleeding, but it looked like he had jelly under his fingernails. LVN J said Resident #1 was old, stubborn, and set in his ways. LVN J said Resident #1 was adamant that he did not want to bathe. During a telephone interview on [DATE] at 3:04 p.m., PA D said he did not recall Resident #1 having a skin condition, but after reviewing records said Resident #1 had pruritic [CONDITION(S)] which was basically an itchy rash that would cause flaking skin. PA D said he thought it would be important to get all the old skin and powder off before applying medication. PA D said the standard of care would be to apply medication to clean skin and not on top of powder or anything that would be a barrier to the medication. PA D said he assumed Resident #1 was receiving regular bathing, but he did not know for sure. PA D said he had not been notified that the facility was having trouble bathing Resident #1 or cleaning the affected areas. During an interview on [DATE] at 3:37 p.m., LVN M (treatment nurse) said Resident #1 had chronic redness mainly under the right arm and on his buttocks. LVN M said Resident #1 would frequently refuse incontinent care. LVN M said Resident #1's current treatment was [MEDICATION(S)] (antiseptic skin cleanser) and a dry dressing under his right arm to prevent skin to skin contact. LVN M said frequently she was not able adequately clean the area under his right arm to get the dead skin off because it hurt him to move the arm. LVN M said treatments should be applied to clean skin. LVN M said Resident #1 would often lay on his right arm (affected by stoke). LVN M said Resident #1's buttocks were like a red incontinent kind of rash.' LVN M said the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN M said maybe because it was all over there wasn't a specific place to be treated. LVN M said she never contacted the physician about Resident #1's refusal of care. LVN M said she thought the physician knew he was refusing care because other nurses (unspecified) said they had talked to him. LVN M said Resident #1 usually responded with yes or no, and that she had never heard him say a complete sentence. LVN M said even though Resident #1's skin was dry and flaky and red and inflamed on his bottom he never had a pressure injury. During an interview on [DATE] at 4:27 p.m., CNA N said she routinely took care of Resident #1. She said he had chronic redness under his right arm which she reported to the nurse, but she did not recall which nurse she told. CNA N said the nurse already knew about the redness and said that he was getting a medicine for it. CNA N said she would try and remove the dead skin when bathing Resident #1, but he would never let her bathe him. CNA N said he would refuse care a lot. She said when Resident #1 refused care she would tell the charge nurse and try again later. CNA N said after incontinent care she would put on the cream that we used for everyone on his bottom. CNA N said Resident #1's bottom was red sometimes, and she told the nurse every time. CNA N said Resident #1 would have a smell when he didn't get a bath. CNA N said she was never told to put a dry dressing under his right arm. During an interview on [DATE] at 4:45 p.m., CNA O said Resident #1 refused care a lot, and that he only wanted to be changed once a shift. CNA O said she used to tell the nurses about him refusing care, but it became so common she stopped telling them. CNA O said he refused care every day. CNA O said Resident #1's skin would be built up and red with a lot of dead skin. She said the redness was on his bottom, in the creases of his groin, and under his arm. CNA O said Resident #1 would lay on his right side to eat rather than sit up. She said Resident #1 would spill food and drinks and it would run down his arm. CNA O said if you tried to move his right arm Resident #1 would say ow and start cussing. CNA O said Resident #1 would have a body odor from refusing baths. CNA O said when she provided incontinent care for Resident #1, he would have a buildup of skin and gunk. During an interview on [TRUNCATED]

Based on interview and record review the facility failed to ensure the right to be free from abuse was provided for 1 of 7 residents reviewed for abuse. (Resident #1) The facility did not implement interventions to provide bathing and hygiene care for Resident #1. The resident developed irritated and inflamed areas, diagnosed as a yeast infection by the hospital, in and around the skin folds of his body that caused him to yell out in pain when moved. This resulted in the resident not receiving incontinent care, treatments, or bathing after refusing due to being in pain, which contributed to further deterioration of the skin and quality of life. The facility did not notify the physician of the residents pain, refusal of care, or that his skin conditions were not improving. Resident #1 who required total assistance from staff for bathing was unkept, had an odor, and had a buildup of old ointment, powder, and flaking skin in the crevices of his body. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:20 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, physical harm, pain, mental anguish, and emotional distress. Findings included: Record review of Record of Death, dated [DATE] indicated Resident #1 died on [DATE] at 2:27 p.m. The immediate cause of death was cardiopulmonary arrest. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year-old male initially admitted on [DATE] with the most current admission on [DATE]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS assessment, dated [DATE], indicated Resident #1 had unclear speech, was rarely or never understood, and sometimes understood others. Resident #1 had severe cognitive impairment. The assessment indicated he had no behaviors and did not reject evaluation or care during the assessment period. Resident #1 required extensive physical assistance of one person for bed mobility, moving between surfaces, dressing, toileting, and personal hygiene. He required supervision and setup help only to eat or drink. Resident #1 was totally dependent on physical assistance of one staff for bathing. The assessment indicated Resident #1 had impaired range of motion in upper and lower extremities on one side. Resident #1 was always incontinent of bowel and bladder. The assessment indicated Resident #1 was at risk of developing pressure injuries but had no unhealed pressure injuries. The pain assessment instructions indicated if the resident was rarely/never understood the pain assessment interview should be skipped and pain should be assessed via staff assessment of indicators of possible pain which included: a] non-verbal sounds such as crying, whining, gasping, moaning or groaning; b] vocal complaints of pain such as that hursts, ouch, stop; c] facial expressions such as grimaces, winces, wrinkled forehead, furrowed, brow, clenched teeth or jaw; or d] protective body movements or postures such as bracing, guarding, clutching or holding a body part during movement. Although Resident #1 was rarely/never understood, the assessment indicated a pain assessment interview was conducted and indicated Resident #1 had no pain during the last five days. Record review of Resident #1's current care plan, reviewed [DATE], indicated he needed extensive assistance with most ADLs. The care plan indicated a focus area for incontinence of bowel and bladder with interventions including 1] monitor for incontinence every 2 hours and as needed. Change promptly and apply a protective skin barrier to skin; 2] monitor for signs and symptoms of skin breakdown and report to physician and responsible party; 3] assess for causes of incontinence; 4] lab as ordered by physician; 5] encourage fluid intake within dietary limits; 6] monitor for signs and symptoms of infection and report to physician. The care plan indicated a focus area for pain management with interventions including 1] monitor for signs and symptoms of increased pain or discomfort and assess resident for possible causes; 2] provide pressure relieving and positioning devices as needed; 3] assist with ADLs and comfort measures as needed; 4] assess and document pain; 5] monitor for constipating effects of pain medication. The care plan indicated Resident #1 was at risk of skin breakdown related to incontinence, bedfast, impaired bed mobility, fragile skin, cognitive impairment, and refusal of showers, incontinent care, and to have lotion applied to his dry skin, with interventions including 1] monitor for incontinence every two hours and change promptly, 2] apply moisturizing lotion, as he allows; 3] encourage PO and fluid intake; 4] monitor for skin breakdown, report to physician and responsible party; 5] assess skin weekly and record findings. The care plan indicated an undated focus area related to skin/tissue integrity status - chronic redness to right arm fold with interventions including 1] assess and monitor skin integrity and signs/symptoms of complications; 2] assess and monitor nutritional status to prevent skin breakdown and signs of complications; 3] assess and monitor incontinence/moisture risk for skin breakdown. The goal date for this focus area was [DATE]. The care plan indicated an undated focus area related to a history of stroke, and included the intervention develop alternate methods of communication. The care plan did not indicate staff interventions for care refusal, nor did it address the contracture of Resident #1's right hand. Record review of Resident #1's weekly head to toe skin assessments dated [DATE], [DATE], [DATE], [DATE], and [DATE] indicated he had clear skin. There were no completed wound assessments for Resident #1 for the month of [DATE] nor for [DATE]-8, 2021. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *order dated [DATE] pain assessments by shift. There were no medication orders to treat pain. *order dated [DATE] dry dressings by shift. Keep wedge or towel under arm (unspecified) to prevent skin to skin contact unless resident is bathing or receiving incontinent care. May cover with dry dressing as needed for drainage. *order dated [DATE] weekly head to toe skin assessment *order dated [DATE] barrier cream one time daily. Cleanse bilateral buttocks with normal saline or skin cleanser. Pat dry. Apply barrier cream. *order dated [DATE] Hibaclens 4% topical liquid one time daily for rash and other nonspecific skin eruption. The order did not specify what area of the body was to be treated or how. Record review of Resident #1's ADL documentation for [DATE] indicated: *[DATE] incontinent care occurred at 3:43 a.m., 11:22 a.m., and 16:24 p.m. *[DATE] personal hygiene occurred at 3:44 a.m., 11:23 a.m., and 16:26 p.m. *[DATE] incontinent care occurred 5:20 a.m. and 10:28 a.m. There was no incontinent care documented for the ,d+[DATE] shift. *[DATE] personal hygiene occurred at 5:21 a.m. and 10:29 a.m. There was no personal hygiene documented for the ,d+[DATE] shift. *[DATE] incontinent care occurred at 10:40 a.m. There was no other incontinent care documented. *[DATE] personal hygiene occurred at 10:40 a.m. There was no other personal hygiene documented. *[DATE] incontinent care occurred at 2:30 a.m. There was no other incontinent care documented. *[DATE] personal hygiene occurred at 2:31 a.m. and 12:48 p.m. There was no other personal hygiene documented. *[DATE] incontinent care occurred at 1:19 a.m. and 12:36 p.m. There was no other incontinent care documented. *[DATE] personal hygiene was documented as did not occur at 1:19 a.m. and as having occurred at 12:37 p.m. There was no documentation of personal hygiene for the ,d+[DATE] shift. *[DATE] incontinent care occurred at 3:04 am, 10:20 a.m., and 21:02 p.m. *[DATE] personal hygiene occurred at 3:05 a.m., 10:21 a.m., and 21:02 p.m. *[DATE] incontinent care occurred at 12:40 p.m., and 15:28 p.m. There was no documentation of incontinent care on the night shift. *[DATE] personal hygiene occurred at 12:43 p.m., and 15:29 p.m. There was no documentation of personal hygiene on the night shift. *[DATE] incontinent care occurred at 1:48 a.m. There was no other incontinent care documented. *[DATE] personal hygiene occurred at 1:49 a.m. There was no other personal hygiene documented. Record review of treatment notes (TAR) dated [DATE], written by LVN S, indicated Resident #1 refused the dry dressing, and the provider was notified. During an interview on [DATE] at 11:20 a.m., LVN S said the treatment notes for [DATE] indicated she had notified the physician, but she did not. LVN S said the electronic record automatically indicated the physician had been notified anytime you document that a resident has refused something. Record review of treatment notes (TAR) dated [DATE], [DATE], [DATE], [DATE], and [DATE] indicated Resident #1 had a pain scale rating of 0 on all shifts, with the location described as not applicable. Record review of treatment notes (TAR) dated [DATE] and [DATE] on the night shift, entered by LVN A, indicated Resident #1 had generalized pain rated as 3. There was no physician notification, nor any interventions implemented to address pain. There were no nursing notes regarding these pain scale ratings. Record review of a Clinical Note written by LVN B, dated [DATE] at 1:43 p.m., indicated Resident #1 was noted to have labored breathing and a cough at the beginning of the shift (6a-6p). The note indicated LVN B was later (time unspecified) alerted by CNA C that Resident #1 was breathing hard and had not eaten his breakfast which was not normal for him. The note indicated LVN B returned to Resident #1's room to find him short of breath with very labored breathing, an oxygen level of 88% (less than 90% is considered low), and respirations were 48 per minute (Normal range for respirations are ,d+[DATE] per minute) with diminished lung sounds. The note indicated LVN B had called to notify PA D of Resident #1's status when she was alerted by CNA C that Resident #1 was declining, and she called 911 for emergency transport. The note indicated Resident #1's nails were trimmed prior to being transferred to the hospital for emergency care. Record review of an EMS report dated [DATE] written by EMT E indicated EMS arrived at the facility at 9:11 a.m. The report indicated Resident #1 had difficulty speaking related to a previous stroke and his primary problem was shortness of breath. The report indicated .this patient is found to be lying in facility hospital bed, attended by multiple staff members, who are quickly wiping down is hands and feet, clipping his fingernails, scrubbing the layers of caked skin off of him. On the ground, in the bed, in the blankets, are seen an excessive amount of thick ships of skin detritus and debris from the cleaning that is happening, that came off of his body. There appear to this crew, to be much more skin debris than should be on a person, IF a person is being cleaned regularly or appropriately. It appears that the staff have not been regularly washing or caring for him, neglecting his hygiene. The patient is an elderly male, attached to a room air concentrator running at 4 L (liters) per minute via nasal cannula, he had a rapid respiratory rate, 30 BPM, but breaths show to be clear, he is breathing well. He answers questions well, if they are worded in yes/no form, and staff advised this is his common mental status presentation, normal to himself, for [CONDITION(S)] deficits. Staff advise that the reason for the call is that they measured his pulse oximetry at the mid-80s, and he had a rapid respiratory rate. Patient advises he is not short of breath any longer, on the device they have placed him on, nor is he in any pain .As we prepare to move him over he shows to wince when his right arm is moved, staff advise us that he has a current yeast rash in his right armpit, say he is affected to have deficits on that side from the old [CONDITION(S)], so he does not move it often, and when the area is exposed, it shows to be rashy, irritated, inflamed, with thickly caked yellow debris in it, unsure if it is old skin or layered ointment, but it is dried and matted, and not freshly applied ointment consistency. He shows bleeding from the tip of his just-now clipped right thumbnail, his nails are over-thick, irregular and rough in texture, and abnormal in growth, possible from a fungal infection or other nailbed issue. The nail was not clipped too close, not carelessly trimmed, it just shows to have abnormal size and increased blood flow in the cent of the nail matrix, and blood flow all the way distal and even past the tip of his thumb. Using staff's assistance, he is lifted/carried, and moved over into the stretcher .Further examination in the ambulance shows that he has a contracture in his right hand, which holds his fist together, but multiple area of his finger skin appear to have pressure sores in the joints and knuckles from hot having padding between the hard spots. Upon arrival at the emergency room his pulse oximetry has remained at ,d+[DATE]% on 3 LPM NC. Throughout the duration of contact he has had no complaints, other than the transfers from bed and cot which are painful to him. As we give a report, we are assisting the nurses in transfer of care. We mention the state of the patient's room and the state of the patient when we first got him, and as the RNs strip his clothes off, they remove his adult diaper, in order to get him washed and in a clean gown, and they find more rashes, skin breakdown in the creases and crevices of his groin, uncleaned feces in his cracks and in the skin below his penis. We advised to the nurses that we will be putting a report in for adult protective services Contact with EMT E was attempted on [DATE] at 10:30 a.m. A message with left with the fire department dispatcher providing the surveyor's contact information and request to return call. EMT E did not return the call. Record review of ED physician documentation dated [DATE] indicated Resident #1 arrived on [DATE] at 9:28 a.m. The record indicated: *patient has cutaneous candidiasis (fungal infection of the skin, caused by yeast) and his axilla and groin creases with [CONDITION(S)] (redness) to the skin. *patient is contracted in the bed responsive to pain only. Record review of ED nurse documentation dated [DATE]-[DATE] indicated: *triage assessment indicated denies pain, appears uncomfortable, behavior is cooperative. Has moderate shortness of breath. *[DATE] at 10:05 a.m. - skin is fragile, dry with flakes to arms, legs, face. Yellow crusty substance to right scalp. Right armpit with redness, swelling, skin scaly. Peri area with redness, dried white powdery crusty substance. Fingernails unkempt, long and curling over fingertips. Right arm with [CONDITION(S)] (paralyzed). *[DATE] at 10:10 a.m. - when asked if he knows where he is, he states eenie, meenie, minie, mo. *[DATE] at 10:48 a.m. - bath given, linen changed. Barrier cream applied to under arm, peri area, buttocks. *[DATE] at 8:39 a.m. - pt grimaces with movement Record review of a hospital discharge summary dated [DATE] indicated: *date of discharge [DATE] *septic shock with Gram negative rod bacteremia (blood borne infection) secondary to acute pyelonephritis (type of urinary tract infection) with obstructive [CONDITION(S)] (obstructed urinary flow) *left sided hydroureteronephrosis (swelling of a kidney due to buildup of urine) with 8 mm ureteric calculus (kidney stone); patient had emergent cystoscopy (procedure used to look inside the bladder) with possible left-sided ureteric stent (tube to allow urine to flow) placement, attempted left-sided ureteric stent placement was unsuccessful. Unable to transfer to higher level of care for left-sided nephrostomy tube placement as the patient was denied. Family had decided on withdrawal of care. *acute hypoxic respiratory failure (respiratory failure related to low levels of oxygen in the blood, possible life threatening) following cystoscopy. Patient have underlying pulmonary [CONDITION(S)] (excess fluid in the blood vessels of the lungs). Withdrawal of care was done today *acute kidney injury with baseline chronic kidney disease stage III; likely precipitated by obstructive [CONDITION(S)]. Patient also had concurrent metabolic acidosis (chemical imbalance of the blood making it more acidic) which has resolved. DC to hospice. *scrotal excoriation/wound/possible laceration (redness and possible wound of the scrotum), continue wound care as appropriate. Record review of Record of Death, dated [DATE] indicated Resident #1 died on [DATE] at 2:27 p.m. The immediate cause of death was cardiopulmonary arrest (heart and lungs stop working). Record review of a Performance Improvement Plan, dated [DATE] indicated problem areas identified included: *skin concerns not addressed according to policy for skin *assessments not completed to represent current skin issues Changes Implemented to reach Baseline: *In-service all nursing staff on PCMS1 (skin policy) *CNA in-service on reporting any skin condition immediately to charge nurse or unit manager and utilizing unity skin alert *Skin sweep of all patients to be completed by managers *Treatment nurse to start completing all weekly head to toe skin assessments *Wound care doctor comes to facility weekly for evaluation and procedures if needed *Treatment nurse to attend stand-up meeting every day with full report on all wounds and interventions in place and any new skin concerns *DON/ADON audit skin report to ensure all area of concern are captured on skin report *UM/ADON/DON/Tx Nurse to round daily to ensure patients with positioning devices are in place and off-loading correctly. Provide individual in-services as warranted *Care plans updated to show any skin concerns chronic and acute, and refusals of care *CNA are to report any shower refusals to charge nurse for follow up and documentation *ensure pre/post pain assessment to all treatment orders During an interview on [DATE] at 12:54 p.m., CNA C said she took care of Resident #1 on [DATE], the day he was transferred to the hospital. CNA C said she told LVN B that he was breathing funny, and that he did not look to be his normal self. CNA C said LVN B checked Resident #1's oxygen levels and then gave him oxygen. CNA C said she had provided incontinent care for Resident #1 earlier that day. CNA C said Resident #1 had an area on his back with red flaky skin. She said the area in between his legs was red as well. She said Resident #1 had an odor and she thought it was from his skin. During an interview on [DATE] at 1:20 p.m., CNA F said Resident #1's right arm did not work and that he could not move it. She said his right hand was contracted into a fist. CNA F said it was hard to get the contracted hand open to clean it, and she had never been told to place anything in the contracted hand to help with the contracture. CNA F said the day Resident #1 was sent to the hospital she pointed out to the nurse (unspecified) how bad his hands and nails looked. She said Resident #1 had an odor as if they did not wash his hand. CNA F said Resident #1's nails were really long and digging into his skin. She said his skin was always red and raw and the CNAs applied barrier cream when providing incontinent care. CNA F said Resident #1 had broken skin around his sacrum, pelvis, testicles, and all of that area from front to back. CNA F said Resident #1 would refuse incontinent care at times. CNA F said Resident #1 needed more care than he got because of his skin issues and his hand contracture, and that when a resident has hand contractures you have to pay more attention to his nails. During an interview on [DATE] at 1:42 p.m., LVN G said she went into Resident #1's room on [DATE] at the end. She said Resident #1 was having difficulty breathing and was receiving supplemental oxygen. LVN G said she did not recall any discussion about Resident #1's nails. She said his hand was contracted, but she was not sure if his hand was so contracted that his nails were into his hand. LVN G said Resident #1 had chronic irritation under his right arm, buttocks, and groin. LVN G said he always had flaky skin. She said the irritated areas were painful and sensitive. During an interview at the receiving hospital on [DATE] at 2:45 p.m., Emergency Department (ED) RN H said Resident #1 was admitted to the ED on [DATE]. RN H said he was not involved in Resident #1's care, but that the nurses assigned to Resident #1 were so concerned about his hygiene that they gave him a bath in the ED. RN H said we don't normally bathe patients in the ED. During an interview at the receiving hospital on [DATE] at 3:00 p.m., ED RN I said she helped care for Resident #1 when he was transferred to the ED on [DATE].RN I said when Resident #1 was undressed he had a smell like rotting flesh she detected through an N95 mask. RN I said Resident #1's right axilla (armpit) had red macerated (skin which may be soft, wet or soggy from being in contact with moisture for too long) skin and was covered in a layer of powder and gunk. She said his nails were unclipped and were growing into the palm of his hand, and there was more macerated tissue underneath his contracted fingers. RN I said the reddened area of his groin extended outside of his briefs and he had macerated skin on both sides. RN I said Resident #1's pubic area was covered in powder and cream and old fecal matter. RN I said once his left groin was separated and cleaned, he had some bleeding, and the creases under his buttocks were bloody and macerated. RN I said Resident #1 was red from below his buttocks to about halfway up his back. She said Resident #1's scalp had yellow dried skin and was caked to the side of his head. RN I said we stopped our ER duties to help clean him up. No one deserves that lack of care; this didn't happen overnight. During a telephone interview on [DATE] at 3:57 p.m., LVN B said she was Resident #1's nurse on [DATE], the day he went to the hospital. LVN B said Resident #1 was not in distress when she made her first round (time unspecified), but that CNA C later alerted her that Resident #1 did not eat his breakfast and did not seem normal. LVN B said when she assessed Resident #1, he had labored breathing and she administered supplemental oxygen. LVN B said while she was calling PA D to notify him of Resident #1's condition and CNA C reported Resident #1's condition was declining, and she called 911 for emergency transport. LVN B said when she went back in the room LVN J was trimming Resident #1's nails and two CNAs (unspecified) were giving him a bed bath. LVN B said it was not normal to give a resident a bed bath or trim their nails before sending them to the hospital for emergency care, and she did not know why it happened. LVN B said Resident #1 had some type of skin condition. LVN B said she did not know what the skin condition was, but that Resident #1 had had it for some time. LVN B said Resident #1''s verbal response for everything is yes, no, maybe but he was not talking at that point. LVN B said Resident #1 had an odor she described as musty. During an interview at the receiving hospital on [DATE] at 11:30 a.m., ED RN K said she was assigned to care for Resident #1 when he was admitted to the ED on [DATE]. RN K described the following areas and conditions of Resident #1's skin: *right thumbnail was overgrown. It had been cut and was bleeding; *fingernails on his contracted hand (right) were overgrown and curling under. They had caused some broken skin in his palm; *right fingers were red from being together; *right axilla - excoriated skin, caked on powder and an odor like a yeast infection. Red scaly skin that was very tender to the touch. He cried out in pain when that arm was moved. The reddened area extended to mid bicep area on the right arm and approximately five inched down the side of his body.; *genital area - caked on powder, redness in groin area past the area of the brief and extending down the inner thighs approximately one hand width. There was a foul smell, and extreme pain on movement. The powder was crusted and there were multiple layers. It was not loose and did not aerate as fresh powder would; *left inguinal fold/crease had crusted caked ointment and powder. The area was red and painful; *buttocks/sacral area - redness and layers of powder. No broken skin but excoriated areas on buttocks and dried fecal matter around the anus. The redness extended from the buttocks to midback on the right side; *scrotum and inner thighs red, inflamed, and tender, covered with layers of powder/ointment; and *right side of head - had food particles, yellow matter and dead skin on the side of his head and in his hair. RN K said Resident #1 would respond to his name, but to most other questions his response was eenie, meenie, miney, mo. During an interview on [DATE] at 1:25 p.m., CNA F said the last time she had bathed Resident #1 was at the beginning of the year. She said Resident #1 hollered all the time. She said Resident #1 was real raw in his pelvic area, and that she had told the nurses. CNA F said there was a cream (unspecified) applied daily. CNA F said she had changed Resident #1 during the week when he was transferred to the hospital. CNA F said she did not see a difference that time from the first of the year. CNA F said his pelvic area had been raw since she started in 2018. CNA F said Resident #1 did not like hygiene care, and that most of the time when he got a bed bath, he would be mad. CNA F said some days he would let you provide care and other days he would not. CNA F said sometimes you could get him cleaner than others, but most of the time he would say no, and we could not get him clean. We would tell the nurses and they would tell us to document that he refused care. During an interview on [DATE] at 1:48 p.m., CNA L said she had not been assigned to care for Resident #1 for the last 2 months. CNA L said Resident #1 did not like to get changed and didn't like to be messed with at all. CNA L said it hurt Resident #1 to move. CNA L said the only skin areas of concern was the redness under his right arm and down his side. CNA L said you could not get all the old cream and powder off before Resident #1 would start yelling at you. CNA L said she told the nurses and they would just document it. CNA L said she did not know specifically what the nurses documented. During an interview on [DATE] at 2:08 p.m., LVN J said Resident #1 refused baths and incontinent care. LVN J said Resident #1 had a chronic skin condition that was normal for him. LVN J said, we keep him creamed and powdered. LVN J said Resident #1 had excoriation really bad under that armpit. LVN J staff tried to put a rolled-up washrag in his contracted hand but Resident #1 refuses. LVN J said Resident #1 cusses at you and refuses care a lot. LVN J said she cut Resident #1's fingernails before he went to the hospital on [DATE] because they needed to be cut. LVN J said she did not nick him or anything. LVN J said Resident #1 was not bleeding, but it looked like he had jelly under his fingernails. LVN J said Resident #1 was old, stubborn, and set in his ways. LVN J said Resident #1 was adamant that he did not want to bathe. During a telephone interview on [DATE] at 3:04 p.m., PA D said he did not recall Resident #1 having a skin condition, but after reviewing records said Resident #1 had pruritic [CONDITION(S)] which was basically an itchy rash that would cause flaking skin. PA D said he thought it would be important to get all the old skin and powder off before applying medication. PA D said the standard of care would be to apply medication to clean skin and not on top of powder or anything that would be a barrier to the medication. PA D said he assumed Resident #1 was receiving regular bathing, but he did not know for sure. PA D said he had not been notified that the facility was having trouble bathing Resident #1 or cleaning the affected areas. During an interview on [DATE] at 3:37 p.m., LVN M (treatment nurse) said Resident #1 had chronic redness mainly under the right arm and on his buttocks. LVN M said Resident #1 would frequently refuse incontinent care. LVN M said Resident #1's current treatment was [MEDICATION(S)] (antiseptic skin cleanser) and a dry dressing under his right arm to prevent skin to skin contact. LVN M said frequently she was not able adequately clean the area under his right arm to get the dead skin off because it hurt him to move the arm. LVN M said treatments should be applied to clean skin. LVN M said Resident #1 would often lay on his right arm (affected by stoke). LVN M said Resident #1's buttocks were like a red incontinent kind of rash.' LVN M said the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN M said maybe because it was all over there wasn't a specific place to be treated. LVN M said she never contacted the physician about Resident #1's refusal of care. LVN M said she thought the physician knew he was refusing care because other nurses (unspecified) said they had talked to him. LVN M said Resident #1 usually responded with yes or no, and that she had never heard him say a complete sentence. LVN M said even though Resident #1's skin was dry and flaky and red and inflamed on his bottom he never had a pressure injury. During an interview on [DATE] at 4:27 p.m., CNA N said she routinely took care of Resident #1. She said he had chronic redness under his right arm which she reported to the nurse, but she did not recall which nurse she told. CNA N said the nurse already knew about the redness and said that he was getting a medicine for it. CNA N said she would try and remove the dead skin when bathing Resident #1, but he would never let her bathe him. CNA N said he would refuse care a lot. She said when Resident #1 refused care she would tell the charge nurse and try again later. CNA N said after incontinent care she would put on the cream that we used for everyone on his bottom. CNA N said Resident #1's bottom was red sometimes, and she told the nurse every time. CNA N said Resident #1 would have a smell when he didn't get a bath. CNA N said she was never told to put a dry dressing under his right arm. During an interview on [DATE] at 4:45 p.m., CNA O said Resident #1 refused care a lot, and that he only wanted to be changed once a shift. CNA O said she used to tell the nurses about him refusing care, but it became so common she stopped telling them. CNA O said he refused care every day. CNA O said Resident #1's skin would be built up and red with a lot of dead skin. She said the redness was on his bottom, in the creases of his groin, and under his arm. CNA O said Resident #1 would lay on his right side to eat rather than sit up. She said Resident #1 would spill food and drinks and it would run down his arm. CNA O said if you tried to move his right arm Resident #1 would say ow and start cussing. CNA O said Resident #1 would have a body odor from refusing baths. CNA O said when she provided incontinent care for Resident #1, he would have a buildup of skin and gunk. During an interview on [DATE] at 12:50 p.m., DON said that although she had spoken to several staff [TRUNCATED]

Based on interview and record review, the facility failed to consult with the physician regarding a change in condition for 1 of 7 residents reviewed for change in condition. (Resident #1) The facility did not implement interventions to provide bathing and hygiene care for Resident #1. The resident developed irritated and inflamed areas, diagnosed as a yeast infection by the hospital, in and around the skin folds of his body that caused him to yell out in pain when moved. This resulted in the resident not receiving incontinent care, treatments, or bathing after refusing due to being in pain, which contributed to further deterioration of the skin and quality of life. The facility did not notify the physician of the residents pain, refusal of care, or that his skin conditions were not improving. Resident #1 who required total assistance from staff for bathing was unkept, had an odor, and had a buildup of old ointment, powder, and flaking skin in the crevices of his body. This failure could place residents at risk of not receiving care and services to meet their needs and a delay in treatment. Findings included: Record review of Record of Death, dated [DATE] indicated Resident #1 died on [DATE] at 2:27 p.m. The immediate cause of death was cardiopulmonary arrest. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year-old male initially admitted on [DATE] with the most current admission on [DATE]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS assessment, dated [DATE], indicated Resident #1 had unclear speech, was rarely or never understood, and sometimes understood others. Resident #1 had severe cognitive impairment. The assessment indicated he had no behaviors and did not reject evaluation or care during the assessment period. Resident #1 required extensive physical assistance of one person for bed mobility, moving between surfaces, dressing, toileting, and personal hygiene. He required supervision and setup help only to eat or drink. Resident #1 was totally dependent on physical assistance of one staff for bathing. The assessment indicated Resident #1 had impaired range of motion in upper and lower extremities on one side. Resident #1 was always incontinent of bowel and bladder. The assessment indicated Resident #1 was at risk of developing pressure injuries but had no unhealed pressure injuries. The pain assessment instructions indicated if the resident was rarely/never understood the pain assessment interview should be skipped and pain should be assessed via staff assessment of indicators of possible pain which included: a] non-verbal sounds such as crying, whining, gasping, moaning or groaning; b] vocal complaints of pain such as that hursts, ouch, stop; c] facial expressions such as grimaces, winces, wrinkled forehead, furrowed, brow, clenched teeth or jaw; or d] protective body movements or postures such as bracing, guarding, clutching or holding a body part during movement. Although Resident #1 was rarely/never understood, the assessment indicated a pain assessment interview was conducted and indicated Resident #1 had no pain during the last five days. Record review of Resident #1's current care plan, reviewed [DATE], indicated he needed extensive assistance with most ADLs. The care plan indicated a focus area for incontinence of bowel and bladder with interventions including 1] monitor for incontinence every 2 hours and as needed. Change promptly and apply a protective skin barrier to skin; 2] monitor for signs and symptoms of skin breakdown and report to physician and responsible party; 3] assess for causes of incontinence; 4] lab as ordered by physician; 5] encourage fluid intake within dietary limits; 6] monitor for signs and symptoms of infection and report to physician. The care plan indicated a focus area for pain management with interventions including 1] monitor for signs and symptoms of increased pain or discomfort and assess resident for possible causes; 2] provide pressure relieving and positioning devices as needed; 3] assist with ADLs and comfort measures as needed; 4] assess and document pain; 5] monitor for constipating effects of pain medication. The care plan indicated Resident #1 was at risk of skin breakdown related to incontinence, bedfast, impaired bed mobility, fragile skin, cognitive impairment, and refusal of showers, incontinent care, and to have lotion applied to his dry skin, with interventions including 1] monitor for incontinence every two hours and change promptly, 2] apply moisturizing lotion, as he allows; 3] encourage PO and fluid intake; 4] monitor for skin breakdown, report to physician and responsible party; 5] assess skin weekly and record findings. The care plan indicated an undated focus area related to skin/tissue integrity status - chronic redness to right arm fold with interventions including 1] assess and monitor skin integrity and signs/symptoms of complications; 2] assess and monitor nutritional status to prevent skin breakdown and signs of complications; 3] assess and monitor incontinence/moisture risk for skin breakdown. The goal date for this focus area was [DATE]. The care plan indicated an undated focus area related to a history of stroke, and included the intervention develop alternate methods of communication. The care plan did not indicate staff interventions for care refusal, nor did it address the contracture of Resident #1's right hand. Record review of physician orders dated [DATE] and active at the time of his transfer to the hospital indicated: *order dated [DATE] pain assessments by shift. There were no medication orders to treat pain. *order dated [DATE] dry dressings by shift. Keep wedge or towel under arm (unspecified) to prevent skin to skin contact unless resident is bathing or receiving incontinent care. May cover with dry dressing as needed for drainage. *order dated [DATE] weekly head to toe skin assessment *order dated [DATE] barrier cream one time daily. Cleanse bilateral buttocks with normal saline or skin cleanser. Pat dry. Apply barrier cream. *order dated [DATE] Hibaclens 4% topical liquid one time daily for rash and other nonspecific skin eruption. The order did not specify what area of the body was to be treated or how. Record review of Resident #1's ADL documentation for [DATE] indicated: *[DATE] incontinent care occurred at 3:43 a.m., 11:22 a.m., and 16:24 p.m. *[DATE] personal hygiene occurred at 3:44 a.m., 11:23 a.m., and 16:26 p.m. *[DATE] incontinent care occurred 5:20 a.m. and 10:28 a.m. There was no incontinent care documented for the ,d+[DATE] shift. *[DATE] personal hygiene occurred at 5:21 a.m. and 10:29 a.m. There was no personal hygiene documented for the ,d+[DATE] shift. *[DATE] incontinent care occurred at 10:40 a.m. There was no other incontinent care documented. *[DATE] personal hygiene occurred at 10:40 a.m. There was no other personal hygiene documented. *[DATE] incontinent care occurred at 2:30 a.m. There was no other incontinent care documented. *[DATE] personal hygiene occurred at 2:31 a.m. and 12:48 p.m. There was no other personal hygiene documented. *[DATE] incontinent care occurred at 1:19 a.m. and 12:36 p.m. There was no other incontinent care documented. *[DATE] personal hygiene was documented as did not occur at 1:19 a.m. and as having occurred at 12:37 p.m. There was no documentation of personal hygiene for the ,d+[DATE] shift. *[DATE] incontinent care occurred at 3:04 am, 10:20 a.m., and 21:02 p.m. *[DATE] personal hygiene occurred at 3:05 a.m., 10:21 a.m., and 21:02 p.m. *[DATE] incontinent care occurred at 12:40 p.m., and 15:28 p.m. There was no documentation of incontinent care on the night shift. *[DATE] personal hygiene occurred at 12:43 p.m., and 15:29 p.m. There was no documentation of personal hygiene on the night shift. *[DATE] incontinent care occurred at 1:48 a.m. There was no other incontinent care documented. *[DATE] personal hygiene occurred at 1:49 a.m. There was no other personal hygiene documented. Record review of treatment notes (TAR) dated [DATE], written by LVN S, indicated Resident #1 refused the dry dressing, and the provider was notified. During an interview on [DATE] at 11:20 a.m., LVN S said the treatment notes for [DATE] indicated she had notified the physician, but she did not. LVN S said the electronic record automatically indicated the physician had been notified anytime you document that a resident has refused something. Record review of treatment notes (TAR) dated [DATE], [DATE], [DATE], [DATE], and [DATE] indicated Resident #1 had a pain scale rating of 0 on all shifts, with the location described as not applicable. Record review of treatment notes (TAR) dated [DATE] and [DATE] on the night shift, entered by LVN A, indicated Resident #1 had generalized pain rated as 3. There was no physician notification, nor any interventions implemented to address pain. There were no nursing notes regarding these pain scale ratings. Record review of a Performance Improvement Plan, dated [DATE] indicated problem areas identified included: *skin concerns not addressed according to policy for skin *assessments not completed to represent current skin issues Changes Implemented to reach Baseline: *In-service all nursing staff on PCMS1 (skin policy) *CNA in-service on reporting any skin condition immediately to charge nurse or unit manager and utilizing unity skin alert *Skin sweep of all patients to be completed by managers *Treatment nurse to start completing all weekly head to toe skin assessments *Wound care doctor comes to facility weekly for evaluation and procedures if needed *Treatment nurse to attend stand-up meeting every day with full report on all wounds and interventions in place and any new skin concerns *DON/ADON audit skin report to ensure all area of concern are captured on skin report *UM/ADON/DON/Tx Nurse to round daily to ensure patients with positioning devices are in place and off-loading correctly. Provide individual in-services as warranted *Care plans updated to show any skin concerns chronic and acute, and refusals of care *CNA are to report any shower refusals to charge nurse for follow up and documentation *ensure pre/post pain assessment to all treatment orders During an interview on [DATE] at 12:54 p.m., CNA C said she took care of Resident #1 on [DATE], the day he was transferred to the hospital. CNA C said she told LVN B that he was breathing funny, and that he did not look to be his normal self. CNA C said LVN B checked Resident #1's oxygen levels and then gave him oxygen. CNA C said she had provided incontinent care for Resident #1 earlier that day. CNA C said Resident #1 had an area on his back with red flaky skin. She said the area in between his legs was red as well. She said Resident #1 had an odor and she thought it was from his skin. During an interview on [DATE] at 1:20 p.m., CNA F said Resident #1's nails were really long and digging into his skin. She said his skin was always red and raw and the CNAs applied barrier cream when providing incontinent care. CNA F said Resident #1 had broken skin around his sacrum, pelvis, testicles, and all of that area from front to back. CNA F said Resident #1 would refuse incontinent care at times. CNA F said Resident #1 needed more care than he got because of his skin issues and his hand contracture, and that when a resident has hand contractures you have to pay more attention to his nails. During an interview on [DATE] at 1:42 p.m., LVN G said Resident #1 had chronic irritation under his right arm, buttocks, and groin. LVN G said he always had flaky skin. She said the irritated areas were painful and sensitive. During an interview at the receiving hospital on ,d+[DATE]//21 at 3:00 p.m., ED RN I said she helped care for Resident #1 when he was transferred to the ED on [DATE]. RN I said when Resident #1 was undressed he had a smell like rotting flesh she detected through an N95 mask. RN I said Resident #1's right axilla (armpit) had red macerated skin and was covered in a layer of powder and gunk. She said his nails were unclipped and were growing into the palm of his hand, and there was more macerated tissue underneath his contracted fingers. RN I said the reddened area of his groin extended outside of his briefs and he had macerated skin on both sides. RN I said Resident #1's pubic area was covered in powder and cream and old fecal matter. RN I said once his left groin was separated and cleaned, he had some bleeding, and the creases under his buttocks were bloody and macerated. RN I said Resident #1 was red from below his buttocks to about halfway up his back. She said Resident #1's scalp had yellow dried skin and was caked to the side of his head. RN I said we stopped our ER duties to help clean him up. No one deserves that lack of care, this didn't happen overnight. During an interview on [DATE] at 1:25 p.m., CNA F said the last time she had bathed Resident #1 was at the beginning of the year. She said Resident #1 hollered all the time. She said Resident #1 was real raw in his pelvic area, and that she had told the nurses. CNA F said there was a cream (unspecified) applied daily. CNA F said she had changed Resident #1 during the week when he was transferred to the hospital. CNA F said she did not see a difference that time from the first of the year. CNA F said his pelvic area has been raw since she started in 2018. CNA F said Resident #1 did not like hygiene care, and that most of the time when he got a bed bath he would be mad. CNA F said some days he would let you provide care and other days he would not. CNA F said sometimes you could get him cleaner than others, but most of the time he would say no, and we could not get him clean. We would tell the nurses and they would tell us to document that he refused care. During an interview on [DATE] at 1:48 p.m., CNA L said she had not been assigned to care for Resident #1 for the last 2 months. CNA L said Resident #1 did not like to get changed and didn't like to be messed with at all. CNA L said it hurt Resident #1 to move. CNA L said the only skin areas of concern was the redness under his arm and down his side. CNA L said you could not get all the old cream and powder off before Resident #1 would start yelling at you. CNA L said she told the nurses and they would just document it. CNA L said she did not know specifically what the nurses documented. During an interview on [DATE] at 2:08 p.m., LVN J said Resident #1 refused baths and incontinent care. LVN J said Resident #1 had a chronic skin condition that was normal for him. LVN J said, we keep him creamed and powdered. LVN J said Resident #1 had excoriation really bad under that armpit. LVN J staff tried to put a rolled-up washrag in his contracted hand but Resident #1 refuses. LVN J said Resident #1 cusses at you and refuses care a lot. LVN J said Resident #1 was adamant that he did not want to bathe. During a telephone interview on [DATE] at 3:04 p.m., PA D said he did not recall Resident #1 having a skin condition, but after reviewing records said Resident #1 had pruritic [CONDITION(S)] which was basically an itchy rash that would cause flaking skin. PA D said he thought it would be important to get all the old skin and powder off before applying medication. PA D said the standard of care would be to apply medication to clean skin and not on top of powder or anything that would be a barrier to the medication. PA D said he assumed Resident #1 was receiving regular bathing, but he did not know for sure. PA D said he had not been notified that the facility was having trouble bathing Resident #1 or cleaning the affected areas. During an interview on [DATE] at 3:37 p.m., LVN M (treatment nurse) said Resident #1 had chronic redness mainly under the right arm and on his buttocks. LVN M said Resident #1 would frequently refuse incontinent care. LVN M said Resident #1's current treatment was [MEDICATION(S)] (antiseptic skin cleanser) and a dry dressing under his right arm to prevent skin to skin contact. LVN M said frequently she was not able adequately clean the area under his right arm to get the dead skin off because it hurt him to move the arm. LVN M said treatments should be applied to clean skin. LVN M said Resident #1 would often lay on his right arm (affected by stoke). LVN M said Resident #1's buttocks were like a red incontinent kind of rash.' LVN M said the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN M said maybe because it was all over there wasn't a specific place to be treated. LVN M said she never contacted the physician about Resident #1's refusal of care. LVN M said she thought the physician knew he was refusing care because other nurses (unspecified) said they had talked to him. LVN M said Resident #1 usually responded with yes or no, and that she had never heard him say a complete sentence. LVN M said even though Resident #1's skin was dry and flaky and red and inflamed on his bottom he never had a pressure injury. During an interview on [DATE] at 4:27 p.m., CNA N said she routinely took care of Resident #1. She said he had chronic redness under his right arm which she reported to the nurse, but she did not recall which nurse she told. CNA N said the nurse already knew about the redness and said that he was getting a medicine for it. CNA N said she would try and remove the dead skin when bathing Resident #1, but he would never let her bathe him. CNA N said he would refuse care a lot. She said when Resident #1 refused care she would tell the charge nurse and try again later. CNA N said after incontinent care she would put on the cream that we used for everyone on his bottom. CNA N said Resident #1's bottom was red sometimes, and she told the nurse every time. CNA N said Resident #1 would have a smell when he didn't get a bath. CNA N said she was never told to put a dry dressing under his right arm. During an interview on [DATE] at 4:45 p.m., CNA O said Resident #1 refused care a lot, and that he only wanted to be changed once a shift. CNA O said she used to tell the nurses about him refusing care, but it became so common she stopped telling them. CNA O said he refused care every day. CNA O said Resident #1's skin would be built up and red with a lot of dead skin. She said the redness was on his bottom, in the creases of his groin, and under his arm. CNA O said Resident #1 would lay on his right side to eat rather than sit up. She said Resident #1 would spill food and drinks and it would run down his arm. CNA O said if you tried to move his right arm Resident #1 would say ow and start cussing. CNA O said Resident #1 would have a body odor from refusing baths. CNA O said when she provided incontinent care for Resident #1, he would have a buildup of skin and gunk. During an interview on [DATE] at 12:50 p.m., DON said that although she had spoken to several staff members about Resident #1's condition when he was transferred to the hospital, none of them had indicated he had skin areas that were red and excoriated, or that he was having pain during care. The DON said staff indicated he was stubborn, refused showers, and did not like care. The DON said if a resident experienced pain it should be reported so it could be treated. The DON said Resident #1 had no active orders for pain medication. The DON said the nurses should have notified the doctor about Resident #1's pain during care. The DON said the weekly head to toe skin assessments consisted of one question does the resident have clear skin. The DON said Resident #1's weekly skin assessments indicated he had clear skin, and that his record did not include wound assessments. The DON said if a resident had any skin issue it should not be recorded as a clear skin assessment, and that a wound assessment should have been done for any problem areas. The DON said she could not explain how a nurse could have assessment findings of clear skin if Resident #1 had red excoriated areas under his arm, groin, and buttocks. The DON said the order for [MEDICATION(S)] did not indicate what part of Resident #1's body should be treated and based on the information in the order she could not tell where it was supposed to be applied. The DON said the order should have been clarified to indicate the area to be treated. The DON said the CNAs document care once per shift. She said ADL care was not always documented at the end of the shift, and that care occurring after the point of documentation was assumed to be completed. The DON said there was not enough documentation in Resident #1's record to support the care refusals described by staff. The DON said she had developed and implemented a performance Improvement Plan on [DATE] because of care concerns related to Resident #1. During an interview on [DATE] at 2:50 p.m., CNA R she assisted other CNAs in providing care for Resident #1 a few times, with the last time being a couple of weeks ago. CNA R said Resident #1's skin was really red and irritated on his scrotum and bottom, and he would push your hands away and start yelling and cussing at you. CNA P said they applied barrier cream as best they could and put some in his brief so hopefully it would get in the right area. CNA R said, you could tell that area of his body was very sensitive, I am sure he was in pain. CNA R said it was possible Resident #1 was yelling out due to the pain. CNA R said she told the charge his skin was red and irritated on his scrotum and his bottom. CNA R said it was possible that the pain was causing Resident #1 to refuse care, and that he would say no get away from me. During an interview on [DATE] at 4:12 p.m., LVN Q said she had frequently taken care of Resident #1. LVN Q said he always had reddened areas under his right arm and on his groin, back, and buttocks. LVN Q said she applied barrier cream when the CNAs performed incontinent care. LVN Q said she had never been told by the CNAs that they could not complete care for Resident #1, nor that he had reddened areas that were painful. LVN Q said Resident #1 did not like to be moved, and that he could tell you if he had pain or not. LVN Q said she did not think Resident #1 was having pain. During an interview on [DATE] PA D said he did not think the facility ever notified him that Resident #1 was having pain or that he was having pain during treatments or routine care. PA D said if pain prevented Resident #1 from receiving care it would be clinically significant. During an interview on [DATE] at 1:45 p.m., LVN Q said weekly skin assessments were usually done while helping a CNA during care. LVN Q said Resident #1 had redness under his arm, around his groin and buttocks, but he always had redness there so it was not new. LVN Q said the weekly head to toe assessment was used to document new skin problems only, otherwise she just checked clear. LVN Q said if a resident experienced pain during care that should be addressed, but Resident #1 never told her he was in pain, and no one had reported that to her. During a telephone interview on [DATE] at 2:07 p.m., LVN S said Resident #1 never complained of pain. She said CNAs had notified her that he refused care at times, but when she asked him why his response was yes, no, maybe. LVN S said the CNAs never told her that Resident #1 refused care because of pain. LVN S said she knew Resident #1 had a lot of skin issues, and I'm sure that caused him pain. LVN S said Resident #1 would frequently refuse to bathe or allow care, and that was normal for him. LVN S said the last time she saw Resident #1's skin was about 2 months ago, and that he always had redness under his right arm and there was a foul smell. LVN S said the area under his right arm always stayed moist and there was supposed to be something under it to prevent the skin from touching. During a telephone interview on [DATE] at 2:46 p.m., LVN T said she had been Resident #1's nurse for 2 years. She said pain assessments were completed each shift. LVN T said Resident #1 hollers when you change him, and that he had some skin problems she believed to be uncomfortable. LVN T said Resident #1's response to any thing she asked him about was no. LVN T said she was told by a CNA that he would not allow the CNA to change him, and they notified the next shift. LVN T said it was common for Resident #1 to refuse incontinent care, but he never gave a reason for the refusal. LVN T said there were times he would go a whole shift without being changed. Contact with LVN A was attempted on [DATE] at 4:36 p.m. at the number provided by the facility. There was no answer, and a message was left with contact information and request to return call. During an interview on [DATE] at 10:30 a.m., the DON said she had been notified by the hospital that Resident #1 had passed away on [DATE]. The DON acknowledged Resident #1's record indicated a pain scale rating of 3 on the night shift pain assessment completed by LVN A on [DATE] and [DATE]. The DON said there was no note regarding the pain assessment, and no indication of an intervention for pain. The DON said Resident #1 did not have any orders for pain medication, and LVN A would have had to call the doctor to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said Resident #1's skin condition should have been addressed on a wound assessment. She said the facility policy indicated if the condition had not improved in 2 weeks the physician should be contacted. During an interview on [DATE] at 11:20 a.m., LVN S said Resident #1 would refuse the dry dressing under his right arm, and if you did put it there, he would remove it. LVN S said nurses are supposed to notify the physician for refusals of care. LVN S said she had notified the physician before, but it was a long time ago. LVN s said Resident #1 had the order for dry dressing for a long time, and he had been refusing it for a long time. LVN S said the treatment notes for [DATE] indicated she had notified the physician, but she did not. LVN S said the electronic record automatically indicated the physician had been notified anytime you document that a resident has refused something. During an interview on [DATE] at 12:31 p.m., CNA U said she had cared for Resident #1 two or three weeks ago. She said Resident #1 acted like it hurt him to move, and that she told the nurses about it. CNA U said Resident #1 had redness under his right arm and between his legs, and it looked like a hot mess. CNA U said she put the barrier cream all over his bottom where it was red. CNA U said she was not able to get all the old cream and powder off because it was caked on. CNA U said she would get as much off as she could, but Resident #1 would be in pain. During an interview on [DATE] at 12:56 p.m., CNA V said she had taken care of Resident #1 sometimes, but it had been quite a while (unspecified), and that she did not normally work that hall. CNA V said the last time she provided care the skin under his arm and in his groin, area was very red and smelled like a yeast infection. Record review of an article titled A Clinician's Guide to the DIignosis and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .ncbi.nlm.nih.gov/pmc/articles/PMC 41/, indicated: *Typically cutaneous candidiasis presents as thin, bright-red plaques that can be erosive, dry, scaly, oozing, or macerated, pustules and collarette scales may also be present. *Affected areas should be kept dry Record review of the facility policy title Physician Notification, updated [DATE], indicated: *The types of conditions which arise frequently include skin rash *It is the responsibility of the nursing staff to observe the change, make an assessment, and notify the physician as indicated based on the assessment. *The nurse will recognize the condition change, monitor the patient, and continue to assess the condition and changes, and notify the physician, patient, and patient representative of any change in condition.

Based on interview and record review, the facility failed to provide pain management consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 7 residents reviewed for pain. (Resident #1) The facility did not implement interventions to provide bathing and hygiene care for Resident #1. The resident developed irritated and inflamed areas, diagnosed as a yeast infection by the hospital, in and around the skin folds of his body that caused him to yell out in pain when moved. This resulted in the resident not receiving incontinent care, treatments, or bathing after refusing due to being in pain, which contributed to further deterioration of the skin and quality of life. The facility did not notify the physician of the residents pain, refusal of care, or that his skin conditions were not improving. Resident #1 who required total assistance from staff for bathing was unkept, had an odor, and had a buildup of old ointment, powder, and flaking skin in the crevices of his body. This failure could place residents who experience pain at risk of unnecessary pain, discomfort, and decreased quality of life. Findings included: Record review of Record of Death, dated [DATE] indicated Resident #1 died on [DATE] at 2:27 p.m. The immediate cause of death was cardiopulmonary arrest. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year-old male initially admitted on [DATE] with the most current admission on [DATE]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS assessment, dated [DATE], indicated Resident #1 had unclear speech, was rarely or never understood, and sometimes understood others. Resident #1 had severe cognitive impairment. The assessment indicated he had no behaviors and did not reject evaluation or care during the assessment period. Resident #1 required extensive physical assistance of one person for bed mobility, moving between surfaces, dressing, toileting, and personal hygiene. He required supervision and setup help only to eat or drink. Resident #1 was totally dependent on physical assistance of one staff for bathing. The assessment indicated Resident #1 had impaired range of motion in upper and lower extremities on one side. Resident #1 was always incontinent of bowel and bladder. The assessment indicated Resident #1 was at risk of developing pressure injuries but had no unhealed pressure injuries. The pain assessment instructions indicated if the resident was rarely/never understood the pain assessment interview should be skipped and pain should be assessed via staff assessment of indicators of possible pain which included: a] non-verbal sounds such as crying, whining, gasping, moaning or groaning; b] vocal complaints of pain such as that hursts, ouch, stop; c] facial expressions such as grimaces, winces, wrinkled forehead, furrowed, brow, clenched teeth or jaw; or d] protective body movements or postures such as bracing, guarding, clutching or holding a body part during movement. Although Resident #1 was rarely/never understood, the assessment indicated a pain assessment interview was conducted and indicated Resident #1 had no pain during the last five days. Record review of Resident #1's current care plan, reviewed [DATE], indicated he needed extensive assistance with most ADLs. The care plan indicated a focus area for incontinence of bowel and bladder with interventions including 1] monitor for incontinence every 2 hours and as needed. Change promptly and apply a protective skin barrier to skin; 2] monitor for signs and symptoms of skin breakdown and report to physician and responsible party; 3] assess for causes of incontinence; 4] lab as ordered by physician; 5] encourage fluid intake within dietary limits; 6] monitor for signs and symptoms of infection and report to physician. The care plan indicated a focus area for pain management with interventions including 1] monitor for signs and symptoms of increased pain or discomfort and assess resident for possible causes; 2] provide pressure relieving and positioning devices as needed; 3] assist with ADLs and comfort measures as needed; 4] assess and document pain; 5] monitor for constipating effects of pain medication. The care plan indicated Resident #1 was at risk of skin breakdown related to incontinence, bedfast, impaired bed mobility, fragile skin, cognitive impairment, and refusal of showers, incontinent care, and to have lotion applied to his dry skin, with interventions including 1] monitor for incontinence every two hours and change promptly, 2] apply moisturizing lotion, as he allows; 3] encourage PO and fluid intake; 4] monitor for skin breakdown, report to physician and responsible party; 5] assess skin weekly and record findings. The care plan indicated an undated focus area related to skin/tissue integrity status - chronic redness to right arm fold with interventions including 1] assess and monitor skin integrity and signs/symptoms of complications; 2] assess and monitor nutritional status to prevent skin breakdown and signs of complications; 3] assess and monitor incontinence/moisture risk for skin breakdown. The goal date for this focus area was [DATE]. The care plan indicated an undated focus area related to a history of stroke, and included the intervention develop alternate methods of communication. The care plan did not indicate staff interventions for care refusal, nor did it address the contracture of Resident #1's right hand. Record review of physician orders dated [DATE] and active at the time of his transfer to the hospital indicated: *order dated [DATE] pain assessments by shift. There were no medication orders to treat pain. Record review of treatment notes (TAR) dated [DATE], [DATE], [DATE], [DATE], and [DATE] indicated Resident #1 had a pain scale rating of 0 on all shifts, with the location described as not applicable. Record review of treatment notes (TAR) dated [DATE] and [DATE] on the night shift, entered by LVN A, indicated Resident #1 had generalized pain rated as 3. There was no physician notification, nor any interventions implemented to address pain. There were no nursing notes regarding these pain scale ratings. Record review of a Clinical Note written by LVN B, dated [DATE] at 1:43 p.m., indicated Resident #1 was noted to have labored breathing and a cough at the beginning of the shift (6a-6p). The note indicated LVN B was later (time unspecified) alerted by CNA C that Resident #1 was breathing hard and had not eaten his breakfast which was not normal for him. The note indicated LVN B returned to Resident #1's room to find him short of breath with very labored breathing, an oxygen level of 88% (less than 90% is considered low), and respirations were 48 per minute (Normal range for respirations are ,d+[DATE] per minute) with diminished lung sounds. The note indicated LVN B had called to notify PA D of Resident #1's status when she was alerted by CNA C that Resident #1 was declining, and she called 911 for emergency transport. The note indicated Resident #1's nails were trimmed prior to being transferred to the hospital for emergency care. Record review of an EMS report dated [DATE] written by EMT E indicated EMS arrived at the facility at 9:11 a.m. The report indicated As we prepare to move him over he shows to wince when his right arm is moved, staff advise us that he has a current yeast rash in his right armpit, say he is affected to have deficits on that side from the old [CONDITION(S)], so he does not move it often, and when the area is exposed, it shows to be rashy, irritated, inflamed, with thickly caked yellow debris in it, unsure if it is old skin or layered ointment, but it is dried and matted, and not freshly applied ointment consistency.Throughout the duration of contact he has had no complaints, other than the transfers from bed and cot which are painful to him. Record review of ED physician documentation dated [DATE] indicated Resident #1 arrived on [DATE] at 9:28 a.m. The record indicated: *patient has cutaneous candidiasis (fungal infection of the skin, caused by yeast) and his axilla and groin creases with [CONDITION(S)] (redness) to the skin. *patient is contracted in the bed responsive to pain only. Record review of ED nurse documentation dated [DATE]-[DATE] indicated: *[DATE] at 8:39 a.m. - pt grimaces with movement Record review of a Performance Improvement Plan, dated [DATE] indicated problem areas identified included: *skin concerns not addressed according to policy for skin *assessments not completed to represent current skin issues Changes Implemented to reach Baseline: *In-service all nursing staff on PCMS1 (skin policy) *Treatment nurse to start completing all weekly head to toe skin assessments *Wound care doctor comes to facility weekly for evaluation and procedures if needed *Treatment nurse to attend stand-up meeting every day with full report on all wounds and interventions in place and any new skin concerns *DON/ADON audit skin report to ensure all area of concern are captured on skin report *ensure pre/post pain assessment to all treatment orders During an interview on [DATE] at 1:42 p.m.,. LVN G said Resident #1 had chronic irritation under his right arm, buttocks, and groin. LVN G said he always had flaky skin. She said the irritated areas were painful and sensitive. During an interview at the receiving hospital on ,d+[DATE]//21 at 3:00 p.m., ED RN I said she helped care for Resident #1 when he was transferred to the ED on [DATE]. RN I said Resident #1's right axilla (armpit) had red macerated skin and was covered in a layer of powder and gunk. She said his nails were unclipped and were growing into the palm of his hand, and there was more macerated tissue underneath his contracted fingers. RN I said the reddened area of his groin extended outside of his briefs and he had macerated skin on both sides RN I said once his left groin was separated and cleaned, he had some bleeding, and the creases under his buttocks were bloody and macerated. RN I said Resident #1 was red from below his buttocks to about halfway up his backRN I said we stopped our ER duties to help clean him up. No one deserves that lack of care, this didn't happen overnight. During an interview at the receiving hospital on [DATE] at 11:30 a.m., ED RN K said she was assigned to care for Resident #1 when he was admitted to the ED on [DATE]. RN K described the following areas and conditions of Resident #1's skin: *right thumbnail was overgrown. It had been cut and was bleeding. *right fingers were red from being together *right axilla - excoriated skin, caked on powder and an odor like a yeast infection. Red scaly skin that was very tender to the touch. He cried out in pain when that arm was moved. The reddened area extended to mid bicep area on the right arm and approximately five inched down the side of his body. *genital area - caked on powder, redness in groin area past the area of the brief and extending down the inner thighs approximately one hand width. There was a foul smell, and extreme pain on movement. The powder was crusted and there were multiple layers. It was not loose and did not aerate as fresh powder would. *left inguinal fold/crease had crusted caked ointment and powder. The area was red and painful. *buttocks/sacral area - redness and layers of powder. No broken skin but excoriated areas on buttocks and dried fecal matter around the anus. The redness extended from the buttocks to midback on the right side. *scrotum and inner thighs red, inflamed, and tender, covered with layers of powder/ointment. During an interview on [DATE] at 1:25 p.m., CNA F said the last time she had bathed Resident #1 was at the beginning of the year. She said Resident #1 hollered all the time. She said Resident #1 was real raw in his pelvic area, and that she had told the nurses. CNA F said there was a cream (unspecified) applied daily. CNA F said she had changed Resident #1 during the week when he was transferred to the hospital. CNA F said she did not see a difference that time from the first of the year. CNA F said his pelvic area has been raw since she started in 2018. During an interview on [DATE] at 1:48 p.m., CNA L said she had not been assigned to care for Resident #1 for the last 2 months. CNA L said Resident #1 did not like to get changed and didn't like to be messed with at all. CNA L said it hurt Resident #1 to move. CNA L said the only skin areas of concern was the redness under his arm and down his side. CNA L said you could not get all the old cream and powder off before Resident #1 would start yelling at you. CNA L said she told the nurses and they would just document it. CNA L said she did not know specifically what the nurses documented. During an interview on [DATE] at 2:08 p.m., LVN J said Resident #1 refuses baths and incontinent care. LVN J said Resident #1 had a chronic skin condition that was normal for him. LVN J said, we keep him creamed and powdered. LVN J said Resident #1 had excoriation really bad under that armpit. LVN J staff tried to put a rolled-up washrag in his contracted hand but Resident #1 refuses. LVN J said Resident #1 cusses at you and refuses care a lot. LVN J said she cut Resident #1's fingernails before he went to the hospital on [DATE] because they needed to be cut. LVN J said she did not nick him or anything. LVN J said Resident #1 was not bleeding, but it looked like he had jelly under his fingernails. LVN J said Resident #1 was old, stubborn, and set in his ways. LVN J said Resident #1 was adamant that he did not want to bathe. During an interview on [DATE] at 3:37 p.m., LVN M (treatment nurse) said Resident #1 had chronic redness mainly under the right arm and on his buttocks. LVN M said Resident #1 would frequently refuse incontinent care. LVN M said Resident #1's current treatment was [MEDICATION(S)] (antiseptic skin cleanser) and a dry dressing under his right arm to prevent skin to skin contact. LVN M said frequently she was not able adequately clean the area under his right arm to get the dead skin off because it hurt him to move the arm. LVN M said treatments should be applied to clean skin. LVN M said Resident #1 would often lay on his right arm (affected by stoke). LVN M said Resident #1's buttocks were like a red incontinent kind of rash.' LVN M said the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN M said maybe because it was all over there wasn't a specific place to be treated LVN M said even though Resident #1's skin was dry and flaky and red and inflamed on his bottom he never had a pressure injury. During an interview on [DATE] at 4:27 p.m., CNA N said she routinely took care of Resident #1. She said he had chronic redness under his right arm which she reported to the nurse, but she did not recall which nurse she told. CNA N said the nurse already knew about the redness and said that he was getting a medicine for it. CNA N said she would try and remove the dead skin when bathing Resident #1, but he would never let her bathe him. CNA N said he would refuse care a lot. She said when Resident #1 refused care she would tell the charge nurse and try again later. CNA N said after incontinent care she would put on the cream that we used for everyone on his bottom. CNA N said Resident #1's bottom was red sometimes, and she told the nurse every time. During an interview on [DATE] at 4:45 p.m., CNA O said Resident #1 refused care a lot, and that he only wanted to be changed once a shift. CNA O said she used to tell the nurses about him refusing care, but it became so common she stopped telling them. CNA O said he refused care every day. CNA O said Resident #1's skin would be built up and red with a lot of dead skin. She said the redness was on his bottom, in the creases of his groin, and under his arm. CNA O said Resident #1 would lay on his right side to eat rather than sit up. She said Resident #1 would spill food and drinks and it would run down his arm. CNA O said if you tried to move his right arm Resident #1 would say ow and start cussing. During an interview on [DATE] at 12:50 p.m., DON said that although she had spoken to several staff members about Resident #1's condition when he was transferred to the hospital, none of them had indicated he had skin areas that were red and excoriated, or that he was having pain during care. The DON said staff indicated he was stubborn, refused showers, and did not like care. The DON said if a resident experienced pain it should be reported so it could be treated. The DON said Resident #1 had no active orders for pain medication. The DON said the nurses should have notified the doctor about Resident #1's pain during care. The DON said the weekly head to toe skin assessments consisted of one question does the resident have clear skin. The DON said Resident #1's weekly skin assessments indicated he had clear skin, and that his record did not include wound assessments. The DON said if a resident had any skin issue it should not be recorded as a clear skin assessment, and that a wound assessment should have been done for any problem areas. The DON said she could not explain how a nurse could have assessment findings of clear skin if Resident #1 had red excoriated areas under his arm, groin, and buttocks. The DON said the order for [MEDICATION(S)] did not indicate what part of Resident #1's body should be treated and based on the information in the order she could not tell where it was supposed to be applied. The DON said the order should have been clarified to indicate the area to be treated. The DON said the CNAs document care once per shift. She said ADL care was not always documented at the end of the shift, and that care occurring after the point of documentation was assumed to be completed. The DON said there was not enough documentation in Resident #1's record to support the care refusals described by staff. The DON said she had developed and implemented a performance Improvement Plan on [DATE] because of care concerns related to Resident #1. During an interview on [DATE] at 2:02 p.m., CNA F said Resident #1 complained of pain when staff moved his legs or right arm, and he would tell you to quit moving his body. CNA F said Resident #1 complained of pain during any kind of care, including incontinent care, bathing, or showering. CNA F said Resident #1's pain prevented care from occurring. CNA F said she would tell the charge nurses and they would acknowledge that she had told them. CNA F said she did not know what happened after that. During an interview on [DATE] at 2:50 p.m., CNA R she assisted other CNAs in providing care for Resident #1 a few times, with the last time being a couple of weeks ago. CNA R said Resident #1's skin was really red and irritated on his scrotum and bottom, and he would push your hands away and start yelling and cussing at you. CNA P said they applied barrier cream as best they could and put some in his brief so hopefully it would get in the right area. CNA R said, you could tell that area of his body was very sensitive, I am sure he was in pain. CNA R said it was possible Resident #1 was yelling out due to the pain. CNA R said she told the charge his skin was red and irritated on his scrotum and his bottom. CNA R said it was possible that the pain was causing Resident #1 to refuse care, and that he would say no get away from me. During an interview on [DATE] at 4:12 p.m., LVN Q said she had frequently taken care of Resident #1. LVN Q said he always had reddened areas under his right arm and on his groin, back, and buttocks. LVN Q said she applied barrier cream when the CNAs performed incontinent care. LVN Q said she had never been told by the CNAs that they could not complete care for Resident #1, nor that he had reddened areas that were painful. LVN Q said Resident #1 did not like to be moved, and that he could tell you if he had pain or not. LVN Q said she did not think Resident #1 was having pain. During an interview on [DATE] PA D said he did not think the facility ever notified him that Resident #1 was having pain or that he was having pain during treatments or routine care. PA D said if pain prevented Resident #1 from receiving care it would be clinically significant. During an interview on [DATE] at 1:45 p.m., LVN Q said weekly skin assessments were usually done while helping a CNA during care. LVN Q said Resident #1 had redness under his arm, around his groin and buttocks, but he always had redness there so it was not new. LVN Q said the weekly head to toe assessment was used to document new skin problems only, otherwise she just checked clear. LVN Q said if a resident experienced pain during care that should be addressed, but Resident #1 never told her he was in pain, and no one had reported that to her. During a telephone interview on [DATE] at 2:07 p.m., LVN S said Resident #1 never complained of pain. She said CNAs had notified her that he refused care at times, but when she asked him why his response was yes, no, maybe. LVN S said the CNAs never told her that Resident #1 refused care because of pain. LVN S said she knew Resident #1 had a lot of skin issues, and I'm sure that caused him pain. LVN S said Resident #1 would frequently refuse to bathe or allow care, and that was normal for him. LVN S said the last time she saw Resident #1's skin was about 2 months ago, and that he always had redness under his right arm and there was a foul smell. LVN S said the area under his right arm always stayed moist and there was supposed to be something under it to prevent the skin from touching. During a telephone interview on [DATE] at 2:46 p.m., LVN T said she had been Resident #1's nurse for 2 years. She said pain assessments were completed each shift. LVN T said Resident #1 hollers when you change him, and that he had some skin problems she believed to be uncomfortable. LVN T said Resident #1's response to any thing she asked him about was no. LVN T said she was told by a CNA that he would not allow the CNA to change him, and they notified the next shift. LVN T said it was common for Resident #1 to refuse incontinent care, but he never gave a reason for the refusal. LVN T said there were times he would go a whole shift without being changed. LVN T said when Resident #1 did get changed he was often very soiled with urine and stool. Contact with LVN A was attempted on [DATE] at 4:36 p.m. at the number provided by the facility. There was no answer, and a message was left with contact information and request to return call. During an interview on [DATE] at 10:30 a.m., the DON said she had been notified by the hospital that Resident #1 had passed away on [DATE]. The DON acknowledged Resident #1's record indicated a pain scale rating of 3 on the night shift pain assessment completed by LVN A on [DATE] and [DATE]. The DON said there was no note regarding the pain assessment, and no indication of an intervention for pain. The DON said Resident #1 did not have any orders for pain medication, and LVN A would have had to call the doctor to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said Resident #1's skin condition should have been addressed on a wound assessment. She said the facility policy indicated if the condition had not improved in 2 weeks the physician should be contacted. During an interview on [DATE] at 12:31 p.m., CNA U said she had cared for Resident #1 two or three weeks ago. She said Resident #1 acted like it hurt him to move, and that she told the nurses about it. CNA U said Resident #1 had redness under his right arm and between his legs, and it looked like a hot mess. CNA U said she put the barrier cream all over his bottom where it was red. CNA U said she was not able to get all the old cream and powder off because it was caked on. CNA U said she would get as much off as she could, but Resident #1 would be in pain. During an interview on [DATE] at 12:56 p.m., CNA V said she had taken care of Resident #1 sometimes, but it had been quite a while (unspecified), and that she did not normally work that hall. CNA V said the last time she provided care the skin under his arm and in his groin area was very red and smelled like a yeast infection. Record review of an article titled A Clinician's Guide to the DIignosis and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .ncbi.nlm.nih.gov/pmc/articles/PMC 41/, indicated: *Typically cutaneous candidiasis presents as thin, bright-red plaques that can be erosive, dry, scaly, oozing, or macerated, pustules and collarette scales may also be present. *Affected areas should be kept dry Record review of the facility policy titled Pain Management, dated [DATE], indicated: *A Pain assessment must be completed for a patient upon admission, the onset or an increase in pain, quarterly and with any significant change in the patient's condition. *Every patient must be assessed for pain utilizing the Pain Intensity Scale (faces/ ,d+[DATE] or PAINAD for the non-verbal, cognitively impaired patient a] every shift; b] prior to and one hour following the administration of as needed pain medication, ; c] prior to and immediately following any invasive procedure, including dressing changes. *If a patient's pain intensity score is equal to or greater than 1 or has been assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . *A care plan must be completed and/or updated for any changes to pain management interventions

Based on interview and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 7 residents reviewed for ADLs (Residents #1). The facility did not implement interventions to provide bathing and hygiene care for Resident #1. The resident developed irritated and inflamed areas, diagnosed as a yeast infection by the hospital, in and around the skin folds of his body that caused him to yell out in pain when moved. This resulted in the resident not receiving incontinent care, treatments, or bathing after refusing due to being in pain, which contributed to further deterioration of the skin and quality of life. The facility did not notify the physician of the residents pain, refusal of care, or that his skin conditions were not improving. Resident #1 who required total assistance from staff for bathing was unkept, had an odor, and had a buildup of old ointment, powder, and flaking skin in the crevices of his body. This failure could place residents who required assistance from staff for ADLs at risk of not receiving necessary services to maintain grooming and personal hygiene. Findings included: Record review of Record of Death, dated [DATE] indicated Resident #1 died on [DATE] at 2:27 p.m. The immediate cause of death was cardiopulmonary arrest. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year-old male initially admitted on [DATE] with the most current admission on [DATE]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS assessment, dated [DATE], indicated Resident #1 had unclear speech, was rarely or never understood, and sometimes understood others. Resident #1 had severe cognitive impairment. The assessment indicated he had no behaviors and did not reject evaluation or care during the assessment period. Resident #1 required extensive physical assistance of one person for bed mobility, moving between surfaces, dressing, toileting, and personal hygiene. He required supervision and setup help only to eat or drink. Resident #1 was totally dependent on physical assistance of one staff for bathing. The assessment indicated Resident #1 had impaired range of motion in upper and lower extremities on one side. Resident #1 was always incontinent of bowel and bladder. The assessment indicated Resident #1 was at risk of developing pressure injuries but had no unhealed pressure injuries. The pain assessment instructions indicated if the resident was rarely/never understood the pain assessment interview should be skipped and pain should be assessed via staff assessment of indicators of possible pain which included: a] non-verbal sounds such as crying, whining, gasping, moaning or groaning; b] vocal complaints of pain such as that hursts, ouch, stop; c] facial expressions such as grimaces, winces, wrinkled forehead, furrowed, brow, clenched teeth or jaw; or d] protective body movements or postures such as bracing, guarding, clutching or holding a body part during movement. Although Resident #1 was rarely/never understood, the assessment indicated a pain assessment interview was conducted and indicated Resident #1 had no pain during the last five days. Record review of Resident #1's current care plan, reviewed [DATE], indicated he needed extensive assistance with most ADLs. The care plan indicated a focus area for incontinence of bowel and bladder with interventions including 1] monitor for incontinence every 2 hours and as needed. Change promptly and apply a protective skin barrier to skin; 2] monitor for signs and symptoms of skin breakdown and report to physician and responsible party; 3] assess for causes of incontinence; 4] lab as ordered by physician; 5] encourage fluid intake within dietary limits; 6] monitor for signs and symptoms of infection and report to physician. The care plan indicated a focus area for pain management with interventions including 1] monitor for signs and symptoms of increased pain or discomfort and assess resident for possible causes; 2] provide pressure relieving and positioning devices as needed; 3] assist with ADLs and comfort measures as needed; 4] assess and document pain; 5] monitor for constipating effects of pain medication. The care plan indicated Resident #1 was at risk of skin breakdown related to incontinence, bedfast, impaired bed mobility, fragile skin, cognitive impairment, and refusal of showers, incontinent care, and to have lotion applied to his dry skin, with interventions including 1] monitor for incontinence every two hours and change promptly, 2] apply moisturizing lotion, as he allows; 3] encourage PO and fluid intake; 4] monitor for skin breakdown, report to physician and responsible party; 5] assess skin weekly and record findings. The care plan indicated an undated focus area related to skin/tissue integrity status - chronic redness to right arm fold with interventions including 1] assess and monitor skin integrity and signs/symptoms of complications; 2] assess and monitor nutritional status to prevent skin breakdown and signs of complications; 3] assess and monitor incontinence/moisture risk for skin breakdown. The goal date for this focus area was [DATE]. The care plan indicated an undated focus area related to a history of stroke, and included the intervention develop alternate methods of communication. The care plan did not indicate staff interventions for care refusal, nor did it address the contracture of Resident #1's right hand Record review of Resident #1's weekly head to toe skin assessments dated [DATE], [DATE], [DATE], [DATE], and [DATE] indicated he had clear skin. There were no completed wound assessments for Resident #1 for the month of [DATE] nor for [DATE]-8, 2021. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *order dated [DATE] pain assessments by shift. There were no medication orders to treat pain. *order dated [DATE] dry dressings by shift. Keep wedge or towel under arm (unspecified) to prevent skin to skin contact unless resident is bathing or receiving incontinent care. May cover with dry dressing as needed for drainage. *order dated [DATE] weekly head to toe skin assessment *order dated [DATE] barrier cream one time daily. Cleanse bilateral buttocks with normal saline or skin cleanser. Pat dry. Apply barrier cream. *order dated [DATE] Hibaclens 4% topical liquid one time daily for rash and other nonspecific skin eruption. The order did not specify what area of the body was to be treated or how. Record review of Resident #1's ADL documentation for [DATE] indicated: *[DATE] incontinent care occurred at 3:43 a.m., 11:22 a.m., and 16:24 p.m. *[DATE] personal hygiene occurred at 3:44 a.m., 11:23 a.m., and 16:26 p.m. *[DATE] incontinent care occurred 5:20 a.m. and 10:28 a.m. There was no incontinent care documented for the ,d+[DATE] shift. *[DATE] personal hygiene occurred at 5:21 a.m. and 10:29 a.m. There was no personal hygiene documented for the ,d+[DATE] shift. *[DATE] incontinent care occurred at 10:40 a.m. There was no other incontinent care documented. *[DATE] personal hygiene occurred at 10:40 a.m. There was no other personal hygiene documented. *[DATE] incontinent care occurred at 2:30 a.m. There was no other incontinent care documented. *[DATE] personal hygiene occurred at 2:31 a.m. and 12:48 p.m. There was no other personal hygiene documented. *[DATE] incontinent care occurred at 1:19 a.m. and 12:36 p.m. There was no other incontinent care documented. *[DATE] personal hygiene was documented as did not occur at 1:19 a.m. and as having occurred at 12:37 p.m. There was no documentation of personal hygiene for the ,d+[DATE] shift. *[DATE] incontinent care occurred at 3:04 am, 10:20 a.m., and 21:02 p.m. *[DATE] personal hygiene occurred at 3:05 a.m., 10:21 a.m., and 21:02 p.m. *[DATE] incontinent care occurred at 12:40 p.m., and 15:28 p.m. There was no documentation of incontinent care on the night shift. *[DATE] personal hygiene occurred at 12:43 p.m., and 15:29 p.m. There was no documentation of personal hygiene on the night shift. *[DATE] incontinent care occurred at 1:48 a.m. There was no other incontinent care documented. *[DATE] personal hygiene occurred at 1:49 a.m. There was no other personal hygiene documented. Record review of treatment notes (TAR) dated [DATE], written by LVN S, indicated Resident #1 refused the dry dressing, and the provider was notified. During an interview on [DATE] at 11:20 a.m., LVN S said the treatment notes for [DATE] indicated she had notified the physician, but she did not. LVN S said the electronic record automatically indicated the physician had been notified anytime you document that a resident has refused something. Record review of an EMS report dated [DATE] written by EMT E indicated EMS arrived at the facility at 9:11 a.m. The report indicated .this patient is found to be lying in facility hospital bed, attended by multiple staff members, who are quickly wiping down is hands and feet, clipping his fingernails, scrubbing the layers of caked skin off of him. On the ground, in the bed, in the blankets, are seen an excessive amount of thick ships of skin detritus and debris from the cleaning that is happening, that came off of his body. There appear to this crew, to be much more skin debris than should be on a person, IF a person is being cleaned regularly or appropriately. It appears that the staff have not been regularly washing or caring for him, neglecting his hygiene. He answers questions well, if they are worded in yes/no form, and staff advised this is his common mental status presentation, normal to himself, for [CONDITION(S)] deficits. Patient advises he is not short of breath any longer, on the device they have placed him on, nor is he in any pain .As we prepare to move him over he shows to wince when his right arm is moved, staff advise us that he has a current yeast rash in his right armpit, say he is affected to have deficits on that side from the old [CONDITION(S)], so he does not move it often, and when the area is exposed, it shows to be rashy, irritated, inflamed, with thickly caked yellow debris in it, unsure if it is old skin or layered ointment, but it is dried and matted, and not freshly applied ointment consistency. He shows bleeding from the tip of his just-now clipped right thumbnail, his nails are over-thick, irregular and rough in texture, and abnormal in growth, possible from a fungal infection or other nailbed issue. The nail was not clipped too close, not carelessly trimmed, it just shows to have abnormal size and increased blood flow in the cent of the nail matrix, and blood flow all the way distal and even past the tip of his thumb. Using staff's assistance, he is lifted/carried, and moved over into the stretcher .Further examination in the ambulance shows that he has a contracture in his right hand, which holds his fist together, but multiple area of his finger skin appear to have pressure sores in the joints and knuckles from hot having padding between the hard spots. We mention the state of the patient's room and the state of the patient when we first got him, and as the RNs strip his clothes off, they remove his adult diaper, in order to get him washed and in a clean gown, and they find more rashes, skin breakdown in the creases and crevices of his groin, uncleaned feces in his cracks and in the skin below his penis. We advised to the nurses that we will be putting a report in for adult protective services . Record review of ED physician documentation dated [DATE] indicated Resident #1 arrived on [DATE] at 9:28 a.m. The record indicated: *patient has cutaneous candidiasis (fungal infection of the skin, caused by yeast) and his axilla and groin creases with [CONDITION(S)] (redness) to the skin. *patient is contracted in the bed responsive to pain only. Record review of ED nurse documentation dated [DATE]-[DATE] indicated: *[DATE] at 10:05 a.m. - skin is fragile, dry with flakes to arms, legs, face. Yellow crusty substance to right scalp. Right armpit with redness, swelling, skin scaly. Peri area with redness, dried white powdery crusty substance. Fingernails unkempt, long and curling over fingertips. Right arm with [CONDITION(S)] (paralyzed). *[DATE] at 10:10 a.m. - when asked if he knows where he is, he states eenie, meenie, minie, mo. *[DATE] at 10:48 a.m. - bath given, linen changed. Barrier cream applied to under arm, peri area, buttocks. Record review of a hospital discharge summary dated [DATE] indicated: *date of discharge [DATE] Record review of a Performance Improvement Plan, dated [DATE] indicated problem areas identified included: *skin concerns not addressed according to policy for skin *assessments not completed to represent current skin issues Changes Implemented to reach Baseline: *In-service all nursing staff on PCMS1 (skin policy) *CNA in-service on reporting any skin condition immediately to charge nurse or unit manager and utilizing unity skin alert *Skin sweep of all patients to be completed by managers *Treatment nurse to start completing all weekly head to toe skin assessments *Wound care doctor comes to facility weekly for evaluation and procedures if needed *Treatment nurse to attend stand-up meeting every day with full report on all wounds and interventions in place and any new skin concerns *DON/ADON audit skin report to ensure all area of concern are captured on skin report *UM/ADON/DON/Tx Nurse to round daily to ensure patients with positioning devices are in place and off-loading correctly. Provide individual in-services as warranted *Care plans updated to show any skin concerns chronic and acute, and refusals of care *CNA are to report any shower refusals to charge nurse for follow up and documentation *ensure pre/post pain assessment to all treatment orders During an interview on [DATE] at 12:54 p.m., CNA C said she took care of Resident #1 on [DATE], the day he was transferred to the hospital. CNA C said she told LVN B that he was breathing funny, and that he did not look to be his normal self. CNA C said LVN B checked Resident #1's oxygen levels and then gave him oxygen. CNA C said she had provided incontinent care for Resident #1 earlier that day. CNA C said Resident #1 had an area on his back with red flaky skin. She said the area in between his legs was red as well. She said Resident #1 had an odor and she thought it was from his skin. During an interview on [DATE] at 1:20 p.m., CNA F said the day Resident #1 was sent to the hospital she pointed out to the nurse (unspecified) how bad his hands and nails looked. She said Resident #1 had an odor as if they did not wash his hand. CNA F said Resident #1's nails were really long and digging into his skin. She said his skin was always red and raw and the CNAs applied barrier cream when providing incontinent care. CNA F said Resident #1 had broken skin around his sacrum, pelvis, testicles, and all of that area from front to back. CNA F said Resident #1 would refuse incontinent care at times. CNA F said Resident #1 needed more care than he got because of his skin issues and his hand contracture, and that when a resident has hand contractures you have to pay more attention to his nails. During an interview on [DATE] at 1:42 p.m., LVN G said she did not recall any discussion about Resident #1's nails. She said his hand was contracted, but she was not sure if his hand was so contracted that his nails were into his hand. LVN G said Resident #1 had chronic irritation under his right arm, buttocks, and groin. LVN G said he always had flaky skin. She said the irritated areas were painful and sensitive. During an interview at the receiving hospital on [DATE] at 2:45 p.m., Emergency Department (ED) RN H said Resident #1 was admitted to the ED on [DATE]. RN H said he was not involved in Resident #1's care, but that the nurses assigned to Resident #1 were so concerned about his hygiene that they gave him a bath in the ED. RN H said we don't normally bathe patients in the ED. During an interview at the receiving hospital on ,d+[DATE]//21 at 3:00 p.m., ED RN I said she helped care for Resident #1 when he was transferred to the ED on [DATE]. RN I said when Resident #1 was undressed he had a smell like rotting flesh she detected through an N95 mask. RN I said Resident #1's right axilla (armpit) had red macerated skin and was covered in a layer of powder and gunk. She said his nails were unclipped and were growing into the palm of his hand, and there was more macerated tissue underneath his contracted fingers. RN I said the reddened area of his groin extended outside of his briefs and he had macerated skin on both sides. RN I said Resident #1's pubic area was covered in powder and cream and old fecal matter. RN I said once his left groin was separated and cleaned, he had some bleeding, and the creases under his buttocks were bloody and macerated. RN I said Resident #1 was red from below his buttocks to about halfway up his back. She said Resident #1's scalp had yellow dried skin and was caked to the side of his head. RN I said we stopped our ER duties to help clean him up. No one deserves that lack of care, this didn't happen overnight. During a telephone interview on [DATE] at 3:57 p.m., LVN B said while she was calling PA D to notify him of Resident #1's condition CNA C reported Resident #1's condition was declining, and she called 911 for emergency transport. LVN B said when she went back in the room LVN J was trimming Resident #1's nails and two CNAs (unspecified) were giving him a bed bath. LVN B said it was not normal to give a resident a bed bath or trim their nails before sending them to the hospital for emergency care, and she did not know why it happened. LVN B said Resident #1 had some type of skin condition. LVN B said she did not know what the skin condition was, but that Resident #1 had had it for some time. LVN B said Resident #1''s verbal response for everything is yes, no, maybe but he was not talking at that point. LVN B said Resident #1 had an odor she described as musty. During an interview at the receiving hospital on [DATE] at 11:30 a.m., ED RN K said she was assigned to care for Resident #1 when he was admitted to the ED on [DATE]. RN K described the following areas and conditions of Resident #1's skin: *right thumbnail was overgrown. It had been cut and was bleeding. *fingernails on his contracted hand (right) were overgrown and curling under. They had caused some broken skin in his palm *right fingers were red from being together *right axilla - excoriated skin, caked on powder and an odor like a yeast infection. Red scaly skin that was very tender to the touch. He cried out in pain when that arm was moved. The reddened area extended to mid bicep area on the right arm and approximately five inched down the side of his body. *genital area - caked on powder, redness in groin area past the area of the brief and extending down the inner thighs approximately one hand width. There was a foul smell, and extreme pain on movement. The powder was crusted and there were multiple layers. It was not loose and did not aerate as fresh powder would. *left inguinal fold/crease had crusted caked ointment and powder. The area was red and painful. *buttocks/sacral area - redness and layers of powder. No broken skin but excoriated areas on buttocks and dried fecal matter around the anus. The redness extended from the buttocks to midback on the right side. *scrotum and inner thighs red, inflamed, and tender, covered with layers of powder/ointment. *right side of head - had food particles, yellow matter and dead skin on the side of his head and in his hair. RN K said Resident #1 would respond to his name, but to most other questions his response was eenie, meenie, miney, mo. During an interview on [DATE] at 1:25 p.m., CNA F said the last time she had bathed Resident #1 was at the beginning of the year. She said Resident #1 hollered all the time. She said Resident #1 was real raw in his pelvic area, and that she had told the nurses. CNA F said there was a cream (unspecified) applied daily. CNA F said she had changed Resident #1 during the week when he was transferred to the hospital. CNA F said she did not see a difference that time from the first of the year. CNA F said his pelvic area has been raw since she started in 2018. CNA F said Resident #1 did not like hygiene care, and that most of the time when he got a bed bath he would be mad. CNA F said some days he would let you provide care and other days he would not. CNA F said sometimes you could get him cleaner than others, but most of the time he would say no, and we could not get him clean. We would tell the nurses and they would tell us to document that he refused care. During an interview on [DATE] at 1:48 p.m., CNA L said she had not been assigned to care for Resident #1 for the last 2 months. CNA L said Resident #1 did not like to get changed and didn't like to be messed with at all. CNA L said it hurt Resident #1 to move. CNA L said the only skin areas of concern was the redness under his arm and down his side. CNA L said you could not get all the old cream and powder off before Resident #1 would start yelling at you. CNA L said she told the nurses and they would just document it. CNA L said she did not know specifically what the nurses documented. During an interview on [DATE] at 2:08 p.m., LVN J said Resident #1 refuses baths and incontinent care. LVN J said Resident #1 had a chronic skin condition that was normal for him. LVN J said, we keep him creamed and powdered. LVN J said Resident #1 had excoriation really bad under that armpit. LVN J staff tried to put a rolled-up washrag in his contracted hand but Resident #1 refuses. LVN J said Resident #1 cusses at you and refuses care a lot. LVN J said she cut Resident #1's fingernails before he went to the hospital on [DATE] because they needed to be cut. LVN J said she did not nick him or anything. LVN J said Resident #1 was not bleeding, but it looked like he had jelly under his fingernails. LVN J said Resident #1 was old, stubborn, and set in his ways. LVN J said Resident #1 was adamant that he did not want to bathe. During a telephone interview on [DATE] at 3:04 p.m., PA D said he did not recall Resident #1 having a skin condition, but after reviewing records said Resident #1 had pruritic [CONDITION(S)] which was basically an itchy rash that would cause flaking skin. PA D said he thought it would be important to get all the old skin and powder off before applying medication. PA D said the standard of care would be to apply medication to clean skin and not on top of powder or anything that would be a barrier to the medication. PA D said he assumed Resident #1 was receiving regular bathing, but he did not know for sure. PA D said he had not been notified that the facility was having trouble bathing Resident #1 or cleaning the affected areas. During an interview on [DATE] at 3:37 p.m., LVN M (treatment nurse) said Resident #1 had chronic redness mainly under the right arm and on his buttocks. LVN M said Resident #1 would frequently refuse incontinent care. LVN M said Resident #1's current treatment was [MEDICATION(S)] (antiseptic skin cleanser) and a dry dressing under his right arm to prevent skin to skin contact. LVN M said frequently she was not able adequately clean the area under his right arm to get the dead skin off because it hurt him to move the arm. LVN M said treatments should be applied to clean skin. LVN M said Resident #1 would often lay on his right arm (affected by stoke). LVN M said Resident #1's buttocks were like a red incontinent kind of rash.' LVN M said the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN M said maybe because it was all over there wasn't a specific place to be treated. LVN M said Resident #1 usually responded with yes or no, and that she had never heard him say a complete sentence. LVN M said even though Resident #1's skin was dry and flaky and red and inflamed on his bottom he never had a pressure injury. During an interview on [DATE] at 4:27 p.m., CNA N said she routinely took care of Resident #1. She said he had chronic redness under his right arm which she reported to the nurse, but she did not recall which nurse she told. CNA N said the nurse already knew about the redness and said that he was getting a medicine for it. CNA N said she would try and remove the dead skin when bathing Resident #1, but he would never let her bathe him. CNA N said he would refuse care a lot. She said when Resident #1 refused care she would tell the charge nurse and try again later. CNA N said after incontinent care she would put on the cream that we used for everyone on his bottom. CNA N said Resident #1's bottom was red sometimes, and she told the nurse every time. CNA N said Resident #1 would have a smell when he didn't get a bath. CNA N said she was never told to put a dry dressing under his right arm. During an interview on [DATE] at 4:45 p.m., CNA O said Resident #1 refused care a lot, and that he only wanted to be changed once a shift. CNA O said she used to tell the nurses about him refusing care, but it became so common she stopped telling them. CNA O said he refused care every day. CNA O said Resident #1's skin would be built up and red with a lot of dead skin. She said the redness was on his bottom, in the creases of his groin, and under his arm. CNA O said Resident #1 would lay on his right side to eat rather than sit up. She said Resident #1 would spill food and drinks and it would run down his arm. CNA O said if you tried to move his right arm Resident #1 would say ow and start cussing. CNA O said Resident #1 would have a body odor from refusing baths. CNA O said when she provided incontinent care for Resident #1, he would have a buildup of skin and gunk. During an interview on [DATE] at 12:50 p.m., DON said that although she had spoken to several staff members about Resident #1's condition when he was transferred to the hospital, none of them had indicated he had skin areas that were red and excoriated, or that he was having pain during care. The DON said staff indicated he was stubborn, refused showers, and did not like care. The DON said if a resident experienced pain it should be reported so it could be treated. The DON said Resident #1 had no active orders for pain medication. The DON said the nurses should have notified the doctor about Resident #1's pain during care. The DON said the weekly head to toe skin assessments consisted of one question does the resident have clear skin. The DON said Resident #1's weekly skin assessments indicated he had clear skin, and that his record did not include wound assessments. The DON said if a resident had any skin issue it should not be recorded as a clear skin assessment, and that a wound assessment should have been done for any problem areas. The DON said she could not explain how a nurse could have assessment findings of clear skin if Resident #1 had red excoriated areas under his arm, groin, and buttocks. The DON said the order for [MEDICATION(S)] did not indicate what part of Resident #1's body should be treated and based on the information in the order she could not tell where it was supposed to be applied. The DON said the order should have been clarified to indicate the area to be treated. The DON said the CNAs document care once per shift. She said ADL care was not always documented at the end of the shift, and that care occurring after the point of documentation was assumed to be completed. The DON said there was not enough documentation in Resident #1's record to support the care refusals described by staff. The DON said she had developed and implemented a performance Improvement Plan on [DATE] because of care concerns related to Resident #1. During an interview on [DATE] at 2:17 p.m., CNA P said she was in Resident #1's room the day he was transferred to the hospital. She said LVN J was clipping his fingernails and other staff were trying to get him cleaned up. CNA P said Resident #1 had an odor and smelled bad. During an interview on [DATE] at 2:50 p.m., CNA R said she assisted other CNAs in providing care for Resident #1 a few times, with the last time being a couple of weeks ago. CNA R said Resident #1's skin was really red and irritated on his scrotum and bottom, and he would push your hands away and start yelling and cussing at you. CNA P said they applied barrier cream as best they could and put some in his brief so hopefully it would get in the right area. CNA R said she told the charge his skin was red and irritated on his scrotum and his bottom. CNA R said it was possible that the pain was causing Resident #1 to refuse care, and that he would say no get away from me. During an interview on [DATE] at 4:12 p.m., LVN Q said she had frequently taken care of Resident #1. LVN Q said he always had reddened areas under his right arm and on his groin, back, and buttocks. LVN Q said she applied barrier cream when the CNAs performed incontinent care. LVN Q said she had never been told by the CNAs that they could not complete care for Resident #1, nor that he had reddened areas that were painful. During an interview on [DATE] at 1:45 p.m., LVN Q said weekly skin assessments were usually done while helping a CNA during care. LVN Q said Resident #1 had redness under his arm, around his groin and buttocks, but he always had redness there so it was not new. LVN Q said the weekly head to toe assessment was used to document new skin problems only, otherwise she just checked clear. During a telephone interview on [DATE] at 2:07 p.m., LVN S said CNAs had notified her that he refused care at times, but when she asked him why his response was yes, no, maybe. LVN S said she knew Resident #1 had a lot of skin issues, and I'm sure that caused him pain. LVN S said Resident #1 would frequently refuse to bathe or allow care, and that was normal for him. LVN S said the last time she saw Resident #1's skin was about 2 months ago, and that he always had redness under his right arm and there was a foul smell. LVN S said the area under his right arm always stayed moist and there was supposed to be something under it to prevent the skin from touching. During a telephone interview on [DATE] at 2:46 p.m., LVN T said she had been Resident #1's nurse for 2 years LVN T said Resident #1's response to any thing she asked him about was no. LVN T said she was told by a CNA that he would not allow the CNA to change him, and they notified the next shift. LVN T said it was common for Resident #1 to refuse incontinent care, but he never gave a reason for the refusal. LVN T said there were times he would go a whole shift without being changed. LVN T said when Resident #1 did get changed he was often very soiled with urine and stool. During an interview on [DATE] at 10:30 a.m., the DON said she had been notified by the hospital that Resident #1 had passed away on [DATE]. The DON said Resident #1's care refusals should have been on his care plan. The DON said Resident #1's skin condition should have been addressed on a wound assessment. She said the facility policy indicated if the condition had not improved in 2 weeks the physician should be contacted. During an interview on [DATE] at 11:20 a.m., LVN S said Resident #1 would refuse the dry dressing under his right arm, and if you did put it there, he would remove it. LVN S said nurses are supposed to notify the physician fo [TRUNCATED]

Based on observation, interview, and record review, the facility failed to implement interventions based on a comprehensive assessment to prevent the development and worsening of pressure ulcers for 2 of 2 residents reviewed for pressure ulcers. (Resident #s 1 and 2) Resident #1 was admitted to the facility with pressure ulcers on his right ankle and 2 on his left foot and was at high risk for the development of pressure ulcers. The resident developed a facility acquired pressure ulcer on his sacral area. The facility did not accurately and timely assess the pressure ulcer, did not notify the physician of the new wound or when the wound worsened, did not contact the physician for treatment orders for the wound, and did not provide treatments ordered by the physician (standing orders). The resident ' s pressure ulcer worsened to a Stage 4 with odor and bone and tendon exposed. Resident #1 was admitted to the hospital with [REDACTED]. Resident #2 was admitted to the facility with a stage 3 pressure ulcer on his sacral area and was at high risk of developing pressure ulcers. The stage 3 pressure ulcer on his sacral area worsened to an unstageable wound. The resident developed 2 facility acquired stage 1 pressure ulcers that worsened with eschar and drainage. The facility did not accurately and timely assess the resident ' s pressure ulcers, did not notify the physician of the new wounds or when the wounds worsened, and did not provide treatments ordered by the physician. An Immediate Jeopardy situation was identified on 5/12/16. The Immediate Jeopardy was removed on 5/13/16; however, the facility remained out of compliance at a pattern of actual harm due to the facility need to complete in-service training and evaluate the effectiveness of corrective systems. This failure could place 7 residents with pressure ulcers at risk for development of new pressure ulcers and decline in existing pressure ulcers, infection, hospitalization , or death. Findings included: Physician orders, from a closed record, dated May 2016 indicated Resident #1, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) and received a protein supplement 30 cc via his [DEVICE] daily. The orders indicated to cleanse Resident #1 ' s sacral area wound with skin cleanser, pat dry, apply Santyl (chemical debridement) ointment to slough, apply calcium alginate to wound bed, and cover with a dressing (start date of 4/13/16.) A Daily Clinical note dated 1/05/16 indicated Resident #1 had a bed sore noted on his coccyx area (sacral area). The pressure ulcer was not staged, measured, or assessed. The note indicated the new area would be reported to the treatment nurse and to be evaluated by the treatment nurse. It did not indicate if the physician was notified. A skin clinical note dated 1/13/16 indicated Resident #1 had pressure ulcer on his right lateral ankle and right heel. The note did not address a wound on the resident ' s sacral area. A wound assessment dated [DATE] indicated Resident #1 had excoriation on his right buttock (sacral area). A wound assessment dated [DATE] indicated Resident #1 had a deep tissue injury (DTI) on his buttock (sacral area) that measured 5.8 cm x 6.0 cm with a purple wound bed. The assessment indicated the wound had deteriorated since 01/27/16. The assessment indicated Resident #1 was on low air loss mattress and lift sheets would be used during care. The assessment indicated the physician was notified on 2/01/16. A skin clinical note report dated 2/02/16 indicated the physician was notified of the original excoriation area on Resident #1 ' s buttock (sacral area) measured 5.8 cm x 6.0 cm and had a purple peri-wound. The note indicated the resident had a new order for active protein 30 cc every day. A treatment sheet dated February 2016 for Resident #1 indicated to cleanse the open area to his right buttock (sacral area - not staged) with normal saline, pat dry, apply thera-honey to the wound bed, and cover with a dry dressing. It indicated a start date of 01/08/16. The physician orders [REDACTED].#1's sacral area. During a telephone interview on 05/11/16 at 3:02 p.m., Resident #1 ' s primary physician said he was not notified Resident #1 had pressure ulcers and he did not provide orders for the ulcer to be treated. A discharge MDS dated [DATE] indicated Resident #1 was discharged to local hospital for an unrelated issue. A nursing admission assessment dated [DATE] indicated Resident #1 returned from the hospital with a pressure ulcer on his sacral area. There were no measurements provided on the assessment. A wound assessment dated [DATE] indicated Resident #1 was readmitted with an unstageable pressure ulcer on his sacral area measuring 12.1 cm x 10.3 cm x 2.8 cm with moderate drainage and slough to the wound bed. No odor was noted. The wound assessment indicated the physician was notified on 2/17/16 and the resident was ordered a wound treatment of [REDACTED]. The physician orders [REDACTED].#1 ' s sacral area. During a telephone interview on 05/11/16 at 3:02 p.m., Resident #1 ' s primary physician said he was not notified Resident #1 had pressure ulcers and he did not provide orders for the ulcer to be treated. A treatment sheet dated February 2016 indicated to cleanse Resident #1 ' s pressure ulcer on his sacral area with wound cleanser, pat dry ,apply [MEDICATION NAME] ointment and Santyl ointment to the wound bed, apply calcium alginate, and cover with dry dressing. The start date was 02/19/2016. The treatment indicated the treatment was done daily from 2/19/2016 -2/26/2016 and discontinued on 2/26/2016. A clinical skin note dated 2/26/16 indicated Resident #1 ' s unstageable pressure ulcer on his sacral area measured 12.1 cm x 10.3 cm x 2.8 cm with a moderate amount of serosanguineous drainage. The pressure ulcer worsened having a slight odor and slough and eschar in the wound bed. There was no indication the physician was notified of the decline in the wound. A treatment sheet for February 2016 (start date 02/26/16) indicated to cleanse Resident #1 ' s sacral area pressure ulcer with wound cleanser, pat dry, apply triple antibiotic ointment (TAO), Santyl ointment, and calcium alginate to the wound bed, and cover with a dry dressing. During an interview on 05/13/16 at 3:35 p.m., the previous treatment nurse said she provided wound care for Resident #1 ' s pressure ulcer according to the facility ' s protocol. The physician orders [REDACTED].#1 ' s sacral area. During a telephone interview on 05/11/16 at 3:02 p.m., Resident #1 ' s primary physician said he was not notified Resident #1 had pressure ulcers and he did not provide orders for the ulcer to be treated. The wound assessment dated [DATE] indicated Resident #1 had a stage 4 pressure ulcer on his sacrum area measuring 11.0 cm x 8.0 cm x 1.5 cm with a moderate amount of drainage. The wound bed had granulating tissue. A clinical skin note with an effective date of 03/15/2016 and electronically sign by the treatment nurse on 03/31/2016 indicated Resident #1 ' s stage 4 pressure ulcer on his sacral area measured 11.06 cm x 2.0 cm x 2.0 with serous sanguineous drainage, no odor noted and continue with calcium alginate. There was no indication the physician was notified. The wound assessment dated [DATE] indicated Resident #1 had a stage 4 pressure ulcer on his sacrum area measuring 11.0 cm x 6.0 cm x 2.0 cm with a moderate amount of drainage. There was no description of the wound bed .The wound assessment indicated the physician was notified on 03/11/2016. A clinical skin note (completed by the treatment nurse) dated 3/31/16 indicated Resident #1 ' s stage 4 pressure ulcer on his sacral area measured 11.0 cm x 9.5 cm x 1.8 cm with moderate serosanguineous drainage and no odor was present. The wound bed was 100% pink, periwound pink and continue with calcium alginate. The most recent MDS assessment dated [DATE] indicated Resident #1 was cognitively impaired, totally dependent on staff for ADLs including bed mobility, always incontinent of bowel, and had an indwelling catheter. The assessment indicated Resident #1 had a stage 4 pressure ulcer measuring 11.0 cm x 8.0 cm x 1.5 cm. The treatment sheet for March 2016 indicated Resident #1 received wound care daily from with calcium alginate and Santyl ointment. The physician orders [REDACTED].#1 ' s sacral area. During a telephone interview on 05/11/16 at 3:02 p.m., Resident #1 ' s primary physician said he was not notified Resident #1 had pressure ulcers and he did not provide orders for the ulcer to be treated. The care plan dated 4/1/16 for Resident #1 indicated pressure ulcer prevention, intervention included .use Patient care management system 1 . The Patient Care Management System 1 dated 2015 indicated: .1. A head to toe skin assessment must be completed by the admitting nurse upon admission (including re-admission) of every Patient and documented on the nursing assessment form. In addition the admitting nurse must notify the physician and responsible party of any identified areas and must implement treatment and interventions. 5. A weekly head to toe skin assessment must be completed and documented on the weekly head to toe skin form on the day of admission (including re admission), once weekly, and prior to discharge/transfer of a Patient . A clinical nurse note dated 04/03/16 at 12:17 p.m. indicated Resident #1 was found with vomit on him and he was having difficulty in breathing. Resident # 1 was sent out to the hospital. A nursing admission note dated 04/08/16 at 9:14 p.m. indicated Resident #1 returned to the facility from the hospital with a [DIAGNOSES REDACTED]. There were no treatment orders from the hospital for the resident ' s sacral pressure ulcer. A clinical nursing note dated 04/08/16 at 9:19 p.m., indicated Resident #1 had stage 4 pressure ulcer on his sacral area. There were no measurements or assessment of the pressure ulcer. A Braden scale dated 04/08/16 indicated Resident #1 was at high risk for pressure ulcer development. The treatment sheet dated April 2016 indicated Resident #1 did not receive wound care for his pressure ulcer on his sacral area on 04/09/16, 04/10/16, 04/11/16, or 04/12/16. The treatment sheet indicated wound care was started 04/13/16. (5 days after the resident was readmitted ) During an interview on 05/13/16 at 10:01 a.m., RNC F said Resident #1 ' s TARs for April were correct and according to the TARs, the treatment for [REDACTED]. (5 days after the resident was readmitted ) During an interview on 05/13/16 at 3:35 p.m., the previous treatment nurse said Resident #1 returned from hospital on [DATE], but she did not work the next few days. She said she completed Resident #1 ' s skin assessment on 04/11/16, when she returned to work. The previous treatment nurse said she called the primary physician and spoke with the nurse at his office. She said on 04/11/16 and 04/12/16 she provided wound care to Resident #1 ' s pressure ulcer according to the facility wound protocol. The wound assessment dated [DATE] electronically signed by the previous treatment nurse on 04/13/16 indicated Resident #1 had a stage 4 pressure ulcer on his sacral area measuring 13.8 cm x 15.9 cm x 2.5 cm with a moderate amount of drainage. The wound bed had slough and undermining measuring 1.4 cm (at 12:00). The wound assessment indicated the family and physician were notified on 04/11/16. The assessment was not done until 3 days after Resident #1 was readmitted . During an interview on 05/10/16 at 3:30 p.m., RNC F said Resident #1 returned from the hospital on [DATE]; however, his skin assessment was not done until 04/11/16. She said skin assessments should be done upon admission. She said she did not know why it was not done. RNC F said the previous treatment nurse no longer worked at the facility. She said when Resident #1 readmitted from the hospital, the resident's sacral pressure ulcer was worse (04/08/16). She said the physician was notified of all changes of the resident ' s pressure ulcer. She said the documentation should be in the clinical notes. A clinical skin note (completed by the previous treatment nurse) dated 04/13/16 indicated Resident #1 ' s stage 4 pressure ulcer on his sacral area had yellow slough and a purple and pink wound bed. The peri-wound was purple with bone exposed. The treatment was calcium alginate and Santyl ointment. The note did not indicate if the physician was notified of the change in the wound ' s appearance and of the bone exposed. A telephone treatment order electronically sent on 04/13/16 to Resident #1 ' s physician indicated .begin on 04/13/16 wound treatment calcium alginate daily, cleanse wound to sacrum with normal saline or wound cleanser, dry apply Santyl ointment to slough, apply calcium alginate to wound bed and cover with dry dressing . The order was not signed by the physician. The physician orders [REDACTED].#1 ' s sacral area. During a telephone interview on 05/11/16 at 3:02 p.m., Resident #1 ' s primary physician said he was not notified Resident #1 had pressure ulcers and he did not provide orders for the ulcer to be treated. A wound assessment dated [DATE] indicated the stage 4 pressure ulcer on Resident #1 ' s sacral area measured 11.8 cm x 11.0 cm x 2.0 cm with moderate amount of drainage, no odor, and had 1.0 cm undermining. The assessment indicated the wound deteriorated and the physician was notified on 04/18/16. It indicated the wound bed was purple and 10% of the wound bed had bone and tendon exposed. The note was electronically signed (by the previous treatment nurse) on 4/20/16. A skin clinical note dated 4/20/16 at 1:00 p.m., indicated Resident #1 ' s stage 4 sacral pressure ulcer had no odor and the wound bed had 10% exposed bone, tendon exposed, and the periwound was purple, fragile, and at risk for further breakdown. The note indicated to continue treatment calcium alginate and Santyl ointment. There was no indication the physician was notified. During an interview on 05/13/16 at 3:35 p.m., the previous treatment nurse said she observed Resident #1 ' s sacral pressure ulcer on 04/22/16. She said the wound bed was purple; the bone was exposed and it did not have an odor, slough, or eschar. She said the primary physician should have known about the wound because he was signing the treatment orders. She said she also sent faxes to the physician. She said if a wound was not improving within 2 weeks, she called the physician. The wound assessment sheet dated 04/27/16 indicated Resident #1 ' s pressure ulcer on his sacral area was a stage 4 and measured 11 cm x 11 cm x 2 cm and 0.9 cm undermining. The pressure ulcer had a change in condition with having a slight odor and the wound bed had black/brown eschar and an increase in the exposed bone from 10% of the wound bed to 20%. The wound assessment indicated treatment was calcium alginate and Santyl. There was no indication the physician was notified. During an interview on 05/12/16 at 4:41 p.m., LVN A said she provided care for Resident #1 at times. She said sometimes his pressure ulcer on his sacral area had an odor and she had to change his dressing if it became soiled with feces. She said she did not recall how long his wound had an odor and she did not notify anyone including the physician of the odor. During an interview on 5/10/16 at 2:00 p.m., the current treatment nurse said Resident #1 ' s pressure ulcer on his sacral area had an odor. The treatment nurse said she had worked at the facility a year, but moved into the position of treatment nurse approximately 2 weeks ago. She said she performed all skin assessments and wound care for the residents. The treatment nurse said the physician should be notified weekly if wounds were not improving. She said she did not notify the physician of the slight odor. A clinical nurse note dated 5/6/16 at 12:52 p.m., indicated a late entry for 5/5/16: the primary physician was in the facility at 7:00 a.m., to assess Resident #1, received orders to send the resident to the hospital for evaluation of unrelated event. During an observation on 5/10/16 at 10:35 a.m., Resident #1 was in the hospital. The resident ' s pressure ulcer on his sacral area measured 17 cm x 16.5 cm with an open area of 9.3 cm x 5.4 cm according to documentation. The pressure ulcer was covered with brown eschar tissue and there was a moderate amount of bloody drainage noted on the dressing. During a telephone interview on 05/11/16 at 3:02 p.m., Resident #1 ' s primary physician said he was not notified Resident #1 had pressure ulcers. He said he was at the facility on 5/05/16 to see Resident #1 and discharged the resident to the hospital for unrelated event. He said the facility never mentioned Resident #1 having pressure ulcers. The physician said he would have expected the facility to notify him of any pressure ulcers. He said the facility should have notified him of Resident #1 ' s pressure ulcer, so it could have been addressed. The physician said he did not recall or find any documentation of giving wound care orders for Resident #1. He said he reviewed Resident #1 ' s office chart back to December 2015 and did not find any notifications about the resident having a pressure ulcer. The physician said he expected the facility to notify him of any wounds and if they were not improving within 10-14 days. He said Resident #1 ' s pressure ulcers should have been monitored closely, due to his condition because they could deteriorate quickly. During a telephone interview on 5/12/16 at 2:55 p.m., the NP said the facility never notified her of any wounds in the facility. She said she spoke with the regional nurse approximately 3 months ago and asked for the facility to provide her with a pressure ulcer report due to concerns with facility not notifying her of wounds or calling for wound treatments. The NP said she had not given any wound care orders for anyone in the facility. She said when she would ask the facility about wounds, they denied having any wounds or would say the current wounds were improving. During an interview on 5/12/16 at 9:40 a.m., CNA B said she gave Resident #1 his showers. She said Resident #1 had a wound to his bottom and it smelled. CNA B said sometimes there would be feces under the dressing. She said Resident #1 would have loose stools. She said she reported any skin issues to the charge nurse or treatment nurse. During an interview on 05/12/16 at 9:15 a.m., CNA C said Resident #1 had several pressure ulcers. He said Resident #1 only got out of bed for showers. CNA C said Resident #1 had been showing a decline for the last month. He said Resident #1 ' s pressure ulcers had an odor. CNA C said Resident #1 required staff to turn and reposition him and provide incontinent care as needed. During a telephone interview on 05/12/16 at 10:11 a.m., CNA D said she provided care for Resident #1 on the nightshift. She said Resident #1 ' s pressure ulcer on his buttocks area had an odor. CNA D said she did not notify the charge nurse of the odor. She said the dressing to the wound would often get stool on it and the charge nurse changed it. During an interview on 05/12/16 at 9:30 a.m., LVN E said she was the unit manager for the hall Resident #1 resided on. She said she had never seen Resident #1 ' s pressure ulcer because the treatment nurse did all the wound treatments. She said she was not aware of any odor to Resident #1 ' s pressure ulcer. She said Resident #1 was on an air mattress and she was not aware of any decline in the resident ' s condition since returning from the hospital in April 2016. During an interview on 05/13/16 at 10:01 a.m., RNC F said the treatment nurse was responsible for calling the resident ' s physicians on wounds. She said she did not recall Resident #1 ' s pressure ulcer having an odor on 05/05/16, the day he went to the hospital. She said she believed Resident #1 ' s pressure ulcer got worse in the hospital. She said she had not seen Resident #1 ' s wound since March 2016. RNC F said if wounds were deteriorating the treatment nurse should notify the DON and physician. She said she thought Resident #1 ' s physician was aware of his pressure ulcer. She said she felt the wound treatment for [REDACTED]. A hospital history and physical dated 05/05/16 for Resident #1 indicated the resident had a stage 4 decubitus (pressure ulcer) with secondary infection [MEDICAL CONDITION] secondary to decubitus. A hospital consultation note dated 05/09/16 for the admission date of [DATE] indicated .the decubitus is quite nasty looking and malodorous . It indicated the infectious disease physician was consulted due to a large wound on the resident ' s sacral area. The note indicated Resident #1 was in the local hospital last month (April) and the decubitus ulcer looked clean. The diagnostic impression the note indicated Resident #1 had large decubitus on the back side (sacral area) and review of photographs were taken during the last hospital stay and currently the [MEDICAL CONDITION] were much worse. Recommendations indicated Resident #1 ' s wound would need to be debrided to get rid of all the dead tissue and the sacral bone was involved. It indicated Resident #1 would require long term intravenous therapy. The note indicated [MEDICAL CONDITIONS] (contagious bacterial infection) contamination of the wound and diverting [MEDICAL CONDITION] would be appropriate. During an interview on 5/10/2016 at 10:35 a.m., the hospital treatment nurse said he provided wound care for Resident #1 ' s sacral pressure ulcer when he (the resident) was in the hospital in April 2016. He said when Resident #1 left the hospital in April 2016, his pressure ulcer was healing and appeared clean. He said he was very concerned about Resident #1 ' s pressure ulcer because it was now larger, smelled, and now it contained lots of eschar. 2. A face sheet 05/13/16 indicated Resident #2 was a [AGE] year old male, admitted [DATE], re-admitted [DATE], with [DIAGNOSES REDACTED]. A computerized physician order [REDACTED].#2 should receive a weekly head to toe skin assessment and wound care daily to a pressure ulcer on his sacral area. The wound care included to cleanse the wound to the sacral area with normal saline, apply Santyl to the wound, and cover with a dry dressing. The order was discontinued on 4/7/16. The most recent MDS dated [DATE] indicated Resident #2 had mild cognitive impairment and no behaviors. He was totally dependent on two staff for bed mobility, transfers, and dressing. He required the assistance of one person for eating. Resident #2 was noted to always be incontinent of bowel and bladder. The MDS indicated Resident #2 was admitted with one stage 3 pressure ulcer measuring 11.7 cm x 7.6 cm x 0.3 cm and the wound had slough. An undated care plan report indicated Resident #2 was at risk for pressure ulcer development due to factors on the Braden Scale. The goal was the resident would not develop any new pressure ulcers. Some of the interventions included .turn every two hours, a pressure reduction mattress, review/ obtain a pre-[MEDICATION NAME] level with the registered dietician, pressure reducing equipment in the chair, and notify the physician of abnormal labs . During an interview on 5/20/16 at 11 a.m., the RNC said the Braden scale and the initial nursing assessment were not completed when Resident #2 was readmitted . A clinical note for Resident #2 indicated the following: *03/31/16 (5 days after admission on 03/25) stage 3 pressure ulcer on his sacral area and it measured 11.7 cm x 7 cm X 0.3 cm with serosanguineous drainage, a small amount, and no odor. The wound bed was pink with yellow slough, and the peri-wound was purple. The treatment was Santyl ointment applied to the wound bed and covered with a dry dressing. The note did not indicate if the physician was notified of the resident ' s pressure ulcer. A computerized physician order [REDACTED].#2 was ordered multi vitamins with minerals one tablet daily related to pressure ulcer of the sacral region and a protein supplement, critical care 30 cc, once daily. A clinical note for Resident #2 indicated the following: *04/07/16 - Stage 3 on the resident ' s sacral area measuring 11.9 cm x 8.3 cm x 0.3 cm. The wound bed was pink with slough with more slough covering the wound bed than previous assessment. Treatment continued as previous. It did not indicate the physician was notified of the increase in slough in the resident ' s pressure ulcer. A computerized physician order [REDACTED].#2 ' s sacral pressure ulcer with normal saline, apply Santyl ointment then calcium alginate, and cover with a dry dressing. A clinical note for Resident #2 indicated the following: *04/13/16 -the sacral pressure ulcer was now unstageable measuring 12.2 cm x 8 cm x unknown depth, with a moderate amount of serosanguineous drainage an no odor. The wound bed was 80% yellow slough, and 20% pink. It did not indicate if the physician was notified. The last wound assessment dated [DATE] indicated the pressure ulcer on Resident #2 ' s sacral area was unstageable, measuring 14.8 cm x 15.8 cm, with a moderate amount of serosanguineous drainage with slough in the wound bed with slough. The wound bed with 70% black slough and 30% purple. The note indicated the physician was notified. A clinical note for Resident #2 indicated the following: 04/19/16 - the unstageable pressure ulcer on his sacral area measured 14.8 cm x 15.6 cm x unknown depth with a moderate amount of serous sanguineous drainage. There was now a slight odor. The wound bed was 70% black with 30% slough. The peri-wound was purple and treated with Santyl ointment and calcium alginate. Resident #2 refused most meals, protein supplements offered. He refused to let staff turn him from side to side. Resident #2 had a recent weight loss. The note did not indicate the physician was notified of the pressure ulcer having odor. During an interview on 05/17/16 at 12:13 p.m., LVN/Unit manager E said Resident #2 had a stage 3 pressure ulcer on his sacral area and he did not have any other wounds. She said she was not aware of Resident #2 ' s pressure ulcer worsening or having odor. The clinical note dated 4/21/16 indicated Resident #2 developed two nickel-sized pressure ulcers located under each of Resident #2 ' s lower extremities at the bend of the knee. The resident had amputations of his lower legs. The wound treatment nurse was notified. The note did not indicate if the physician was notified of the new pressure ulcers. The skin assessment sheets for Resident #2 indicated the following: -Left below the knee [MEDICAL CONDITION] (LBKA)- *04/21/16 - Stage 1 pressure ulcer on his LBKA measuring 0.9 cm x 0.8 cm x 0.1cm. and described as open area of unknown origin. No new physician orders [REDACTED]. *04/28/16 - Stage 1 pressure ulcer on LBKA measuring 1 cm x 1 cm, with brown eschar (dark scab or falling away of dead skin). There was 100% eschar. A physician order [REDACTED].#2 ' s left stump indicated .cleanse the wound with normal saline , pat dry, apply silver gel to the wound bed, and cover with dry dressing . The skin assessment sheets for Resident #2 indicated the following: Right below the knee [MEDICAL CONDITION] (RBKA)- *4/21/16 - a Stage 1 pressure ulcer on his RBKA measured 1.2 cm x 1.7 cm x 0.1 cm. and described as a scabbed open area. No new physician orders [REDACTED]. *4/28/16 - Stage 1 pressure ulcer on his RBKA measured 1.3 cm x 1.5 cm x 0.1 cm, with a scant amount of serous drainage. The wound was described as having 30% eschar, 60% granulation tissue, and 10% slough present. It did not indicate the physician was notified of the pressure ulcer ' s deterioration. A physician order [REDACTED].#2 ' s wound treatment was to .cleanse the right stump with normal saline, pat dry apply skin prep to affected area and cover with dry dressing . The Administration History (a record of treatments provided) report indicated the first treatment to Resident #2 ' s RBKA and LBKA was 4/29/16 (8 days after found). A computerized physician order [REDACTED].#2 was admitted to hospice. During an interview on 05/17/16 at 12:28 p.m., the treatment nurse said Resident #2 had a stage 3 pressure ulcer on his sacral area. She said she had been the treatment nurse since the end of April 2016, but she had not assessed the area on Resident #2 ' s sacral area. The treatment nurse said Resident #2 left the facility the first of May 2016 with the sacral pressure ulcer and areas to both of his stumps (BKAs). She said the areas on his LBKA developed in the facility on 4/28/16 and had eschar. The treatment nurse said the area on Resident #2 ' s RBKA was open with drainage. The treatment nurse said she had not notified the physician about the sacral wound, because it looked the same to her. A physician order [REDACTED].#2 was discharged at 10:00 a.m. via stretcher. An admission assessment dated [DATE] indicated Resident #2 was admitted to a new facility at 11:00 a.m. with the following wound assessment. Wound #1(Sacral Area)- *5/3/16 at 11:49 a.m. - unstageable pressure ulcer on the resident ' s sacral area measuring 18 cm x 18 cm x unknown depth. The wound bed was open pink, yellow, gray, and black. The surrounding skin was red. There was eschar to the wound bed with a 100 percent necrosis and heavy drainage with a tan color. The drainage was opaque or purulent with a strong odor and the resident was in constant pain. There were signs and symptoms of infection observed. The hospice NP was notified and gave orders for a wound culture. The assessment indicated the edges of the wound were pink/moist, however; there was not enough pink to document. Wound #2 (LBKA)- * 5/3/16 at 11:49 a.m. - unstageable pressure ulcer on the resident ' s LBKA. It measured 2.0 cm x 2.5 cm. The wound bed was opened, dry, and black. The tissue had eschar at 100 percent and the resident had intermittent pain. Wound # 3 (RBKA) - * 5/3/16 at 11:49 a.m. - unstageable pressure ulcer to the RBKA. It measured 3.0 cm x 2.5 cm and was opened, black, with 100% eschar and 100% necrosis. During a telephone interview on 05/19/16 at 1:50 p.m., Resident #2 ' s primary physician said the facility never notified him regarding Resident ' s #2 pressure ulcers. He said he never gave any wound care orders concerning Resident #2's pressure ulcers. He said he would expect the facility to notify him of wounds so that they could be addressed or if needed obtain a wound care consult. The ph

Based on observation, interview, and record review, the facility failed consult with the physician when a significant change in the resident's physical, mental, or psychosocial status occurred for 2 of 2 residents reviewed for pressure ulcers. (Resident #s 1 and 2) Resident #1 was admitted to the facility with pressure ulcers on his right ankle and 2 on his left foot and was at high risk for the development of pressure ulcers. The resident developed a facility acquired pressure ulcer on his sacral area. The facility did not accurately and timely assess the pressure ulcer, did not notify the physician of the new wound or when the wound worsened, did not contact the physician for treatment orders for the wound, and did not provide treatments ordered by the physician (standing orders). The resident ' s pressure ulcer worsened to a Stage 4 with odor and bone and tendon exposed. Resident #1 was admitted to the hospital with [REDACTED]. Resident #2 was admitted to the facility with a stage 3 pressure ulcer on his sacral area and was at high risk of developing pressure ulcers. The stage 3 pressure ulcer on his sacral area worsened to an unstageable wound. The resident developed 2 facility acquired stage 1 pressure ulcers that worsened with eschar and drainage. The facility did not accurately and timely assess the resident ' s pressure ulcers, did not notify the physician of the new wounds or when the wounds worsened, and did not provide treatments ordered by the physician. An Immediate Jeopardy situation was identified on 5/12/16. The Immediate Jeopardy was removed on 5/13/16. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 7 residents with pressure ulcers at risk for development of new pressure ulcers and decline in existing pressure ulcers, infection, hospitalization , or death. Findings included: Physician orders, from a closed record, dated May 2016 indicated Resident #1, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) and received a protein supplement 30 cc via his [DEVICE] daily. The orders indicated to cleanse Resident #1 ' s sacral area wound with skin cleanser, pat dry, apply Santyl (chemical debridement) ointment to slough, apply calcium alginate to wound bed, and cover with a dressing (start date of 4/13/16.) A Daily Clinical note dated 1/05/16 indicated Resident #1 had a bed sore noted on his coccyx area (sacral area). The pressure ulcer was not staged, measured, or assessed. The note indicated the new area would be reported to the treatment nurse and to be evaluated by the treatment nurse. It did not indicate if the physician was notified. A skin clinical note dated 1/13/16 indicated Resident #1 had pressure ulcer on his right lateral ankle and right heel. The note did not address a wound on the resident ' s sacral area. A wound assessment dated [DATE] indicated Resident #1 had excoriation on his right buttock (sacral area). A wound assessment dated [DATE] indicated Resident #1 had a deep tissue injury (DTI) on his buttock (sacral area) that measured 5.8 cm x 6.0 cm with a purple wound bed. The assessment indicated the wound had deteriorated since 01/27/16. The assessment indicated Resident #1 was on low air loss mattress and lift sheets would be used during care. The assessment indicated the physician was notified on 2/01/16. A skin clinical note report dated 2/02/16 indicated the physician was notified of the original excoriation area on Resident #1 ' s buttock (sacral area) measured 5.8 cm x 6.0 cm and had a purple peri-wound. The note indicated the resident had a new order for active protein 30 cc every day. A treatment sheet dated February 2016 for Resident #1 indicated to cleanse the open area to his right buttock (sacral area - not staged) with normal saline, pat dry, apply thera-honey to the wound bed, and cover with a dry dressing. It indicated a start date of 01/08/16. The physician orders [REDACTED].#1's sacral area. During a telephone interview on 05/11/16 at 3:02 p.m., Resident #1 ' s primary physician said he was not notified Resident #1 had pressure ulcers and he did not provide orders for the ulcer to be treated. A discharge MDS dated [DATE] indicated Resident #1 was discharged to local hospital for an unrelated issue. A nursing admission assessment dated [DATE] indicated Resident #1 returned from the hospital with a pressure ulcer on his sacral area. There were no measurements provided on the assessment. A wound assessment dated [DATE] indicated Resident #1 was readmitted with an unstageable pressure ulcer on his sacral area measuring 12.1 cm x 10.3 cm x 2.8 cm with moderate drainage and slough to the wound bed. No odor was noted. The wound assessment indicated the physician was notified on 2/17/16 and the resident was ordered a wound treatment of [REDACTED]. The physician orders [REDACTED].#1 ' s sacral area. During a telephone interview on 05/11/16 at 3:02 p.m., Resident #1 ' s primary physician said he was not notified Resident #1 had pressure ulcers and he did not provide orders for the ulcer to be treated. A treatment sheet dated February 2016 indicated to cleanse Resident #1 ' s pressure ulcer on his sacral area with wound cleanser, pat dry ,apply [MEDICATION NAME] ointment and Santyl ointment to the wound bed, apply calcium alginate, and cover with dry dressing. The start date was 02/19/2016. The treatment indicated the treatment was done daily from 2/19/2016 -2/26/2016 and discontinued on 2/26/2016. A clinical skin note dated 2/26/16 indicated Resident #1 ' s unstageable pressure ulcer on his sacral area measured 12.1 cm x 10.3 cm x 2.8 cm with a moderate amount of serosanguineous drainage. The pressure ulcer worsened having a slight odor and slough and eschar in the wound bed. There was no indication the physician was notified of the decline in the wound. A treatment sheet for February 2016 (start date 02/26/16) indicated to cleanse Resident #1 ' s sacral area pressure ulcer with wound cleanser, pat dry, apply triple antibiotic ointment (TAO), Santyl ointment, and calcium alginate to the wound bed, and cover with a dry dressing. During an interview on 05/13/16 at 3:35 p.m., the previous treatment nurse said she provided wound care for Resident #1 ' s pressure ulcer according to the facility ' s protocol. The physician orders [REDACTED].#1 ' s sacral area. During a telephone interview on 05/11/16 at 3:02 p.m., Resident #1 ' s primary physician said he was not notified Resident #1 had pressure ulcers and he did not provide orders for the ulcer to be treated. The wound assessment dated [DATE] indicated Resident #1 had a stage 4 pressure ulcer on his sacrum area measuring 11.0 cm x 8.0 cm x 1.5 cm with a moderate amount of drainage. The wound bed had granulating tissue. A clinical skin note with an effective date of 03/15/2016 and electronically sign by the treatment nurse on 03/31/2016 indicated Resident #1 ' s stage 4 pressure ulcer on his sacral area measured 11.06 cm x 2.0 cm x 2.0 with serous sanguineous drainage, no odor noted and continue with calcium alginate. There was no indication the physician was notified. The wound assessment dated [DATE] indicated Resident #1 had a stage 4 pressure ulcer on his sacrum area measuring 11.0 cm x 6.0 cm x 2.0 cm with a moderate amount of drainage. There was no description of the wound bed .The wound assessment indicated the physician was notified on 03/11/2016. A clinical skin note (completed by the treatment nurse) dated 3/31/16 indicated Resident #1 ' s stage 4 pressure ulcer on his sacral area measured 11.0 cm x 9.5 cm x 1.8 cm with moderate serosanguineous drainage and no odor was present. The wound bed was 100% pink, periwound pink and continue with calcium alginate. The most recent MDS assessment dated [DATE] indicated Resident #1 was cognitively impaired, totally dependent on staff for ADLs including bed mobility, always incontinent of bowel, and had an indwelling catheter. The assessment indicated Resident #1 had a stage 4 pressure ulcer measuring 11.0 cm x 8.0 cm x 1.5 cm. The treatment sheet for March 2016 indicated Resident #1 received wound care daily from with calcium alginate and Santyl ointment. The physician orders [REDACTED].#1 ' s sacral area. During a telephone interview on 05/11/16 at 3:02 p.m., Resident #1 ' s primary physician said he was not notified Resident #1 had pressure ulcers and he did not provide orders for the ulcer to be treated. The care plan dated 4/1/16 for Resident #1 indicated pressure ulcer prevention, intervention included .use Patient care management system 1 . The Patient Care Management System 1 dated 2015 indicated: .1. A head to toe skin assessment must be completed by the admitting nurse upon admission (including re-admission) of every Patient and documented on the nursing assessment form. In addition the admitting nurse must notify the physician and responsible party of any identified areas and must implement treatment and interventions. 5. A weekly head to toe skin assessment must be completed and documented on the weekly head to toe skin form on the day of admission (including re admission), once weekly, and prior to discharge/transfer of a Patient . A clinical nurse note dated 04/03/16 at 12:17 p.m. indicated Resident #1 was found with vomit on him and he was having difficulty in breathing. Resident # 1 was sent out to the hospital. A nursing admission note dated 04/08/16 at 9:14 p.m. indicated Resident #1 returned to the facility from the hospital with a [DIAGNOSES REDACTED]. There were no treatment orders from the hospital for the resident ' s sacral pressure ulcer. A clinical nursing note dated 04/08/16 at 9:19 p.m., indicated Resident #1 had stage 4 pressure ulcer on his sacral area. There were no measurements or assessment of the pressure ulcer. A Braden scale dated 04/08/16 indicated Resident #1 was at high risk for pressure ulcer development. The treatment sheet dated April 2016 indicated Resident #1 did not receive wound care for his pressure ulcer on his sacral area on 04/09/16, 04/10/16, 04/11/16, or 04/12/16. The treatment sheet indicated wound care was started 04/13/16. (5 days after the resident was readmitted ) During an interview on 05/13/16 at 10:01 a.m., RNC F said Resident #1 ' s TARs for April were correct and according to the TARs, the treatment for [REDACTED]. (5 days after the resident was readmitted ) During an interview on 05/13/16 at 3:35 p.m., the previous treatment nurse said Resident #1 returned from hospital on [DATE], but she did not work the next few days. She said she completed Resident #1 ' s skin assessment on 04/11/16, when she returned to work. The previous treatment nurse said she called the primary physician and spoke with the nurse at his office. She said on 04/11/16 and 04/12/16 she provided wound care to Resident #1 ' s pressure ulcer according to the facility wound protocol. The wound assessment dated [DATE] electronically signed by the previous treatment nurse on 04/13/16 indicated Resident #1 had a stage 4 pressure ulcer on his sacral area measuring 13.8 cm x 15.9 cm x 2.5 cm with a moderate amount of drainage. The wound bed had slough and undermining measuring 1.4 cm (at 12:00). The wound assessment indicated the family and physician were notified on 04/11/16. The assessment was not done until 3 days after Resident #1 was readmitted . During an interview on 05/10/16 at 3:30 p.m., RNC F said Resident #1 returned from the hospital on [DATE]; however, his skin assessment was not done until 04/11/16. She said skin assessments should be done upon admission. She said she did not know why it was not done. RNC F said the previous treatment nurse no longer worked at the facility. She said when Resident #1 readmitted from the hospital, the resident's sacral pressure ulcer was worse (04/08/16). She said the physician was notified of all changes of the resident ' s pressure ulcer. She said the documentation should be in the clinical notes. A clinical skin note (completed by the previous treatment nurse) dated 04/13/16 indicated Resident #1 ' s stage 4 pressure ulcer on his sacral area had yellow slough and a purple and pink wound bed. The peri-wound was purple with bone exposed. The treatment was calcium alginate and Santyl ointment. The note did not indicate if the physician was notified of the change in the wound ' s appearance and of the bone exposed. A telephone treatment order electronically sent on 04/13/16 to Resident #1 ' s physician indicated .begin on 04/13/16 wound treatment calcium alginate daily, cleanse wound to sacrum with normal saline or wound cleanser, dry apply Santyl ointment to slough, apply calcium alginate to wound bed and cover with dry dressing . The order was not signed by the physician. The physician orders [REDACTED].#1 ' s sacral area. During a telephone interview on 05/11/16 at 3:02 p.m., Resident #1 ' s primary physician said he was not notified Resident #1 had pressure ulcers and he did not provide orders for the ulcer to be treated. A wound assessment dated [DATE] indicated the stage 4 pressure ulcer on Resident #1 ' s sacral area measured 11.8 cm x 11.0 cm x 2.0 cm with moderate amount of drainage, no odor, and had 1.0 cm undermining. The assessment indicated the wound deteriorated and the physician was notified on 04/18/16. It indicated the wound bed was purple and 10% of the wound bed had bone and tendon exposed. The note was electronically signed (by the previous treatment nurse) on 4/20/16. A skin clinical note dated 4/20/16 at 1:00 p.m., indicated Resident #1 ' s stage 4 sacral pressure ulcer had no odor and the wound bed had 10% exposed bone, tendon exposed, and the periwound was purple, fragile, and at risk for further breakdown. The note indicated to continue treatment calcium alginate and Santyl ointment. There was no indication the physician was notified. During an interview on 05/13/16 at 3:35 p.m., the previous treatment nurse said she observed Resident #1 ' s sacral pressure ulcer on 04/22/16. She said the wound bed was purple; the bone was exposed and it did not have an odor, slough, or eschar. She said the primary physician should have known about the wound because he was signing the treatment orders. She said she also sent faxes to the physician. She said if a wound was not improving within 2 weeks, she called the physician. The wound assessment sheet dated 04/27/16 indicated Resident #1 ' s pressure ulcer on his sacral area was a stage 4 and measured 11 cm x 11 cm x 2 cm and 0.9 cm undermining. The pressure ulcer had a change in condition with having a slight odor and the wound bed had black/brown eschar and an increase in the exposed bone from 10% of the wound bed to 20%. The wound assessment indicated treatment was calcium alginate and Santyl. There was no indication the physician was notified. During an interview on 05/12/16 at 4:41 p.m., LVN A said she provided care for Resident #1 at times. She said sometimes his pressure ulcer on his sacral area had an odor and she had to change his dressing if it became soiled with feces. She said she did not recall how long his wound had an odor and she did not notify anyone including the physician of the odor. During an interview on 5/10/16 at 2:00 p.m., the current treatment nurse said Resident #1 ' s pressure ulcer on his sacral area had an odor. The treatment nurse said she had worked at the facility a year, but moved into the position of treatment nurse approximately 2 weeks ago. She said she performed all skin assessments and wound care for the residents. The treatment nurse said the physician should be notified weekly if wounds were not improving. She said she did not notify the physician of the slight odor. A clinical nurse note dated 5/6/16 at 12:52 p.m., indicated a late entry for 5/5/16: the primary physician was in the facility at 7:00 a.m., to assess Resident #1, received orders to send the resident to the hospital for evaluation of unrelated event. During an observation on 5/10/16 at 10:35 a.m., Resident #1 was in the hospital. The resident ' s pressure ulcer on his sacral area measured 17 cm x 16.5 cm with an open area of 9.3 cm x 5.4 cm according to documentation. The pressure ulcer was covered with brown eschar tissue and there was a moderate amount of bloody drainage noted on the dressing. During a telephone interview on 05/11/16 at 3:02 p.m., Resident #1 ' s primary physician said he was not notified Resident #1 had pressure ulcers. He said he was at the facility on 5/05/16 to see Resident #1 and discharged the resident to the hospital for unrelated event. He said the facility never mentioned Resident #1 having pressure ulcers. The physician said he would have expected the facility to notify him of any pressure ulcers. He said the facility should have notified him of Resident #1 ' s pressure ulcer, so it could have been addressed. The physician said he did not recall or find any documentation of giving wound care orders for Resident #1. He said he reviewed Resident #1 ' s office chart back to December 2015 and did not find any notifications about the resident having a pressure ulcer. The physician said he expected the facility to notify him of any wounds and if they were not improving within 10-14 days. He said Resident #1 ' s pressure ulcers should have been monitored closely, due to his condition because they could deteriorate quickly. During a telephone interview on 5/12/16 at 2:55 p.m., the NP said the facility never notified her of any wounds in the facility. She said she spoke with the regional nurse approximately 3 months ago and asked for the facility to provide her with a pressure ulcer report due to concerns with facility not notifying her of wounds or calling for wound treatments. The NP said she had not given any wound care orders for anyone in the facility. She said when she would ask the facility about wounds, they denied having any wounds or would say the current wounds were improving. During an interview on 5/12/16 at 9:40 a.m., CNA B said she gave Resident #1 his showers. She said Resident #1 had a wound to his bottom and it smelled. CNA B said sometimes there would be feces under the dressing. She said Resident #1 would have loose stools. She said she reported any skin issues to the charge nurse or treatment nurse. During an interview on 05/12/16 at 9:15 a.m., CNA C said Resident #1 had several pressure ulcers. He said Resident #1 only got out of bed for showers. CNA C said Resident #1 had been showing a decline for the last month. He said Resident #1 ' s pressure ulcers had an odor. CNA C said Resident #1 required staff to turn and reposition him and provide incontinent care as needed. During a telephone interview on 05/12/16 at 10:11 a.m., CNA D said she provided care for Resident #1 on the nightshift. She said Resident #1 ' s pressure ulcer on his buttocks area had an odor. CNA D said she did not notify the charge nurse of the odor. She said the dressing to the wound would often get stool on it and the charge nurse changed it. During an interview on 05/12/16 at 9:30 a.m., LVN E said she was the unit manager for the hall Resident #1 resided on. She said she had never seen Resident #1 ' s pressure ulcer because the treatment nurse did all the wound treatments. She said she was not aware of any odor to Resident #1 ' s pressure ulcer. She said Resident #1 was on an air mattress and she was not aware of any decline in the resident ' s condition since returning from the hospital in April 2016. During an interview on 05/13/16 at 10:01 a.m., RNC F said the treatment nurse was responsible for calling the resident ' s physicians on wounds. She said she did not recall Resident #1 ' s pressure ulcer having an odor on 05/05/16, the day he went to the hospital. She said she believed Resident #1 ' s pressure ulcer got worse in the hospital. She said she had not seen Resident #1 ' s wound since March 2016. RNC F said if wounds were deteriorating the treatment nurse should notify the DON and physician. She said she thought Resident #1 ' s physician was aware of his pressure ulcer. She said she felt the wound treatment for [REDACTED]. A hospital history and physical dated 05/05/16 for Resident #1 indicated the resident had a stage 4 decubitus (pressure ulcer) with secondary infection [MEDICAL CONDITION] secondary to decubitus. A hospital consultation note dated 05/09/16 for the admission date of [DATE] indicated .the decubitus is quite nasty looking and malodorous . It indicated the infectious disease physician was consulted due to a large wound on the resident ' s sacral area. The note indicated Resident #1 was in the local hospital last month (April) and the decubitus ulcer looked clean. The diagnostic impression the note indicated Resident #1 had large decubitus on the back side (sacral area) and review of photographs were taken during the last hospital stay and currently the [MEDICAL CONDITION] were much worse. Recommendations indicated Resident #1 ' s wound would need to be debrided to get rid of all the dead tissue and the sacral bone was involved. It indicated Resident #1 would require long term intravenous therapy. The note indicated [MEDICAL CONDITIONS] (contagious bacterial infection) contamination of the wound and diverting [MEDICAL CONDITION] would be appropriate. During an interview on 5/10/2016 at 10:35 a.m., the hospital treatment nurse said he provided wound care for Resident #1 ' s sacral pressure ulcer when he (the resident) was in the hospital in April 2016. He said when Resident #1 left the hospital in April 2016, his pressure ulcer was healing and appeared clean. He said he was very concerned about Resident #1 ' s pressure ulcer because it was now larger, smelled, and now it contained lots of eschar. 2. A face sheet 05/13/16 indicated Resident #2 was a [AGE] year old male, admitted [DATE], re-admitted [DATE], with [DIAGNOSES REDACTED]. A computerized physician order [REDACTED].#2 should receive a weekly head to toe skin assessment and wound care daily to a pressure ulcer on his sacral area. The wound care included to cleanse the wound to the sacral area with normal saline, apply Santyl to the wound, and cover with a dry dressing. The order was discontinued on 4/7/16. The most recent MDS dated [DATE] indicated Resident #2 had mild cognitive impairment and no behaviors. He was totally dependent on two staff for bed mobility, transfers, and dressing. He required the assistance of one person for eating. Resident #2 was noted to always be incontinent of bowel and bladder. The MDS indicated Resident #2 was admitted with one stage 3 pressure ulcer measuring 11.7 cm x 7.6 cm x 0.3 cm and the wound had slough. An undated care plan report indicated Resident #2 was at risk for pressure ulcer development due to factors on the Braden Scale. The goal was the resident would not develop any new pressure ulcers. Some of the interventions included .turn every two hours, a pressure reduction mattress, review/ obtain a pre-[MEDICATION NAME] level with the registered dietician, pressure reducing equipment in the chair, and notify the physician of abnormal labs . During an interview on 5/20/16 at 11 a.m., the RNC said the Braden scale and the initial nursing assessment were not completed when Resident #2 was readmitted . A clinical note for Resident #2 indicated the following: *03/31/16 (5 days after admission on 03/25) stage 3 pressure ulcer on his sacral area and it measured 11.7 cm x 7 cm X 0.3 cm with serosanguineous drainage, a small amount, and no odor. The wound bed was pink with yellow slough, and the peri-wound was purple. The treatment was Santyl ointment applied to the wound bed and covered with a dry dressing. The note did not indicate if the physician was notified of the resident ' s pressure ulcer. A computerized physician order [REDACTED].#2 was ordered multi vitamins with minerals one tablet daily related to pressure ulcer of the sacral region and a protein supplement, critical care 30 cc, once daily. A clinical note for Resident #2 indicated the following: *04/07/16 - Stage 3 on the resident ' s sacral area measuring 11.9 cm x 8.3 cm x 0.3 cm. The wound bed was pink with slough with more slough covering the wound bed than previous assessment. Treatment continued as previous. It did not indicate the physician was notified of the increase in slough in the resident ' s pressure ulcer. A computerized physician order [REDACTED].#2 ' s sacral pressure ulcer with normal saline, apply Santyl ointment then calcium alginate, and cover with a dry dressing. A clinical note for Resident #2 indicated the following: *04/13/16 -the sacral pressure ulcer was now unstageable measuring 12.2 cm x 8 cm x unknown depth, with a moderate amount of serosanguineous drainage an no odor. The wound bed was 80% yellow slough, and 20% pink. It did not indicate if the physician was notified. The last wound assessment dated [DATE] indicated the pressure ulcer on Resident #2 ' s sacral area was unstageable, measuring 14.8 cm x 15.8 cm, with a moderate amount of serosanguineous drainage with slough in the wound bed with slough. The wound bed with 70% black slough and 30% purple. The note indicated the physician was notified. A clinical note for Resident #2 indicated the following: 04/19/16 - the unstageable pressure ulcer on his sacral area measured 14.8 cm x 15.6 cm x unknown depth with a moderate amount of serous sanguineous drainage. There was now a slight odor. The wound bed was 70% black with 30% slough. The peri-wound was purple and treated with Santyl ointment and calcium alginate. Resident #2 refused most meals, protein supplements offered. He refused to let staff turn him from side to side. Resident #2 had a recent weight loss. The note did not indicate the physician was notified of the pressure ulcer having odor. During an interview on 05/17/16 at 12:13 p.m., LVN/Unit manager E said Resident #2 had a stage 3 pressure ulcer on his sacral area and he did not have any other wounds. She said she was not aware of Resident #2 ' s pressure ulcer worsening or having odor. The clinical note dated 4/21/16 indicated Resident #2 developed two nickel-sized pressure ulcers located under each of Resident #2 ' s lower extremities at the bend of the knee. The resident had amputations of his lower legs. The wound treatment nurse was notified. The note did not indicate if the physician was notified of the new pressure ulcers. The skin assessment sheets for Resident #2 indicated the following: -Left below the knee [MEDICAL CONDITION] (LBKA)- *04/21/16 - Stage 1 pressure ulcer on his LBKA measuring 0.9 cm x 0.8 cm x 0.1cm. and described as open area of unknown origin. No new physician orders [REDACTED]. *04/28/16 - Stage 1 pressure ulcer on LBKA measuring 1 cm x 1 cm, with brown eschar (dark scab or falling away of dead skin). There was 100% eschar. A physician order [REDACTED].#2 ' s left stump indicated .cleanse the wound with normal saline , pat dry, apply silver gel to the wound bed, and cover with dry dressing . The skin assessment sheets for Resident #2 indicated the following: Right below the knee [MEDICAL CONDITION] (RBKA)- *4/21/16 - a Stage 1 pressure ulcer on his RBKA measured 1.2 cm x 1.7 cm x 0.1 cm. and described as a scabbed open area. No new physician orders [REDACTED]. *4/28/16 - Stage 1 pressure ulcer on his RBKA measured 1.3 cm x 1.5 cm x 0.1 cm, with a scant amount of serous drainage. The wound was described as having 30% eschar, 60% granulation tissue, and 10% slough present. It did not indicate the physician was notified of the pressure ulcer ' s deterioration. A physician order [REDACTED].#2 ' s wound treatment was to .cleanse the right stump with normal saline, pat dry apply skin prep to affected area and cover with dry dressing . The Administration History (a record of treatments provided) report indicated the first treatment to Resident #2 ' s RBKA and LBKA was 4/29/16 (8 days after found). A computerized physician order [REDACTED].#2 was admitted to hospice. During an interview on 05/17/16 at 12:28 p.m., the treatment nurse said Resident #2 had a stage 3 pressure ulcer on his sacral area. She said she had been the treatment nurse since the end of April 2016, but she had not assessed the area on Resident #2 ' s sacral area. The treatment nurse said Resident #2 left the facility the first of May 2016 with the sacral pressure ulcer and areas to both of his stumps (BKAs). She said the areas on his LBKA developed in the facility on 4/28/16 and had eschar. The treatment nurse said the area on Resident #2 ' s RBKA was open with drainage. The treatment nurse said she had not notified the physician about the sacral wound, because it looked the same to her. A physician order [REDACTED].#2 was discharged at 10:00 a.m. via stretcher. An admission assessment dated [DATE] indicated Resident #2 was admitted to a new facility at 11:00 a.m. with the following wound assessment. Wound #1(Sacral Area)- *5/3/16 at 11:49 a.m. - unstageable pressure ulcer on the resident ' s sacral area measuring 18 cm x 18 cm x unknown depth. The wound bed was open pink, yellow, gray, and black. The surrounding skin was red. There was eschar to the wound bed with a 100 percent necrosis and heavy drainage with a tan color. The drainage was opaque or purulent with a strong odor and the resident was in constant pain. There were signs and symptoms of infection observed. The hospice NP was notified and gave orders for a wound culture. The assessment indicated the edges of the wound were pink/moist, however; there was not enough pink to document. Wound #2 (LBKA)- * 5/3/16 at 11:49 a.m. - unstageable pressure ulcer on the resident ' s LBKA. It measured 2.0 cm x 2.5 cm. The wound bed was opened, dry, and black. The tissue had eschar at 100 percent and the resident had intermittent pain. Wound # 3 (RBKA) - * 5/3/16 at 11:49 a.m. - unstageable pressure ulcer to the RBKA. It measured 3.0 cm x 2.5 cm and was opened, black, with 100% eschar and 100% necrosis. During a telephone interview on 05/19/16 at 1:50 p.m., Resident #2 ' s primary physician said the facility never notified him regarding Resident ' s #2 pressure ulcers. He said he never gave any wound care orders concerning Resident #2's pressure ulcers. He said he would expect the facility to notify him of wounds so that they could be addressed or if needed obtain a wound care consult. The physi