Every finding on record at Laurel Hill Nursing Center

Based on interview and record review it was determined the facility failed to ensure bed brakes were engaged during resident care for fall prevention for 1 of 3 sampled residents (#8) reviewed for accidents. Resident 8 experienced a fall from bed and sustained a skin abrasion, increased lower extremity pain, and a decline in mobility status. Findings include:Resident 8 was admitted to the facility in 10/2024 with diagnoses including hemiparesis (one-sided weakness) following a stroke.An 11/18/25 Quarterly MDS Assessment for Resident 8 demonstrated a BIMS Score of 14, indicating intact cognitive function.An undated fall investigation document revealed Resident 8 suffered a fall to the floor between her/his bed and the wall which occurred while Staff 9 (CNA) was providing personal care and the bed moved. Emergency Responders assisted facility staff to transfer the resident safely back to bed.On 7/21/26 at 2:57 PM, Resident 8 stated she/he had been in terrible pain while she/he was on the floor awaiting emergency responders to arrive following the 12/10/25 fall. Resident 8 reported the fall caused her/him a major setback in progress with ambulation and indicated her/his knee and ankle pain started after the incident.A 12/11/25 Nursing Alert Note revealed Resident 8 suffered scrapes and bruises from the 12/10/25 fall including an open area on her/his left shin. The resident complained of pain and required pain medication for alleviation.Physical Therapy Treatment Encounter Notes from 12/1/25 through 12/10/25 revealed Resident 8's previous mobility status included walking 40 feet with a walker and contact guard assistance on 12/1/25, sit to stand transfer with moderate assistance on 12/2/25, and completing sit to stand transfers in the parallel bars with contact guard assistance.A 12/11/25 Therapy Care Plan Communication Form completed by Staff 7 (Physical Therapist, Director of Rehabilitation) indicated Resident 8 was downgraded for transfers to a two staff mechanical lift dependent transfer for moving from bed to and from wheelchair. The document indicated Resident 8 was more fearful with standing following the recent fall, and required increased assistance for sit to stand due to left knee and ankle pain.A Physical Therapy Progress Report dated 12/16/25 summarizing Resident 8 services provided from 11/28/25 through 12/16/25 stated: Analysis of Goal Progress: Patient with decline in level of function status post fall off of bed on 12/10/25 where [she/he] is reported to have slid onto the floor between wall and bed onto [her/his] knees. Patient reported [she/he] was stuck on [her/his] knees for extended period while awaiting for [emergency responders] to help get [her/him] up. Patient reported increased and now decreasing new left knee and ankle pain as well as bilateral foot plantar surface pain with weight bearing. Patient with only limited standing to date since fall and no gait yet but should be able to return to at least parallel bar ambulation throughout the next week. A 12/17/25 Occupational Therapy evaluation for Resident 8 indicated Reason for referral: Patient referred to OT due to decline in independence with self-care transfers and ADL independence. Patient had a recent fall sustaining soft tissue injury to feet and ankles. Patient is now struggling with ADL transfers and tasks. This evaluation reported pain intensity with activity as eight out of ten during weight bearing and six out of ten at rest in bilateral ankles, with pain during movement reported as shooting, throbbing, stabbing and excruciating.The 12/29/25 Physical Therapy Treatment Encounter Note completed by Staff 13 (Physical Therapist Assistant) reported sit to stand transfer was attempted from Resident 8's elevated bed due to resident tall height. Resident 8 was unable to move the left leg when weight bearing due to complaints of ten out of ten pain. Staff 13 documented nursing staff was alerted this resident's pain has not come down since fall a couple weeks ago.On 7/21/26 at 8:14 PM, Staff 8 (LPN) stated Resident 8's bed wheels were not locked when she/he fell from the bed. Staff 8 indicated the fall was pretty traumatic for Resident 8 and stated she/he was very shaken up and in a lot of pain afterwards. Staff 8 stated the resident was positioned on the floor while waiting for emergency responders to arrive with most of her/his body weight on her/his knees. Staff 8 stated Resident 8 was bent like a pretzel despite Staff 8 using her body to support and offload a some of the resident's body weight to help reduce discomfort. Staff 8 encouraged Resident 8 to go to the emergency department for evaluation after the fall, however this resident declined.On 7/22/26 at 12:46 PM, Staff 9 stated the bed moved as the resident turned in bed on to her/his side. Staff 9 indicated the bed brake was not engaged.On 7/23/26 at 6:02 PM, Staff 2 (DNS) stated she was aware of the fall regarding Resident 8. Staff 2 stated maintenance staff checked Resident 8's bed on 12/11/25 and found no functional issues with the brakes.On 7/24/26 at 9:49 AM, Staff 7 and Staff 13 were interviewed together regarding Resident 8's fall on 12/10/25 and the impact on her/his mobility level. Staff 7 stated after the 12/10/25 fall Resident 8 complained of a lot of pain with weight bearing, and Staff 13 voiced agreement. Staff 7 stated the fall caused a significant decline for Resident 8 with transfers, walking, and standing tolerance.On 7/24/26 at 11:30 AM, Staff 2 (DNS) stated the only time a resident bed brake should be unlocked/disengaged is when the bed was empty; for cleaning or readjusting the bed position.A 12/11/25 Performance Documentation record completed by Staff 2 confirmed the fall suffered by Resident 8 was caused by staff failure to lock the brakes on the resident's bed. This deficient practice was identified as Past Noncompliance based on the following:The facility identified an avoidable accident related to a failure to engage bed brakes during resident care.1. On 12/11/25, the Maintenance Director confirmed Resident 8's bed had fully functioning brakes and no mechanical issues.2. Staff 9 received education 12/11/25 for not ensuring bed brakes were engaged.3. In-Service Training on 1/7/26 was provided to all nursing staff and CNA's on proper brake engagement during personal care.4. Avoidable and unavoidable falls continued to be reviewed through QAPI.All corrective actions were completed as of 1/7/26.

Based on interview and record review it was determined the facility failed to complete a timely assessment of a new wound for 1 of 1 sampled resident (#8) reviewed for non-pressure skin injury. This placed residents at risk for worsening wounds. Findings include: An undated Skin Issue Protocol document for new injuries included the following steps a nurse must take upon identification of a new skin injury: assess and treat the injury, obtain/add the treatment order into the EMR (Electronic Medical Record), take a photograph of the skin injury and enter this into the EMR, fill out and communicate SBAR (Situation, Background Assessment, Recommendation) to the physician, document a progress note the communications made regarding the injury to resident family and physician as well as the injury and treatment provided, complete risk management assessment, obtain witness statements of CNAs and nurse, and place resident on alert charting for each shift for 72 hours following the new injury.Resident 8 was admitted to the facility in 10/2024 with diagnoses including hemiparesis (one-sided weakness) following a stroke.A Progress Note written by Staff 8 (LPN) on 12/10/25 indicated Resident 8 had fallen from her/his bed to the floor, with small skin tear to left shin noted as a result of the fall.An undated fall investigation document contained a Witness Statement from Staff 9 (CNA) dated 12/20/25 which indicated Resident 8 suffered a skin injury to left shin size of a quarter from the fall.Nursing Progress Notes dated 12/11/25 and 12/12/25 revealed Resident 8 had a wound on her/his left shin with a dressing present.A New Skin Issue assessment was completed six days after the fall for the left shin abrasion on 12/16/25 by Staff 14 (LPN) including measurements, photograph of wound, and the wound was acquired in house.On 7/22/26 at 8:35 AM, Staff 14 stated she was aware of Resident 8's 12/10/25 fall but was not the assigned nurse to the resident that day. Staff 14 stated she completed a nurse assessment on 12/16/25, six days after the fall, and an injury assessment should have occurred immediately after the incident once the resident was safe.On 7/23/26 at 6:10 PM, Staff 2 (DNS) confirmed that a new skin injury assessment including wound measurements was not completed until 12/16/25 for the left shin wound Resident 8 sustained during a fall on 12/10/25. Refer to F689

Based on interview and record review it was determined the facility failed to thoroughly investigate a fall incident for 1 of 3 sampled residents (#8) reviewed for accidents. This placed residents at risk for injuries. Findings include: A 10/2022 Incident Documentation and Investigation facility Policy and Procedure revealed the following: Document and investigate incidents in order to protect residents from further incidents. An incident report would be completed for occurrences and should begin as soon as the incident was identified including falls, witnessed, unwitnessed or staff lowered resident to the floor. The Incident Report is completed to include date, time of occurrence and location of the incident. Procedures listed in the document included 9. The licensed nurse obtains witness statements from the assigned nursing assistant, nursing assistants in the immediate area, nursing assistants from the shift prior to the incident's discovery, visitors, family, roommates., and 15. a) Interview of the resident.Resident 8 was admitted to the facility in 10/2024 with diagnoses including hemiparesis (one-sided weakness) following a stroke.An 11/18/25 Quarterly MDS Assessment for Resident 8 demonstrated a BIMS Score of 14, indicating intact cognitive function.An undated fall investigation document indicated Resident 8 suffered a fall to the floor between her/his bed and the wall which occurred while Staff 9 (CNA) was providing personal care and the bed moved. Emergency Responders removed the transfer pole from the resident room to allow adequate access to the resident and then assisted facility staff to transfer the resident safely back to bed.Only one witness statement was included in the facility fall investigation by Staff 9 on 12/10/25 at 9:15 PM. A 12/10/25 Nursing Progress Note from Staff 8 (LPN) documented the fall briefly in the EMR (Electronic Medical Record) as well as Resident 8's vital signs and nurse assessment data post-fall.Interviews with nursing staff conducted on 7/21/26 through 7/24/26 revealed six staff (Staff 8, Staff 12 (LPN), Staff 14 (LPN), Staff 15 (CNA), and staff 16 (CNA) were present and responded to the incident.On 7/22/26 at 12:06 PM Resident 8 stated she/he was not interviewed by Staff 2 about the incident or what she/he experienced.On 7/23/26 at 6:00 PM and 7/24/26 at 11:35 AM, Staff 2 (DNS) stated she did not interview the resident or all potential parties involved. Staff 2 stated the facility standards required interviews with all staff on duty during a fall, including at least two CNA witnesses and the resident's nurse.

Based on interviews and record review it was determined the facility failed to follow physician orders for wound care interventions for 1 of 3 sampled resident's (# 101) reviewed for coordination of wound care. This placed residents at risk for unmet wound care needs. Findings include:Resident 101 was admitted to the facility in 2024 with diagnoses including a Stage 4 pressure ulcer (most severe form of pressure injury characterized by full-thickness tissue loss with exposed fascia, muscle, tendon or bone) to the sacrum (triangular bone at the base of the spine connecting the spine to the pelvis), and stroke. On 5/7/25 a BIMS evaluation indicated Resident 101 had a BIMS score of 14 and was cognitively intact. A 5/28/25 Wound Ostomy Clinic Progress Note indicated Resident 101's wound healing had stalled, and an order was faxed to the facility for the resident to get a wheelchair seat mapping completed. The order also included the facility should schedule Resident 101's seat mapping appointment. A 5/28/25 Progress Note revealed the resident returned from wound care with a new order for a wheelchair seat mapping related to pressure injury of the sacral region. The order faxed to the vendor on 5/28/25 at 11:05 AM. On 5/30/25 at 11:03 AM, Witness 1 (Nurse Practitioner) reported Resident 101 was her/his patient at the local wound clinic. Witness 1 stated on 5/28/25 she/he ordered a seat mapping for a new wheelchair cushion due to a previous cushion (Roho cushion) she/he had ordered being removed from the resident's use. When Witness 1 checked on 5/30/25 the seat mapping for the new cushion had still not been ordered or completed. A 6/19/25 Progress Note indicated a nurse called the vendor that morning for an update on the seat mapping. The vendor requested the order be faxed. A 7/29/25 Progress Note indicated staff called the vendor and they had not received any faxes from the facility. It was confirmed the facility had faxed to the incorrect fax number. On 1/27/26 at 3:13 PM, Staff 2 (DNS) provided a timeline for the 5/28/25 seat mapping for a new wheelchair cushion order. In 7/2025, the facility refaxed the referral. Staff 2 indicated that both sides attempted to contact each other but was unsuccessful. In 8/2025, a vendor nurse requested the facility to re-fax the information. Staff 2 stated the vendor failed to explain the cushion needed to be billed directly to the facility and not to the resident's insurance. Staff 2 stated they scheduled an appointment for Resident 101 on 2/13/25 at 1:00 PM, 10 months after the original order was received. Staff 2 indicated they had dropped the ball by not following up on the order promptly and she was putting a new procedure in place to ensure there was appropriate follow-up on orders.

Based on observation, interview, and record review it was determined the facility failed to properly follow dish sanitation practices for 1 of 1 kitchen. This placed residents at risk for food borne illnesses. Findings include: Instructions for the facility dish machine revealed the dish machine required 50 parts per million of chlorine rinse to santize. On 3/27/25 at 12:40 PM Staff 26 was observed to use the dish machine to wash dishes. Staff 26 stated she started the dish machine in the mornings when she worked and ensured chemicals were visually flowing into the dish machine to verify the chemical concentration was adequate in the dish machine. Staff 26 stated she did not know how to test for the chemcial levels of the dishwasher. The 3/2025 Sanitizing Strips and Dish Machine log indicated Staff 26 (Cook) verified the concentration of the chemical sanitation for the dishwasher was at 50 for multiple shifts on the following days she worked: 3/1/25 through 3/3/25, 3/8/25 through 3/20/25, and 3/18/25 through 3/22/25. On 3/27/25 at 1:24 PM Staff 26 stated she completed the Dish Machine log using the documented trends of other staff. Staff 27 (Dietary Manager) acknowledged the Dish Machine log was not accurate and the facility did not verify proper chemical levels of the dish machine during each shift. On 3/28/25 at 10:19 AM Staff 1 (Administrator), Staff 2 (DNS), and Staff 12 (Regional Director of Clinical Operations) acknowledged consistent testing of the chemical levels in the dish machine using test strips should be completed to ensure proper dish sanitation.

Based on interview and record review it was determined the facility failed to report to the State Survey Agency an allegation of abuse for 3 of 3 sampled residents (#s 7, 12 and 19) reviewed for abuse. This placed residents at risk for reoccurring abuse. Findings include: 1. Resident 7 was admitted to the facility in 3/2022 with a diagnosis of dementia. The 6/2/23 care plan revealed Resident 7 had impaired cognitive function related to dementia. Staff were to ask yes/no questions to determine her/his needs. The facility's investigation revealed on 11/24/24 Staff 32 (Former CNA) reported to Staff 34 (Former LPN) Resident 7 had inappropriately touched another resident. The 1/26/25 Quarterly MDS indicated Resident 7 had mild cognitive impairment. On 3/25/25 multiple attempts were made to contact Staff 32 and Staff 18 (Former DNS) but no response was received. On 3/27/25 at 9:21 PM Staff 34 confirmed Staff 32 told her that she witnessed Resident 7 touch another resident inappropriately. Staff 34 further stated she did not report the allegation to the State Survey Agency. On 12/9/24 a Facility Reported Incident (FRI) was submitted to the State Survey Agency. The report revealed the facility became aware of the allegation of sexual abuse on 11/24/24 but did not report the allegation until 16 days later. On 3/28/25 at 9:02 AM Staff 1 (Administrator) stated she did not become aware of the allegation until two weeks later. Staff 1 acknowledged the facility failed to report the allegation of sexual abuse to the State Survey Agency in a timely manner. 2. Resident 19 admitted to the facility in 11/2024 with a diagnosis of stroke. The 3/3/25 Quarterly MDS indicated Resident 19 had severe cognitive impairment. The facility's investigation revealed on 11/24/24 Staff 32 (Former CNA) reported to Staff 34 (Former LPN) she witnessed another resident touch Resident 19's breast. On 3/25/25 multiple attempts were made to contact Staff 32 and Staff 18 (Former DNS) but no response was received. On 3/27/25 at 9:21 PM Staff 34 confirmed Staff 32 told her that she witnessed Resident 19 being touched inappropriately by another resident. Staff 34 further stated she did not report the allegation to the State Survey Agency. On 12/9/24 a Facility Reported Incident (FRI) was submitted to the State Survey Agency. The report revealed the facility became aware of the allegation of sexual abuse on 11/24/24 but did not report the allegation until 16 days later. On 3/28/25 at 9:02 AM Staff 1 (Administrator) stated she did not become aware of the allegation until two weeks later. Staff 1 acknowledged the facility failed to report the allegation of sexual abuse to the State Survey Agency in a timely manner. 41455 3. A 10/2022 revised facility Incident Documentation and Investigation policy indicated staff were to document and investigate incidents to protect residents from further incidents, including resident to resident altercations. Resident 12 was admitted to the facility in 3/2025 with diagnoses including dementia and depression. The 3/9/25 Admission MDS and Cognition CAA indicated Resident 12's cognition was moderately impaired, and she/he was at risk for depression, anxiety, diminished psychosocial well-being and non-participation in activities. Resident 20 was admitted to the facility in 4/2024 with diagnoses including delusional (beliefs that are contrary to reality) disorders and mild cognitive impairment. A 1/22/25 Quarterly MDS indicated Resident 20 had hallucinations, delusions, and one to three verbal behaviors directed towards others during the review period. On 3/24/25 at 12:44 PM Resident 12 was asked by a surveyor if she/he ever felt abused at the facility. Resident 12 stated, a few weeks ago during dinner, Resident 20 yelled and cussed at Resident 12 which made her/him feel uncomfortable and intimidated by Resident 20. Resident 12 stated she/he was only eating her/his meal at the same table as Resident 20 when the incident occurred. On 3/25/25 at 11:28 AM Staff 2 (DNS) stated she was not informed of an incident between Resident 12 and Resident 20. On 3/25/25 at 11:36 AM Staff 13 (CNA) stated she was aware Resident 20 was upset with Resident 12, but was not present during the incident. Staff 13 stated she received information about an incident between Resident 12 and Resident 20 at shift change on 3/23/25. On 3/25/25 at 11:53 AM Staff 17 (Social Services Manager) stated staff were instructed to report any altercation between residents to the administration and was unaware of any incident between Resident 20 and Resident 12. On 3/25/25 at 12:20 PM and 3/28/25 at 9:57 AM Staff 1 (Administrator) stated she expected an incident report regarding the altercation between Resident 12 and Resident 20 which occurred on 3/20/25. Staff 1 stated a FRI was completed on 3/25/25 and acknowledged the required reporting to the State Agency for the resident to resident altercation was not completed timely.

Based on observation, interview, and record review it was determined the facility failed to follow physician orders and provide medications to treat a chronic condition for 4 of 4 sampled residents (#s 6, 19, 25, and 84) reviewed for constipation, hospice, abuse, and choices. This placed residents at risk for bowel obstruction and unmet care needs. Findings include: 1. Resident 6 was admitted to the facility in 12/2017 with diagnoses including stroke. The 1/7/25 physician's order indicated Resident 6's bowel care protocol for constipation included: -Senna (laxative medication) tablets or Miralax powder (laxative medication) may be used as needed if there was no bowel movement (BM) within 24 hours after two consecutive days without a BM. -Take one bisacodyl (laxative medication) tablet orally every 24 hours if there was no BM in three days. -Administer one bisacodyl suppository rectally every 24 hours if no BM in four days. If this occurs, notify provider. -A fleet enema (laxative medication) should be administered every 24 hours if there was no bowel movement for five days. A review of Resident 6's clinical record from 2/24/25 through 3/1/25 revealed no bowel care medication was administered to Resident 6 after five days without a bowel movement. From 3/6/25 through 3/14/25. A Bisacodyl tablet was administered on 3/10/24, after four consecutive days without a bowel movement and an enema was given on 3/14/25. No bowel medication was provided after four consecutive days without a bowel movement. On 3/27/25 at 10:03 AM, Staff 2 (DNS) stated she expected the timely administration of bowel medication and acknowledged the physician's order for Resident 6's bowel care was not followed. 40774 2. Resident 19 was admitted to the facility in 11/2024 with diagnoses including stroke affecting the left and right sides. The 2/27/25 care plan revealed Resident 19 was at risk for falls related to cognitive and communication deficits, right and left side impairment, and a history of seizures. The resident was totally dependent on staff for ADL care. The 3/3/25 Quarterly MDS revealed Resident 19 had one fall without injury. On 3/24/25 at 12:27 PM Resident 19 was observed in the dining room. She/he was able to answer simple yes/no questions but tired quickly. On 3/25/25 at 12:47 PM Staff 13 (CNA) stated she was aware of the resident's fall history. Staff 13 stated anytime a resident had an unwitnessed fall, the nurses assessed the resident for injury and started neuro checks. CNAs were required to complete a full set of vitals for the following 72 hours and report back to the nurse. Staff 13 stated CNAs wrote the vitals down on a piece of paper and gave them to the nurse and they put the vitals in the resident's chart. On 3/25/25 at 1:12 PM Staff 4 (CNA/RA) stated Resident 19 had a history of unwitnessed falls and she was familiar with the facility's fall protocol. On 3/27/25 at 9:28 AM Staff 22 (RN) stated she started the 3/11/25 fall investigation after Resident 19's unwitnessed fall. Staff 22 stated for an unwitnessed fall nurses were required to assess the resident for injury, ROM and complete a set of [NAME] checks. CNAs continued to take the resident's vitals per facility protocol write them down on a piece of paper and give them to the nurse to document in the resident's chart. Staff 22 stated she did not follow up with the CNAs to ensure the resident's vitals were completed but it was her responsibility. On 3/27/25 at 9:21 PM Staff 31 (Former LPN) stated Resident 19 had a history of unwitnessed falls. Nurses were required to assess the resident for injury, ROM and obtain a full set of vitals. CNAs were expected to continue taking vitals per facility policy for the following 72 hours and give a copy to the nurse. On 3/28/25 at 8:45 AM Staff 1 (Administrator) stated staff were expected to complete neuro checks for unwitnessed falls. Staff 1 was unable to provide documentation of completed neuro checks or completed staff education for the 3/11/25 unwitnessed fall. 41455 3. Resident 25 was admitted to the facility in 1/2025 with diagnoses including heart failure and encounter for palliative care (specialized treatment for serious illnesses). The 1/30/25 care plan revealed Resident 25's pain management was provided by hospice. The 2/3/25 Admission MDS indicated Resident 25 was moderately cognitively impaired, received hospice services, and had unstable angina (chest pains). A 2/24/25 signed physician order indicated to administer nitroglycerin (medication to treat chest pain) as needed to Resident 25 every five minutes for chest pains and to call hospice after the first tablet was given. The 3/2025 MAR indicated Resident 25 received nitroglycerin three times on 3/3/25 and one time on 3/6/25. On 3/26/25 at 9:41 AM Staff 30 (RN) stated she was not present when Resident 25 was administered nitroglycerin and verified the orders for the medication included to notify hospice. On 3/26/25 at 11:09 AM Resident 25 recalled when medication was provided to address her/his chest pain. On 3/26/25 at 2:58 PM Witness 11 (Hospice Director) stated each resident on hospice had different needs and confirmed hospice was not informed Resident 25 was administered nitroglycerin on 3/3/25 or 3/6/25 as ordered. On 3/27/25 at 6:47 PM Staff 28 (LPN) acknowledged he administered Resident 16's nitroglycerin medication on 3/3/25, but was unaware of the order to contact the hospice physician when the medication was administered. On 3/28/25 at 10:19 AM Staff 2 (DNS) stated orders to notify hospice of Resident 25's nitroglycerin administration should be followed. 26991 4. Resident 84 was admitted to the facility in 4/2024 with a diagnosis of chronic pancreatitis (long term condition: symptoms include stomach pain). Resident 84's 4/22/24 hospital Discharge Orders revealed staff were to administer Zenpep (medication to help digest food when the pancreas does not make enough enzymes to digest food) three times a day with food. A 4/24/24 Facility/Account clinical Edit Notification form revealed the facility approved to be billed the cost of Resident 84's Zenpep. Resident 84's 4/2024 and 5/2024 MAR revealed she/he received Zenpep three times a day from 4/27/24 through 5/14/24. A 5/21/24 Encounter Note by Staff 11 (Physician) revealed Resident 84 had a diagnosis of chronic pancreatitis and the facility was not able to obtain Zenpep since the resident's admission to the facility. The note indicated even without taking the medication, she/he did not have nausea, vomiting, or diarrhea. Staff 11 discontinued the Zenpep and staff were to monitor the resident. A 5/27/24 Nursing Communication fax to Staff 11 revealed Resident 84 reported nausea and diarrhea for three days and requested immodium (treats diarrhea). Resident 84 reported to staff she/he took Zenpep for her/his pancreatic condition, but recently on 5/14/24, the medication was stopped. Staff 11 responded with a note indicating the facility was not able to obtain the mediation and to communicate with the pharmacy to obtain a medication which could be substituted for Zenpep or to see if Resident 84 was able to supply her/his own medication. On 3/27/25 at 11:27 AM Staff 11 stated she was informed by Staff 18 (Former DNS) the facility was not able to obtain Resident 84's Zenpep and the pharmacy did not have the medication, therefore, she discontinued the order. On 3/27/25 at 11:39 AM Witness 9 (Pharmacy Technician) stated in 5/2024 the facility sent a second Facility/Account clinical Edit Notification form to the facility requesting approval to bill the facility for Resident 84's Zenpep, but the facility did not send back a response. On 3/27/25 at 12:08 PM Staff 12 (Regional RN) stated there was nothing in Resident 84's clinical record to indicate the facility attempted to find alternatives to Resident 84's Zenpep or to ensure she/he received medication to treat her/his chronic pancreatitis.

Based on observation and interview it was determined the facility failed to ensure clean items were not stored in contaminated areas for 1 of 1 laundry room reviewed for infection control. This placed residents at risk for cross contamination. Findings include: On 3/26/25 at 12:16 PM observations of the dirty side of the laundry room revealed the following: -approximately 15 pillows -four uncovered styrofoam cushions -and a triangular wedge were present on the shelf. On 3/26/25 at 12:02 PM Staff 35 (Laundry/housekeeping) stated the pillows, styrofoam cushions and a triangular wedge had been stored on the dirty laundry side for approximately one month. She reported her concerns to the maintenance director but the items were not removed. On 3/26/25 at 12:17 PM Staff 36 (Assistant Maintenance Director) confirmed he placed the pillows, styrofoam cushions, and a triangular wedge in the laundry room on the soiled linen side some time ago. He stated he did not know this was an infection control issue. On 3/28/25 at 9:20 AM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the findings from the laundry room observation. Staff 1 and 2 confirmed the storage of clean items in proximity to dirty laundry posed an infection control concern due to potential cross-contamination.

Based on observation, interview, and record review it was determined the facility failed to ensure residents were provided dental services for 1 of 1 sampled resident (#26) reviewed for dental. This placed residents at risk for unmet dental needs. Findings include: Resident 26 was admitted to the facility in 12/2024 with a diagnosis of a stroke. Resident 26's 1/4/25 admission MDS revealed Resident 26 was alert, unable to communicate, had likely cavities, and broken molars. Resident 26's 1/13/25 Care Conference did not address if Resident 26 or her/his representative wanted Resident 26 to be assessed by a dentist for her/his identified dental issues. On 3/25/25 at 11:53 AM Resident 26 was observed to eat and did not show signs of pain while eating. On 3/26/25 at 11:07 AM Staff 17 (Social Services) stated if a resident was assessed to have dental issues on the MDS, staff were to offer dental services. Staff 17 stated she did not reach out to Resident 26's representative to offer dental services. On 3/26/25 at 11:12 AM and on 3/27/25 at 12:15 PM Staff 15 (LPN Resident Care Manager) stated if a resident was assessed to have dental issues, a dental referral was made. Staff 15 stated Resident 26 had dental issues, but did not report dental pain. Staff 15 stated she did not address the dental issues with Resident 26's representative. An interview occurred on 3/28/25 at 9:57 AM with Staff 2 (DNS) and Staff 12 (Regional RN). Staff 2 stated if a resident had missing or broken teeth, or cavities, the MDS triggered staff to make a referral to dental after checking with the resident and or resident representative.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant pain medication errors for 1 of 6 sampled residents (#16) reviewed for medications. This placed residents at risk for complications related to medications. Findings include: Resident 16 was admitted to the facility in 2/2025 with diagnoses including prostate cancer, UTI, and chronic pain. The 2/18/25 Admission MDS indicated Resident 16 had constant pain throughout the day and her/his pain frequently interfered with her/his daily activities. The 2/2025 MAR revealed Resident 16 was to receive one fentanyl transdermal patch (opioid pain medication applied to the skin) every three days for 14 days beginning on 2/15/25 and to remove the old fentanyl patch when the new fentanyl patch was applied. On 2/27/25 the fentanyl patch was applied by Staff 22 (LPN). A 2/17/25 care plan indicated staff were to monitor Resident 16's pain and her/his pain medication administration. A 3/2/25 Nursing Note indicated two fentanyl patches were found on Resident 16, the resident was easily aroused from sleep, and no new orders were received from the physician. A 3/2/25 Medication Error investigation completed by Staff 29 (RNCM) for Resident 16 revealed, during the process of applying a new fentanyl patch on the resident, Staff 23 (LPN) found two fentanyl patches on the front of both of the resident's shoulders. The investigation revealed no dates or signatures were found on either of Resident 16's patches on 3/2/25. On 3/27/25 at 9:09 AM Witness 6 (Family) stated it was difficult to manage Resident 16's pain when she/he was in the facility. On 3/27/25 at 10:17 AM Staff 22 stated her process for Resident 16's fentanyl patch administration was to rotate locations on her/his skin. On 3/27/25 at 5:57 PM Staff 23 confirmed he discovered two fentanyl patches on Resident 16 on 3/2/25. Staff 23 stated the standard of practice was to remove the old fentanyl patch prior to the administration of a new patch. On 3/28/25 at 10:19 AM Staff 2 (DNS) confirmed, after the 3/2/25 medication error, the expectation for nurses was as follows: -Ensure fentanyl patches were applied as ordered. -Identify fentanyl patches with dates and initials when applied. -A witness must observe the disposal of the old fentanyl patch. The deficient practice was identified as Past Noncompliance based on the following: On 3/3/25, the deficient practice was identified by the facility and was corrected when the facility implemented a Plan of Correction which included: 1. Nursing staff were educated regarding fentanyl patch administration, 2. Other residents with fentanyl patches were reviewed for proper administration. 3. Licensed nurses were instructed to initiate incident reports for medication errors. 4. The fentanyl patch administration procedure was updated to include a witness nurse signature in the fentanyl administration record. During the survey process from 3/24/25 through 3/28/25 no concerns regarding fentanyl patch administration were identified.

Based on interview and record review it was determined the facility failed to provide appropriate dosing of medications for 1 of 6 sampled residents (#12) reviewed for medications. This placed residents at risk for complications related to medications. Findings include: Resident 12 was admitted to the facility in 3/2025 with diagnoses including atrial fibrillation (irregular heart rhythm) and high blood pressure. The 3/9/25 revised care plan indicated Resident 12 received medication for her/his atrial fibrillation and medications were to be provided according to physician orders. The 3/2025 MAR indicated to administer hydralazine (blood pressure medication) three times daily and hold for a systolic (upper number) blood pressure less than 120. Resident 12 was administered hydralazine as follows: -3/13/25 at 8:00 AM with a systolic blood pressure of 119. -3/13/25 at 12:00 PM with a systolic blood pressure of 119. -3/13/25 at 4:00 PM with a systolic blood pressure of 104. -3/18/25 at 4:00 PM with a systolic blood pressure of 108. -3/19/25 at 12:00 PM with a systolic blood pressure of 115. On 3/26/25 at 9:37 AM Staff 30 (RN) reviewed Resident 12's medication administration record for 3/19/25 and acknowledged she incorrectly provided the resident's hydralazine outside of the written parameters on 3/19/25. On 3/27/25 at 10:07 AM Staff 22 (LPN) stated the medication administration system required her to enter a blood pressure for Resident 12 before her/his hydralazine was administered and she double-checked her results. Staff 22 confirmed she administered Resident 12's blood pressure medication incorrectly on 3/13/25 and 3/18/25. On 3/27/25 at 10:45 AM Staff 2 (DNS) confirmed physician orders should be followed and acknowledged staff did not follow the parameters for the administration of Resident 12's hydralazine.

Based on interview and record review it was determined the facility failed to assess a pressure ulcer at the time it was identified for 1 of 2 sampled residents (#83) reviewed for pressure ulcers. This placed residents at risk for delayed treatment and pain. Findings include: An Incident Documentation and Investigation policy revised on 10/2022 revealed an incident report was to be completed when new pressure ulcers, Stage II (partial thickness skin loss or may present as an intact or open/ruptured blister) or greater were identified. When the incident occurred, the resident was to be examined by the nurse and care provided. Once immediate care was provided, the nurse was to initiate an investigation. Resident 83 was admitted to the facility in 3/2025 with a diagnosis of a respiratory illness. Resident 83's 3/13/25 Admission Profile form revealed, upon admission to the facility in 3/2025, she/he did not have a pressure ulcer. Resident 83's 3/2025 Documentation Survey Report (CNA documentation of care provided) revealed on 3/18/25, during the evening shift, a CNA identified a new open area to Resident 83's left leg. Resident 83's clinical record did not have documentation to indicate her/his new open area, identified on 3/18/25 to the left leg, was assessed by a nurse on 3/18/25 during the evening shift. Resident 83's 3/19/25 New Pressure Injury investigation revealed on 3/19/25 a CNA reported Resident 83 had a new wound on her/his heel that needed to be assessed because it was leaking. Resident 83's 3/19/25 Skin and Wound Evaluation form revealed she/he had a Stage II pressure ulcer to the left heel and coccyx. The left heel pressure ulcer was 6.2 cm long and 4.8 cm wide and had heavy drainage which was blood tinged. On 3/27/25 at 1:53 PM Staff 20 (LPN) stated she was assigned to care for Resident 83 on 3/18/25 and the CNA did not notify her that Resident 83 had a new pressure ulcer to her/his left heel. On 3/27/25 On 4:39 PM Staff 10 (LPN Wound Nurse) stated she was not sure what time on 3/19/25 she was notified of Resident 83's new heel pressure ulcer, but when she was notified, she assessed the wound, and provided treatment. On 3/27/25 at 4:51 PM Staff 19 (LPN) stated she worked the evening shift on 3/18/25 when Resident 83 was identified to have a new left heel pressure ulcer, but was not assigned to care for Resident 83. Staff 19 stated a CNA notified her Resident 83 had an open area, and Staff 19 informed the CNA to let Staff 20 know when she returned from her/his lunch break. Staff 19 stated she also notified the CNA to let her know if Staff 20 was unable to assess the open area. Staff 19 stated the CNA did not reapproach her, did not ask her to assist with Resident 83, and she did not assess Resident 83's pressure ulcer when it was first identified. On 3/27/25 at 1:30 PM Staff 15 (LPN Resident Care Manager) verified staff identified Resident 83's pressure ulcer on the evening shift of 3/18/25 but it was not assessed and treatment was not provided until 3/19/25 on the day shift. An interview occurred on 3/28/25 at 10:05 AM with Staff 2 (DNS) and Staff 12 (Regional RN). Staff 2 stated CNAs were to document new skin issues on shower sheets and also on residents' ADL documentation reports. Staff 2 stated CNA staff were also able to create an alert in a resident's clinical record to notify the nurse regarding a change in condition. Staff 12 stated Resident 83's pressure ulcer was identified on 3/18/25 during the evening shift and was assessed the following morning. Staff 2 and Staff 12 acknowledged there were no treatments placed to protect the blister and to ensure the heel was elevated to prevent potential discomfort after the ulcer was initially identified.

Based on observation, interview, and record review, it was determined the facility failed to protect the resident's right to be free from verbal abuse by a resident for 1 of 3 sampled residents (#12) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's 10/2022 revised Abuse/Neglect/Misappropriation/Exploitation policy was to implement procedures designed to prevent, identify, report, and investigate potential instances of abuse and mistreatment. Resident 12 was admitted to the facility in 3/2025 with diagnoses including dementia and depression. The 3/9/25 Admission MDS and Cognition CAA indicated Resident 12's cognition was moderately impaired, the resident had short and long term memory loss, and she/he was at risk for depression, anxiety, diminished psychosocial well-being, and non-participation in activities. Resident 20 was admitted to the facility in 4/2024 with diagnoses including delusional (beliefs that were contrary to reality) disorders and mild cognitive impairment. The 1/22/25 Quarterly MDS indicated Resident 20 had hallucinations, delusions, and one to three verbal behaviors directed towards others during the review period. On 3/24/25 at 12:44 PM Resident 12 was asked by a surveyor if she/he experienced abuse at the facility. Resident 12 was observed to sit alone at a dining room table during lunch and stated she/he preferred to eat with others. Resident 12 stated, a few weeks ago during dinner, Resident 20 yelled and cussed at Resident 12 which made her/him feel uncomfortable and intimidated by Resident 20. Resident 12 stated she/he was eating her/his meal at the same table as Resident 20 when the incident occurred. Resident 12 stated staff separated her/him from Resident 20 and explained to Resident 12 that Resident 20's behaviors were not uncommon. On 3/25/25 at 11:36 AM Staff 13 (CNA) stated she was aware Resident 20 was upset with Resident 12, but was not present during any incident. Staff 13 stated she received information about an incident between Resident 12 and Resident 20 at shift change on 3/23/25. Staff 13 stated on 3/24/25 Resident 20 stated look at how Resident 12 stares at me and continued to glare at Resident 12 throughout the day. On 3/26/25 at 8:41 AM Staff 27 (Dietary Manager) stated he heard commotion from the kitchen on 3/22/25 during lunch. Staff 27 stated Resident 12 was at the dining room table with Resident 20 when Resident 20 yelled. Staff 27 stated CNAs had the situation under control in the dining room and Resident 20's behaviors were not isolated to 3/22/25. Staff 27 was not aware if any incident report was filed. On 3/27/25 at 10:20 AM Staff 3 (LPN) stated she was unaware of any incident between Resident 12 and Resident 20. Staff 3 stated she heard yelling in the dining room during the previous week, but there were no reports of any issues from staff. On 3/28/25 at 10:49 AM Staff 21 (CNA) stated she was aware of an incident between Resident 20 and Resident 12 when they were both at the same dining room table. Resident 20 yelled at Resident 12 who became upset by the altercation. Staff 21 stated she reassured Resident 12 that Resident 20's behaviors and yelling were normal. Staff 21 stated she did not report the incident to a nurse because the situation was de-escalated. Staff 21 stated, the following day, Resident 12 chose to sit at a dining room table alone and Resident 20 remained at the table with other residents. On 3/28/25 at 9:57 AM Staff 1 (Administrator) stated the idea held by staff that Resident 20's behavior was normal towards Resident 12 needed correction. Staff 1 acknowledged Resident 12 was verbally abused by Resident 20.

Based on interview and record review it was determined the facility failed to thoroughly investigate allegations of abuse and injuries of unknown origin for 3 of 3 sampled residents (#s 4, 7 and 19) reviewed for abuse and skin conditions. This placed residents at risk for abuse. Findings include: 1. Resident 4 was admitted to the facility in 2/2025 with diagnoses including dementia. The 2/25/25 Admission MDS indicated Resident 4 had severe cognitive impairment and was never/rarely able to make decisions. The 2/25/25 Fall Risk Evaluation revealed Resident 4 had no falls within the past three months. The 2/26/25 Initial Skin Evaluation revealed no bruising. On 3/24/25 at 1:12 PM Resident 4 was observed to have a dark bruise/mark under her/his left eye that was approximately 1-inch by 1-inch. The resident was unable to be interviewed due to her/his impaired cognition. On 3/25/25 at 1:29 PM Staff 25 (LPN) stated approximately a week ago Staff 5 (CNA) reported Resident 4's black eye during the morning shift. Staff 25 confirmed sometimes it took 2 to 3 aides to help with the resident's bed mobility and transfers but she did not recall who else assisted with the resident. Staff 25 acknowledged she did not collect witness statements from all CNAs involved. On 3/26/25 at 4:15 PM Staff 5 (CNA) stated she and two additional CNA's assisted Resident 4 out of bed before breakfast. Staff 5 stated she only remembered Staff 21's (CNA) name and she did not recall who reported the incident to the nurse or providing a witness statement. On 3/27/25 at 9:08 AM Staff 21 stated it sometimes took two or three aids to assist Resident 4 with bed mobility and transfers due to the resident's fear and anxiety. She confirmed she did not assist Resident 4 with care that morning but noticed the bruise while the resident was being wheeled down the hall. Staff 21 reported Staff 7 assisted Staff 5 during the resident's care and stated she informed the DNS how she believed the black eye may have occurred. On 3/27/25 at 9:15 AM Staff 7 (CNA) confirmed she assisted Staff 5 with Resident 4's bed mobility and transfers. She noticed a bruise under the resident's left eye which darkened over the next few days. She assumed Staff 5 reported the bruise to management and acknowledged she was also responsible for completing a witness statement and management did not follow up with her. On 3/28/25 at 6:54 AM Staff 8 (CNA) confirmed she worked with Resident 4 the day before during the night shift and was not asked to fill out a witness statement. On 3/28/25 at 7:11 AM Staff 19 (LPN) confirmed she worked with Resident 4 the day before during the night shift. She stated no one contacted her regarding the resident's bruise and she was not asked to fill out a witness statement. On 3/28/25 at 8:45 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed the investigation was not thorough or complete. 2. Resident 7 was admitted to the facility in 3/2022 with diagnoses including dementia. Resident 19 was admitted to the facility in 11/2024 with diagnoses including stroke. The facility's 10/2022 Incident Documentation and Investigation revealed the following: -Licensed nurses were required to obtain witness statements from the assigned nursing assistants and other staff in the immediate area. The 11/24/24 facility investigation indicated Staff 32 (Former CNA) reported to Staff 34 (Former LPN) she witnessed Resident 7 touching Resident 19's breast The Incident Witness Statement completed by Staff 34 on 12/9/24 confirmed other witnesses were present during the incident, but no additional details were provided. The Incident Witness Statement completed by Staff 32 on 12/9/24 was incomplete. It failed to document: -The time of the incident -The type and location of the incident -Events preceding and following the incident -The witnesses' names and signatures On 3/25/25 multiple attempts were made to contact Staff 32 but no response was received. On 3/27/25 at 9:21 PM Staff 34 confirmed she received this report from Staff 32. Staff 34 stated three additional CNAs witnessed the incident but she did not recall their names or obtain witness statements. Staff 34 further stated she was unaware of the facility's abuse protocol. On 3/28/25 at 9:02 AM Staff 1 (Administrator) acknowledged staff failed to conduct a thorough investigation of the alleged incident. On 3/28/25 at 9:02 AM Staff 1 (Administrator) acknowledged staff failed to conduct a thorough investigation of the alleged incident.

Based on observation, interview, and record review it was determined the facility failed to provide adequate supervision, follow care plans, complete thorough investigations and timely assess smoking for 4 of 4 sampled residents (#s 6,15, 23, and 134) reviewed for accidents. Resident 15 and Resident 134 experienced falls resulting in fractures. Findings include: 1. Resident 15 was admitted to the facility in 2022 with diagnoses including Alzheimer's disease and stroke. A 7/13/22 Admission MDS and CAAs indicated Resident 15 was impaired on both sides, at risk for falls due to weakness, required increased ADL support and her/his care plan was to include interventions to reduce the risk of falls. a. A 3/10/23 revised care plan indicated Resident 15's bed would be in a low position for safety. A 3/20/23 Fall Investigation indicated Resident 15 fell out of her/his bed around 12:15 AM, her/his bed was not in the lowest position at the time of the fall. No staff interviews were completed as part of the investigation. At the time of the fall Resident 15 did not complaint of pain and alert monitoring began. A 3/22/23 Alert Note (monitoring after the 3/20/23 fall) indicated Resident 15's foot and ankle were observed swollen with bruising to her/his ankle by staff, the resident had uncontrolled pain even after pain medication was provided and Resident 15 was sent to the emergency room . A 3/22/23 hospital History and Physical indicated Resident 15's was diagnosed with an ankle fracture after x-rays were completed in the emergency room . Resident 15 remained in the hosptial for pain control. On 12/13/23 at 4:29 PM and 12/14/23 at 4:44 PM Staff 2 (DNS) acknowledged Resident 15's care plan at the time of the 3/20/23 fall was not followed, Resident 15's fall resulted in an ankle fracture and staff interviews were needed for a thorough investigation. b. A 10/29/23 Fall investigation revealed Resident 15 was found on the floor in the dining room at 8:57 AM (after the breakfast meal) near her/his wheelchair which was in the upright position. A new intervention for Resident 15's fall prevention was to ensure she/he did not remain alone in the dining room. No staff interviews were found. A 12/11/23 revised care plan did not include Resident 15 was to be supervised after meals. On 12/13/23 at 10:48 AM Staff 6 (LPN) confirmed she completed the 10/29/23 fall investigation and did not update Resident 15's care plan as needed. Staff 6 acknowledged, because of many new staff, care plan updates to prevents further falls for Resident 15 were important. On 12/13/23 at 3:23 PM Staff 24 (CNA) stated Resident 15's care plan was not updated to include active fall preventions which were necessary to know to prevent further falls. On 12/14/23 at 9:02 AM, 10:33 AM and 4:44 PM Staff 2 (DNS) acknowledged she needed to improve fall investigations to include staff interviews especially at the time of the fall and Resident 15's care plan was not updated as necessary after her/his 10/29/23 fall. 34703 2. Resident 134 was admitted to the facility in 2023 with diagnoses including falls and back fracture. The Fall CAA dated 6/18/23 revealed Resident 21 was a fall risk due to the need for assistance with mobility, transfers and ADLs due to self-care deficit, recent hospitalization , weakness, balance problems and pain. The resident's 7/6/23 revised care plan indicated Resident 134 required the assistance of two staff members for toileting. A 9/18/23 Quarterly MDS indicated Resident 134 required one person to assist her/him to and from the toilet due to unsteadiness and only able to stabilize with staff assistance. A 9/20/23 FRI indicated on 9/19/23 Resident 134 was assisted to stand at the toilet by Staff 21 (Former CNA) before shift change at 10:00 PM. Staff 21 left the resident standing in front of the toilet in the bathroom to give report to the oncoming shift. The night shift staff found the resident on the floor 15 minutes later. Resident 134 complained of pain related to the fall, was sent to the hospital and found to have a pelvic fracture from the fall. On 12/14/23 at 10:11 AM Staff 2 (DNS) acknowledged the resident was a fall risk, the care plan was not revised and indicated Resident 134 was two person assistance to the toilet and Staff 21 did not follow the care plan. 3. Resident 6 was admitted to the facility in 2023 with diagnoses including diabetes and respiratory failure. The 10/17/23 Admission Profile indicated Resident 6 smoked. The 10/17/23 care plan indicated Resident 6 was an independent smoker and would remain compliant with facility smoking policy. Interventions included: instruct the resident about smoking times, locations and safety concerns; staff were to observe clothing for cigarette burns and smoking supplies would be stored at the nurses' station. There was no smoking assessment or Resident 6's acknowledgement of the smoking policy found in the resident's clinical record. On 12/13/23 at 8:13 AM Resident 6 stated she/he smoked since arrival to the facility on [DATE]. Resident 6 stated she/he did not sign any paperwork related to smoking in the facility. On 12/13/23 at 12:50 PM Resident 6 was observed smoking outside alone. On 12/15/23 at 8:29 AM Staff 9 (CNA) and Staff 18 (CNA) stated they worked with the resident since she/he admitted to the facility and observed Resident 6 getting her/his smoking materials and going outside to smoke. On 12/15/23 at 9:10 AM Staff 3 (Social Service Manager) acknowledged Resident 6 was not assessed for smoking and did not sign a smoking agreement upon admission. 34667 4. Resident 23 was admitted to the facility in 2023 with diagnoses including dementia and end of life care. Records indicated Resident 23 had a history of falls and remained at risk for further falls. A review of three fall investigations dated 9/26/23, 11/5/23 and 11/26/23 revealed a lack of witness statements and/or an explanation of how the facility ruled out abuse and neglect related to Resident 23's falls. On 12/15/23 at 11:02 AM Fall investigations were reviewed with Staff 2 (DNS). Staff 2 stated she interviewed staff as part of her investigation of falls. Staff 2 added further education was needed related to the facility staff's responsibility to gather information, document and rule out abuse and neglect at the time of the fall.

Based on observation and interview it was determined the facility failed to maintain a sanitary kitchen and follow proper handwashing practices for 1 of 1 facility kitchen. This placed residents at risk for food-borne illnesses. Findings include: On 12/13/23 at 8:55 AM Staff 13 (Dietary Aide) was observed to wash her hands in a sink with dirty dishes. Staff 13's hands appeared to touch the dirty dishes in the sink before she attempted to dry her hands prior to the removal of clean dishes from the dish washer. Staff 13 stated it was difficult not to touch the dirty dishes after her hands were washed. On 12/13/23 at 11:52 AM Staff 17 (RD) acknowledged hand washing should not take place in a sink with dirty dishes and a separate hand washing sink should be used. On 12/13/23 at 1:12 PM the kitchen was observed: -The floor had a two foot by three foot outline in the vinyl flooring that was approximately one inch wide. The outline contained sections where wood underlayment was exposed. -Shelves against the wall, the top of a juice dispenser and hoses behind the juice dispenser all contained a layer of dust and grease. -A pipe was located along the base of the floor and against the wall where black debris accumulated under the pipe. On 12/13/23 at approximately 1:20 PM Staff 17 confirmed the floor was in disrepair and areas in the kitchen needed improved cleaning.

Based on interview and record review it was determined the facility failed to employ a director of food and nutrition services with the required certification for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: A 9/19/19 Nutrition and Food Service Training Program indicated Staff 4 (Dietary Manager) completed 270 contact hours of the program. On 12/12/23 at 11:05 AM Staff 4 indicated he did not yet pass the test for the nutrition program certification. On 12/13/23 at 1:35 PM Staff 1 (Administrator) stated she was only recently aware that Staff 4 did not possess the required certification as required.

Based on interview and record review, it was determined the facility failed to provide information related to the Quality Improvement Organization (QIO) for 3 of 3 sampled residents (#s 234, 235, and 236) reviewed for liability and appeal notices. This placed residents at risk for accurate QIO information. Findings include: The review of three Medicare discharged residents revealed the following: -Resident 234's services ended on 9/30/23. The NOMNC (Notice of Medicare Non-Coverage) form provided to the resident did not include QIO information. -Resident 235's services ended on 10/10/23. The NOMNC form provided to the resident did not include QIO information. -Resident 236's services ended on 10/27/23. The NOMNC form provided to the resident did not include QIO information. On 12/12/23 at 12:15 PM Staff 1 (Administrator) verified there was no documentation Resident 234, Resident 235, and Resident 236 were notified of the appropriate QIO.

Based on observation and interview it was determined the facility failed to provide a clean and well-maintained environment for 2 of 23 resident room floors. This placed residents at risk for lack of a clean and homelike environment. Findings include: On 12/12/23 at 12:38 PM room [ROOM NUMBER] was observed to have a large split and separation of the vinyl flooring revealing the wood underlayment. The flooring felt soft and spongy. On 12/14/23 at 3:33 PM room [ROOM NUMBER] was observed to have a large split and separation of the vinyl flooring revealing the wood underlayment. The flooring felt soft and spongy. On 12/15/23 at 11:58 AM Staff 5 (Environmental Service Manager) acknowledged the findings above. He stated the floors were old and needed to be replaced.

Based on interview and record review it was determined the facility failed to follow-up with residents related to their desire to formulate advance directives for 2 of 13 sampled residents (#s 4 and 20) reviewed for advance directives. This placed residents at risk for healthcare decisions in conflict with their wishes. Findings include: 1. Resident 4 was admitted to the facility in 2019 with diagnoses including heart failure and kidney disease. A 7/12/23 Social Service Progress Note indicated no advance directive was offered and Resident 4 declined to sign a declination on 7/19/19. No follow-up regarding an advance directive was found in the electronic record. An 8/7/23 Significant Change MDS revealed Resident 4 was cognitively intact. On 12/14/23 at 10:14 AM Staff 3 (Social Service Manager) stated she addressed advance directives with residents every quarter but did not document it was completed. Staff 3 acknowledged she should follow-up with Resident 4 related to her/his advance directive. 2. Resident 20 was admitted to the facility in 2022 with diagnoses including stroke and kidney failure. There was no advance directive found in Resident 20's clinical record. A 7/18/23 Annual IDT (Interdisciplinary Care Conference) meeting revealed Resident 20 had a BIMS score of 11 indicating moderate cognitive impairment. There was no indication the facility followed up with the resident related to her/his desire to execute an advance directive. On 12/14/23 at 10:14 AM Staff 3 (Social Service Manager) stated she addressed advance directives with residents every quarter but did not document it was completed. Staff 3 acknowledged she should follow-up with Resident 20 related to her/his advance directive.

Based on interview and record review it was determined the facility failed to ensure a surgical wound was monitored and assessed for 1 of 1 sampled resident (#177) reviewed for non-pressure skin. This resulted in Resident 177's surgical wound becoming infected, and the resident being hospitalized . Findings include: The facility's 4/2018 Skin at Risk Program Overview indicated: 16. Skin conditions other than pressure ulcers, etc. will be documented on the resident's treatment record. Other skin conditions (rashes, skin tears, excoriations, abrasions, bruises or surgical wounds) would be addressed with appropriate treatment orders. 17. The Non-Ulcer Skin Condition Evaluation would be completed weekly for wounds likely to result in complications including delayed wound healing or infections (examples: poorly approximated surgical wound or large skin tear, etc.). Resident 177 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 177 discharged from the facility on 10/18/21. The initial 10/5/21 Non-Pressure Skin Condition Assessment indicated the resident had a left toe scab that measured 1.5 cm x 0.5 cm x 0 cm. The note indicated there was no exudate (drainage) or odor. The wound bed had black/brown eschar (dead tissue) and necrotic tissue with normal edges for skin type. The assessment was completed by Staff 10 (LPN). An 10/5/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/10/21 Admission MDS indicated Resident 177 was cognitively intact and had surgical wound(s). During the look-back period the resident had frequent, severe pain that made it difficult for the resident to sleep and participate in ADLs. The 10/10/21 Pain CAA indicated the resident's pain was related to the left foot. Resident 177's Care Plan did not mention the left fifth toe amputation surgical wound or include interventions to monitor or prevent worsening. An 10/12/21 Physician Visit indicated the resident had left foot rest pain symptoms. The resident reported in the last month she/he had increasing rest pain symptoms in the left lower extremity. The exam was noted as deferred. There was no indication the surgeon examined Resident 177's left lower extremity. An 10/13/21 primary care physician (PCP) visit indicated the resident felt her/his pain was not well controlled and may need something for nerve pain. The exam of the left lower extremity noted no tenderness to palpitation, no [CONDITION(S)], or ecchymosis (discoloration/bruising of skin) and no pain during ROM. The assessment noted Continue Wound care to foot per the surgeon's orders. The resident's narcotic pain medication was increased. A verbal order was received on 10/14/22 to monitor the left foot, fifth toe amputation site for breakdown every shift for fragile skin. An 10/15/21 at 11:28 AM Nursing Note indicated Resident 177 had a new skin issue, a 0.5 cm x 0.5 cm blood blister on top of the left great toe. The amputation site of fifth toe was noted as covered with a dry crusty scab and no drainage or open area noted. The amputation site was left open to air. Weekly Skin Sheets indicated the following: *10/7/21: No new skin issues noted at this time. There were no measurements or description of the fifth toe amputation wound or worsening/healing noted. The note was completed by Staff 14 (LPN). *10/14/21: Open area on L foot at 5th toe amputation site. Order entered. There were no measurements or description of the fifth toe amputation wound. The note was completed by Staff 13 (LPN). *10/18/21: Left foot big toe noted red with a big toe scab and oozing clear fluids. Treatment order in place at this time. Patient to see MD today for follow up appointment. There were no measurements or description of the fifth toe amputation wound or worsening/healing noted. The note was completed by Staff 14 (LPN). The 10/2021 TAR indicated Resident 177 had the following orders: *Order implemented 10/11/21: Check skin and indicate + if a new skin condition is present and - if no new skin condition is present. Initiate skin documentation form every day shift on Monday. The TAR was marked as negative on 10/11/21 and 10/18/21. *Order implemented 10/15/21 Order: Monitor left foot, 5th toe amputation site for breakdown every day shift for fragile skin. The TAR was checked off as completed on 10/15/21 through 10/18/21. Nursing Progress Notes and Skilled Service Notes indicated the following: *10/14/21: The resident was assessed for pain. Resident had left foot pain. Intensity and frequency varied. Sometimes she/he waited too long to ask for pain medication and cried. The resident had [MEDICATION(S)] (narcotic pain medication) at 12:30 PM and was comfortable at 4:00 PM. The resident wanted to wait until later for another pill. The resident was crying at 7:00 PM and had another [MEDICATION(S)] and was feeling better at 9:00 PM. *10/15/21: The resident did not need any narcotics this shift and stated her/his left foot was feeling better today. *10/16/21: The resident had a narcotic pain medication two times that evening. The first time was before dinner, when staff saw her/him wincing when moving and then again after getting on and off the commode. The resident was crying after getting back in bed from the commode. *10/17/21: The resident was assessed for pain and reported left foot pain and back pain. The intensity and frequency varied. Pain medication provided per physician order. *10/18/21 at 11:08 AM: spoke with resident's son regarding the resident's pain. The resident stated the pain medication was not really helping but the doctor stated the resident was already on too much medication and did not want to add anything else. *10/18/21 at 2:34 PM: Received a call from the resident's PCP clinic and they sent the resident to the ER via ambulance for intractable left foot pain. *10/18/21 at 5:52 PM: Resident went out to a doctor appointment and was sent and admitted to the hospital for possible gangrene. An 10/18/21 PCP appointment note indicated the resident's family had asked for wound care by the facility and it was not provided. The resident saw the surgeon the week prior, and the PCP feared the resident was not getting better at the facility and was getting weaker. The resident's left foot was noted to have purulent (puss) drainage, was severely tender, and was not even dressed. The exam indicated the resident had severe tenderness to palpitation present to the dorsum of foot, the left fifth toe amputation site had a thick ulcer draining purulent material, and the wound was red and inflamed. The resident was unwilling to walk and was not able to stand and pivot any longer on the left lower extremity ulcer. Cultures were obtained and the resident was sent to the ED. The 10/18/21 Hospital Records indicated the resident was admitted for wound care and the left lateral foot wound status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Labs indicated the resident had local [CONDITION(S)] (infection of the bone) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . At that time the resident's toe amputation site was a small scab. Staff 10 stated the resident refused all showers and physical therapy since arrival due to pain level. The note indicated Staff 10 further stated the resident refused to be touched by staff except to be put on a bed pan and screamed in pain when touched. Staff 10 stated facility staff were unaware of wound progression on foot. An 10/20/21 Hospital Record indicated the wound was not healing and the surgeon stated he would advise an above knee amputation or hospice care for Resident 177 but would stabilize the resident for now. On 9/12/22 at 12:39 PM Witness 3 (Family Member) stated the resident had so much foot pain she/he would not lift the bedding covers at the facility so the resident was sent to the doctor. Witness 3 stated at the clinic on 10/18/21 they had to put a pad on the floor to collect the brown drainage from Resident 177's left foot. Witness 3 stated facility staff told Resident 177's family that if they moved the covers the resident would become upset, so staff were not looking at the wound. Witness 3 stated the resident had a lot of pain due to her/his left foot and stated to the family, I hurt and they are not helping. Witness 3 stated the doctor was not notified of refusals or wound concerns. Witness 3 stated Resident 177 ended up losing her/his left leg due to the infection. Interviews were conducted on 9/13/22 and 9/14/22 with Staff 13 (LPN) and Staff 14 (LPN) who were unable to recall the resident or if the resident had skin issues related to her/his fifth toe amputation site. Both Staff 13 and Staff 14 stated resident care managers (RCMs) were responsible for assessing new/worsening wounds once identified by nursing staff. On 9/13/22 at 12:01 PM and 9/14/22 at 1:04 PM Staff 10 (LPN Resident Care Manager) stated for surgical site wounds, if a wound worsened the floor nurses did the initial assessment and treatments and then RCMs measured the wounds once a week and notified the provider if worsening. Staff 10 stated she completed the initial skin assessment for Resident 177 on 10/5/21 and did not observe the left fifth toe amputation after the initial assessment. Staff 10 confirmed there was no description on 10/18/21 of the left fifth toe amputation site and stated this was due to the resident having an appointment with her/his PCP that same day. Staff 10 stated the resident experienced a lot of pain but did not want to see the facility's medical provider and there was difficulty contacting the resident's PCP for orders and appointments. Staff 10 stated the resident had relentless pain and was never not in pain. Staff 10 stated the facility did not send the resident to the ER as they were under the impression the resident wanted to be seen in-house but the resident changed her/his mind and wanted to be seen by her/his outside PCP and the on-call provider would not prescribe narcotics. Staff 10 stated she was not made aware of any changes to Resident 177's left fifth toe amputation site. On 9/15/22 at 2:09 PM and 2:31 PM Staff 2 (DNS) stated for any change from baseline to a wound, the expectation was for staff to assess, measure, and monitor until healed. Staff 2 stated staff absolutely should have measured and described the wound and how it changed. Staff 2 stated it would be hard to go from nothing on the early morning of 10/18/21 to then fully infected later that day. Staff 2 further stated for pain management, if the doctor was not available and the on-call provider was not willing to prescribe pain medications, the expectation was to send the resident to the hospital if the resident was crying out in pain or not participating in therapy due to pain. Staff 2 acknowledged Resident 177's wound worsened from baseline and became infected, resulting in hospitalization on [DATE].

Based on observation, interview and record review it was determined the facility failed to follow a care plan which resulted in a femur fracture for Resident 25. This placed residents at risk for abuse. Findings include: Resident 25 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The care plan dated 7/19/19 revealed Resident 25 required total assistance of two staff with a mechanical lift for transfers and extensive assistance of two staff for bed mobility. An Incident Report dated 2/6/20 indicated Staff 4 (CNA) witnessed Resident 25's injury. A witness statement by Staff 4 on 2/6/20 stated Resident 25 complained of knee pain after Staff 4 transferred her/him from the bed into the shower chair using a mechanical lift. After the transfer, Staff 4 proceeded to wheel Resident 25 to the shower room. Once in the shower room Staff 13 (NA) came into the room to observe. After Resident 25's shower Staff 4 and Staff 13 wheeled Resident 25 back to her/his room. Staff 4 stated he then physically lifted Resident 25 from the shower chair into her/his bed. Resident 25 was crying and agitated during the transfer. Staff 4 confirmed he was aware of Resident 25's care plan requiring a mechanical lift A witness statement on 2/6/20 by Staff 13 revealed she had observed Staff 4 physically lift and transfer Resident 25 from the shower chair into her/his bed. Staff 13 stated Resident 25 had increased agitation following the transfer. A witness statement from Staff 12 (RN Nursing Assistant Trainer) on 2/6/20 stated she came into Resident 25's room after the resident was dressed and was being transferred from the bed into a wheelchair. During this time Resident 25 was crying out please don't hurt me. Resident 25 stopped crying out once she/he was in the wheelchair. On 2/6/20 at 2:23 PM Staff 5 (LPN) assessed Resident 25 and indicated she/he was grimacing in pain and holding her/his left leg with the knee bent. After further assessment Staff 5 noted swelling, warmth and pain to the knee. On 2/7/20 at 9:33 AM the facility requested an x-ray for Resident 25. On 2/7/20 at 12:15 AM a Radiology Report confirmed Resident 25 sustained a left femur fracture. A FRI received by the State agency on 2/7/20 indicated Resident 25 sustained an injury of unknown origin. On 2/12/20 at 11:00 AM Resident 25 was not interviewable due to severe cogitative loss. Resident 25 was observed lying in bed with no signs of pain or discomfort. On 2/12/20 at 1:55 PM Staff 4 confirmed he was aware of Resident 25's transfer status and care plan and acknowledged he failed to follow the care plan. On 2/13/20 at 1:03 PM Staff 3 (CNA) confirmed on 2/6/20 she became aware of Resident 25's increased pain and the resident showed visible signs of pain. In an interview on 2/14/20 at 10:30 AM Witness 3 (family) indicated she became aware of Resident 25's femur fracture on 2/12/20. On 2/14/20 at 9:42 AM Staff 2 confirmed Staff 4 did not follow the care plan for transfers for Resident 25.

Based on interview and record review it was determined the facility failed to revise the care plan related to pressure ulcers for 2 of 5 sampled residents (#s 39 and 2) who were reviewed for pressure ulcers, discontinued hospice services and range of motion (ROM). This resulted in Resident 39 developing multiple pressure ulcers including two preventable unstageable pressure ulcers. Findings include: The facility's November 2015 Initial Ulcer Assessment policy indicated an Initial Ulcer Assessment was to be completed when a new skin issue was identified. An evaluation of the wound, plan, treatment and interventions was to be documented and the care plan was to be updated as appropriate. The National Pressure Ulcer Advisory Panel defined Stage I, Stage II and unstageable pressure ulcers as follows: Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury. Unstageable: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. 1. Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility in December 2015. Resident 39's 10/5/15 Admission Care Plan indicated the resident had skin breakdown. The Admission Care Plan did not indicate the use of pressure reduction devices on the bed or chair or to assist the resident with repositioning every two hours. An Initial Ulcer Assessments dated 10/23/15 indicated Resident 39 developed a 3 cm by 2 cm Stage I pressure ulcer to the left buttock. Resident 39's clinical record revealed no new wound treatment or care plan interventions to address the new pressure ulcer. An Incident Note and Nursing Notes dated 10/9/15 and 10/10/15 indicated Resident 39 fell by the resident's bed and was taken to the hospital with a possible right lower leg fracture. The resident returned to the facility the same day with a right tibia and fibia (fibula) fracture (the tibia and fibula are the two long bones in the lower leg below the knee). The resident had an immobilizer in place to the right leg. Resident 39's comprehensive care plan was not revised to include interventions to monitor the resident's skin around and under the immobilizer to the right leg for skin breakdown. Resident 39's 10/9/15 Bedside Care Plan indicated the resident required staff assistance with bed mobility, however, the Bedside Care Plan did not indicate the use of pressure reduction devices on the bed or chair, or to assist the resident with repositioning every two hours. An Initial Ulcer assessment dated [DATE] indicated Resident 39 developed a 3 cm by 1.7 cm unstageable pressure ulcer to the right inner ankle and the resident's brace was the probable cause of the wound. Resident 39's care plan was not revised with interventions to monitor or prevent further skin breakdown related to the right leg immobilizer. A 10/25/15 Nursing Note indicated Resident 39 developed a 2.3 cm by 2 cm Stage II pressure ulcer to the right Achilles area with a moderate amount of bloody drainage and was probably caused by pressure from the right lower leg immobilizer. A dressing was placed between the wound and the immobilizer to relieve the pressure. No Initial Ulcer Assessment was found for this wound in the resident's clinical record. An 11/1/15 Nursing Note indicated the wound on Resident 39's right Achilles had slough with [DIAGNOSES REDACTED] (redness that could be indicative of infection). The presence of slough indicated the wound had deteriorated from a Stage II to unstageable. An 11/3/15 Skin/Wound Note indicated Resident 39's right Achilles wound was 2 (cm) by 2.3 (cm), was irregular in shape and was covered by slough with a moderate amount of bloody drainage. The area around the wound was reddened and some soggy areas noted. The resident was painful during the dressing change. A change in treatment orders was requested. An 11/10/15 Skin/Wound Note indicated Resident 39's right Achilles wound was 1.4 (cm) by 2 cm, covered with slough and there was no redness. The note did not indicate if any other wound assessment characteristics were present such as drainage, tunneling, undermining, or how it compared to previous assessments. An 11/17/15 Skin/Wound Note indicated Resident 39's right Achilles wound was 2 cm by 1 cm and covered by slough. The note did not indicate if any other wound assessment characteristics were present such as redness, drainage, tunneling, undermining, or how it compared to previous assessments. On 1/15/16 at 11:17 am Staff 7 (Physical Therapist/Wound Care Specialist) stated the cause of the wound was determined to be from the resident's leg brace. A 12/7/15 Nursing Note indicated Resident 39 had a skin opening on the right side of hip. The note did not indicate the cause of the wound, size, drainage, or other pertinent wound characteristics. (An open wound over a boney prominence such as the hip is highly indicative of at least a Stage II pressure ulcer.) In an interview on 1/15/16 at 11:59 am with Staff 2 (DNS) and Staff 8 (Regional Nurse Consultant), Staff 2 stated the facility's wound charting was not consistent. When asked about Resident 39's hip wound regarding the type of wound, the cause, assessment and tracking of the wound Staff 2 stated she was baffled. She stated she could not locate a fax for the hip wound (communication to the physician). Staff 2 acknowledged the care plan was not updated with new interventions such as daily monitoring of Resident 39's skin under and around the brace to prevent further skin breakdown. Staff 2 acknowledged the Bedside Care Plan should have included interventions including repositioning. She stated the resident had an air mattress but acknowledged it was not on the care plan. Refer to F-314 example 1 2. Resident 2 was admitted to the facility in 9/15 with [MEDICAL CONDITION] and hospice services. The resident's admission MDS dated [DATE] indicated the resident had a terminal prognosis, had no functional rehabilitation potential, and was dependent on staff for bed mobility. On 10/9/15 hospice services were discontinued by the physician due to the resident was no longer terminal. On 11/20/15 the resident was discontinued from OT with a recommendation for the facility to provide right upper extremity massage three days per week and an upper extremity exercise program. On 1/14/16 the resident's care plan was dated as revised on 1/12/16. The care plan contained no interventions related to right upper extremity massage or an upper extremity exercise program. The care plan still indicated the resident had a terminal prognoses, was receiving hospice and palliative care and directed staff to keep hospice aware of pain management issues, work cooperatively with hospice to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met, and provide care per hospice guidelines for the resident's chronic. On 1/14/16 at 4:00 pm Staff 2 (DNS) verified the resident's care plan had not been updated related to hospice services or ROM.

Based on interview and record review, it was determined that the facility failed to to comprehensively assess pressure ulcers and pressure ulcer risk, hydration, behaviors and emotional status, urinary catheter, and [MEDICAL CONDITION] drug use for 5 of 23 residents (#s 22, 39, 41, 52, and 2 ) for whom assessments were reviewed. This resulted in Resident 39 developing multiple pressure ulcers including two preventable unstageable pressure ulcers. Findings include: The National Pressure Ulcer Advisory Panel defined Stage I, Stage II and unstageable pressure ulcers as follows: Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury. Unstageable: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. 1. Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility in December 2015. Resident 39's 10/5/15 Admission Care Plan indicated the resident had skin breakdown. Resident 39's 10/5/15 Admission Profile indicated the resident had a 2.7 cm by 1.2 cm ulcer on the left front lower leg. The assessment did not indicate the ulcer was not pressure related. Two Initial Ulcer Assessments dated 10/6/15 indicated Resident 39 had a 5 cm by 2.5 cm Stage I pressure ulcer related wound on the right buttock and a 6 cm by 3 cm Stage I pressure related wound to the left buttock which were present on admission to the facility on [DATE]. An Incident Note and Nursing Notes dated 10/9/15 and 10/10/15 indicated Resident 39 fell by the resident's bed and was taken to the hospital with a possible right lower leg fracture. The resident returned to the facility the same day with a right tibia and fibia (fibula) fracture (the tibia and fibula are the two long bones in the lower leg below the knee). The resident had an immobilizer in place to the right leg. Resident 39's 10/15/15 MDS indicated the resident was at risk for developing pressure ulcers and the resident had one unhealed Stage I pressure ulcer. The resident had no diabetic ulcers or any other open [MEDICAL CONDITION]. The resident did not have pressure reducing devices for bed or chair and was not on a turning or repositioning program. Resident 39's 10/15/15 Pressure Ulcer CAA failed to identify the problem, pertinent risk factors, devices that could cause pressure (such as the resident's leg immobilizer) and the impact on the resident. The assessment was incomplete. An Initial Ulcer assessment dated [DATE] indicated Resident 39 developed a 3 cm by 1.7 cm unstageable pressure ulcer to the right inner ankle and the resident's brace was the probable cause of the wound. An Initial Ulcer Assessments dated 10/23/15 indicated Resident 39 developed a 3 cm by 2 cm Stage I pressure ulcer to the left buttock. A 10/25/15 Nursing Note indicated Resident 39 developed a 2.3 cm by 2 cm Stage II pressure ulcer to the right Achilles area with a moderate amount of bloody drainage and was probably caused by pressure from the right lower leg immobilizer. A dressing was placed between the wound and the immobilizer to relieve the pressure. An 11/1/15 Nursing Note indicated the wound on Resident 39's right Achilles had slough with [DIAGNOSES REDACTED] (redness that could be indicative of infection). The presence of slough indicated the wound had deteriorated from a Stage II to unstageable pressure ulcer. An 11/3/15 Skin/Wound Note indicated Resident 39's right Achilles wound was 2 (cm) by 2.3 (cm), was irregular in shape and was covered by slough with a moderate amount of bloody drainage. The area around the wound was reddened and some soggy areas noted. The resident was painful during the dressing change. A 12/7/15 Nursing Note indicated Resident 39 had a skin opening on the right side of her/his hip. The wound was cleaned and covered with a dressing. The note did not indicate the cause of the wound, size, drainage, or other pertinent wound characteristics. (An open wound over a boney prominence such as the hip is indicative of at least a Stage II pressure ulcer.) On 1/15/16 at 11:17 am Staff 7 (Physical Therapist/Wound Care Specialist) stated she became involved in treating Resident 39's right Achilles unstageable pressure ulcer on 11/20/15. She stated the cause of the wound was determined to be from the resident's leg brace and nursing staff were already putting padding in the brace. In an interview on 1/15/16 at 11:59 am with Staff 2 (DNS) and Staff 8 (Regional Nurse Consultant), Staff 2 stated the facility's wound charting was not consistent. Staff 8 agreed the resident's right Achilles wound went from a Stage II to unstageable on 11/1/15. Staff 8 acknowledged Resident 39's Pressure Ulcer CAA was not comprehensive. Refer to F-314 example 1 2. Resident 41 was admitted to the facility in 12/2015 with [DIAGNOSES REDACTED]. The resident's 12/21/15 Admission Progress note indicated the resident's right heel was soft and scabbed. The resident's 12/21/15 Admission Profile revealed the resident had [MEDICAL CONDITION] of both lower extremities, required extensive assistance with bed mobility, and had pressure and non-pressure skin ulcers on her/his coccyx and right heel. The resident's 12/28/15 Admission MDS indicated the resident was at risk for pressure ulcers but did not indicate the resident had a pressure ulcer. The Pressure Ulcer Care Area was triggered for comprehensive assessment and included a note of boggy right heel. There was no analysis or assessment of the resident's existing pressure ulcer or the resident's risk factors. During interview on 1/14/16 at 4:00 pm Staff 2 (DNS) verified the lack of comprehensive assessment of Resident 41's risk for pressure ulcers. 3. Resident 52 was admitted to the facility in December 2015 with [DIAGNOSES REDACTED]. The resident's Admission MDS indicated the resident did not have a skin ulcer on admit but identified the resident was at risk for pressure ulcers and the Pressure Ulcer Care Area was triggered for comprehensive assessment. The CAA contained boxes checked with the information transferred from the MDS and referral was made multiple times to a history and physical dated 12/24/15, before the resident's admission to the facility. The history and physical included no information related to the resident's skin or potential for pressure ulcers. The CAA contained no analysis or assessment of the resident's contributing factors or risk factors. On 1/14/16 at 4:00 pm Staff 2 (DNS) verified the lack of comprehensive assessment of Resident 52's risk for pressure ulcers. 4. Resident 2 was admitted to the facility in 9/2015 with [DIAGNOSES REDACTED]. The resident had an indwelling suprapubic urinary catheter in place. The resident's 9/29/15 Admission MDS identified the use of an indwelling catheter and was triggered for a comprehensive assessment of the care area. The Urinary Incontinence and Indwelling Catheter CAA contained boxes checked from the information transferred from the MDS, but there was no analysis of those findings and how it pertained to Resident 2. On 1/14/16 at 4:00 pm Staff 2 (DNS) verified the lack of comprehensive assessment of the residents catheter use. 5. Resident 22 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Resident 22's October and November 2015 MARs indicated the resident received [MEDICATION NAME] (an antipsychotic medication) 12.5 mg BID for [MEDICAL CONDITION]. Resident 22's [MEDICAL CONDITION] Drug CAA dated 11/5/15 revealed she/he used an antipsychotic medication. No other information related to Resident 22's [MEDICAL CONDITION] medication use, including the resident's behaviors, name/dose/frequency of medication, non-drug interventions, pertinent clinical [DIAGNOSES REDACTED]. On 1/15/16 at 12:43 pm Staff 1 (Administrator) confirmed the CAA was not comprehensive.

Based on observation, interview and record review it was determined the facility failed to provide care and treatment to prevent the development of pressure ulcers for 4 of 5 sampled residents (#s 39, 68, 41 and 52) who were reviewed for pressure ulcers. This resulted in Resident 39 developing two preventable unstageable pressure ulcers. Findings include: The facility's November 2015 Initial Ulcer Assessment policy indicated an Initial Ulcer Assessment was to be completed when a new skin issue was identified. The assessment was to document the date it was identified, if it was present on admission, site, type, size, depth and stage. Also wound characteristics such as infection, undermining, tunneling, wound edges, pain, drainage, wound bed, surrounding tissue and wound status were to be documented. An evaluation of the wound, plan, treatment and interventions was to be documented and the care plan was to be updated as appropriate. The facility's November 2015 Weekly Ulcer Evaluation policy indicated it was the facility's policy to monitor the progress of wound healing weekly to ensure care and services are provided to promote healing and prevent infection. The policy indicated a Weekly Ulcer Evaluation was to be completed weekly for each ulcer present. The Weekly Ulcer Evaluation was to document wound characteristics similar to the Initial Ulcer Assessment. The National Pressure Ulcer Advisory Panel defined stage 1, stage 2 and unstageable pressure ulcers as follows: Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury. Unstageable: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. 1. Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility in December 2015. Resident 39's 10/5/15 Admission Care Plan indicated the resident had skin breakdown. The Admission Care Plan did not indicate the use of pressure reduction devices on the bed or chair or to assist the resident with repositioning every two hours. a. Resident 39's 10/5/15 Admission Profile indicated the resident had a 2.7 cm by 1.2 cm ulcer on the left front lower leg. The assessment did not indicate the ulcer was not pressure related. An 11/16/15 Physician's Order Note indicated a new treatment order was received for Resident 39's left leg including antibiotic gel and gauze once a day. The order failed to indicate what specific wound or location to the left leg was to be treated. Resident 39's clinical record revealed no comprehensive weekly wound monitoring or assessments for the resident's left front lower leg ulcer. On 1/15/16 at 11:59 am Staff 2 (DNS) stated the facility's wound charting was not consistent. b. Two Initial Ulcer Assessments dated 10/6/15 indicated Resident 39 had a 5 cm by 2.5 cm Stage I pressure ulcer related wound on the right buttock and a 6 cm by 3 cm Stage 1 pressure related wound to the left buttock, which were present on admission to the facility on [DATE]. A fax to the physician dated 10/7/15 indicated Resident 39 admitted to the facility with sores to buttocks and requested orders to clean, and cover them with a dressing every three days. The request failed to provide an adequate description of the wounds for the physician to make an informed treatment decision. The physician agreed with the requested treatment orders on 10/13/15. The order was noted by the facility on 10/13/15. Resident 39's October 2015 TAR indicated the ordered wound treatment to the buttocks was started on 10/14/15. This was nine days after the resident was admitted to the facility with the wounds. Resident 39's clinical record revealed no comprehensive weekly wound monitoring or assessments for the resident's left and right buttocks wounds. On 1/15/16 at 11:59 am Staff 2 (DNS) acknowledged there was no documented evidence of treatment to Resident 39's buttocks wounds until nine days after the resident was admitted to the facility. c. An Initial Ulcer Assessments dated 10/23/15 indicated Resident 39 developed a 3 cm by 2 cm Stage I pressure ulcer to the left buttock. Resident 39's clinical record revealed no weekly wound monitoring or assessments for the resident's buttocks wound. Resident 39's clinical record revealed no new wound treatment or care plan interventions to address the new pressure ulcer. On 1/15/16 at 11:59 am Staff 2 (DNS) stated the facility's wound charting was not consistent. d. An Incident Note and Nursing Notes dated 10/9/15 and 10/10/15 indicated Resident 39 fell by the resident's bed and was taken to the hospital with a possible right lower leg fracture. The resident returned to the facility the same day with a right tibia and fibia (fibula) fracture (the tibia and fibula are the two long bones in the lower leg below the knee). The resident had an immobilizer in place to the right leg. Resident 39's comprehensive care plan was not revised to include interventions to monitor the resident's skin around and under the immobilizer to the right leg for skin breakdown. Resident 39's 10/9/15 Bedside Care Plan indicated the resident required staff assistance with bed mobility, however, the Bedside Care Plan did not indicate the use of pressure reduction devices on the bed or chair, or to assist the resident with repositioning every two hours. Resident 39's 10/15/15 Pressure Ulcer CAA failed to identify the problem, pertinent risk factors, devices that could cause pressure and the impact on the resident. Other than a few check boxes the assessment was blank. An Initial Ulcer assessment dated [DATE] indicated Resident 39 developed a 3 cm by 1.7 cm unstageable pressure ulcer to the right inner ankle and the resident's brace was the probable cause of the wound. Resident 39's October, November and December 2015 TARs revealed no treatment in place for the unstageable pressure ulcer on the resident's right inner ankle. Resident 39's clinical record revealed no comprehensive weekly wound monitoring or assessments for the resident's right inner ankle wound. Resident 39's care plan was not revised with interventions to monitor or prevent further skin breakdown related to the right leg immobilizer. On 1/15/16 at 11:59 am Staff 2 (DNS) acknowledged there was no documented evidence of treatment or weekly wound tracking to the resident's right inner ankle unstageable pressure ulcer. e. A 10/25/15 Nursing Note indicated Resident 39 developed a 2.3 cm by 2 cm Stage II pressure ulcer to the right Achilles area with a moderate amount of bloody drainage and was probably caused by pressure from the right lower leg immobilizer. A dressing was placed between the wound and the immobilizer to relieve the pressure. No Initial Ulcer Assessment was found for this wound in the resident's clinical record. A 10/28/15 Nursing Note indicated new treatment orders for the right Achilles Stage II wound were received. This was three days after the wound was identified. An 11/1/15 Nursing Note indicated the wound on Resident 39's right Achilles had slough with [DIAGNOSES REDACTED] (redness that could be indicative of infection). The presence of slough indicated the wound had deteriorated from a Stage II to unstageable. An 11/3/15 Skin/Wound Note indicated Resident 39's right Achilles wound was 2 (cm) by 2.3 (cm), was irregular in shape and was covered by slough with a moderate amount of bloody drainage. The area around the wound was reddened and some soggy areas noted. The resident was painful during the dressing change. A change in treatment orders was requested. A faxed order noted on 11/4/15 indicated new treatment orders to Resident 39's right Achilles including cleanse, apply [MEDICATION NAME] (antimicrobial wound gel), apply skin prep to the area around the wound and cover with a foam dressing daily and as needed. An 11/10/15 Skin/Wound Note indicated Resident 39's right Achilles wound was 1.4 (cm) by 2 cm, covered with slough and there was no redness. The note did not indicate if any other wound assessment characteristics were present such as drainage, tunneling, undermining, or how it compared to previous assessments. An 11/17/15 Skin/Wound Note indicated Resident 39's right Achilles wound was 2 cm by 1 cm and covered by slough. The note did not indicate if any other wound assessment characteristics were present such as redness, drainage, tunneling, undermining, or how it compared to previous assessments. An 11/18/15 Physician's Order Note indicated a new treatment order was received for Resident 39's right Achilles including wound team to debride (removal of dead or adherent tissue). No comprehensive weekly wound monitoring or assessments for the resident's right Achilles wound was found in Resident 39's clinical record. On 1/15/16 at 11:17 am Staff 7 (Physical Therapist/Wound Care Specialist) stated she became involved in treating Resident 39's right Achilles unstageable pressure ulcer on 11/20/15. This was 19 days after the wound was identified as unstageable. She did not know why there was a delay in getting her involved in treating the wound. She stated the cause of the wound was determined to be from the resident's leg brace and nursing staff were already putting padding in the brace. Staff 7 stated she noticed a superficial wound on the resident's left leg but she was not treating it. She acknowledged her wound assessment notes were not in the resident's clinical record. In an interview on 1/15/16 at 11:59 am with Staff 2 (DNS) and Staff 8 (Regional Nurse Consultant), Staff 2 stated the facility's wound charting was not consistent. Staff 8 agreed the resident's right Achilles wound went from a Stage II to unstageable on 11/1/15. Staff 2 acknowledged there was a 19 day delay in getting Staff 7 involved in treating the wound. Staff 2 acknowledged the care plan was not updated with new interventions such as daily monitoring of Resident 39's skin under and around the brace to prevent further skin breakdown. Staff 2 acknowledged the Bedside Care Plan should have included interventions including repositioning. She stated the resident had an air mattress but acknowledged it was not on the care plan. f. A 12/7/15 Nursing Note indicated Resident 39 had a skin opening on the right side of hip. The wound was cleaned and covered with a dressing. The note did not indicate the cause of the wound, size, drainage, or other pertinent wound characteristics. (An open wound over a boney prominence such as the hip is highly indicative of at least a Stage II pressure ulcer.) Resident 39's December 2015 TAR revealed no treatment for [REDACTED]. Resident 39's clinical record revealed no Initial Ulcer Assessment or weekly wound monitoring or assessments for this wound. On 1/15/16 at 11:59 am Staff 2 (DNS) stated the facility's wound charting was not consistent. When asked about Resident 39's hip wound regarding the type of wound, the cause, assessment and tracking of the wound Staff 2 stated she was baffled. She stated she could not locate a fax for the hip wound (communication to the physician). g. A 12/10/15 Nursing Note indicated Resident 39's right calf ulcer was resolved. Resident 39's December 2015 TAR revealed no treatment for [REDACTED]. No Initial Ulcer Assessment or documentation regarding the onset, treatment or monitoring of an ulcer to Resident 39's right calf was found in the resident's clinical record. On 1/15/16 at 11:59 am Staff 2 (DNS) stated the facility's wound charting was not consistent. 2. Resident 68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/12/16 at 10:49 am Staff 2 (DNS) stated Resident 68 admitted to the facility with a Stage III pressure ulcer. Resident 68's 12/2/15 hospital Discharge summary and the History and Physical did not identify any skin breakdown or treatments for skin issues. The Admission Profile dated 12/2/15 did not identify any pressure areas on the resident. The non-pressure skin condition did describe a 3 inch superficial open area without drainage on the coccyx and a 0.2 cm open area to the right buttock. there was no evidence the areas on the buttock were assessed. Resident 68's Admission MDS dated [DATE] indicated the resident had no pressure ulcers. The pressure ulcer CAA indicated no actual ulcer present at this time. The Nutritional CAA did not include nutritional needs related to a pressure ulcer. A therapy progress note dated 12/8/15 indicated Resident 68's sacral/coccyx wound was being treated by nursing and therapy (Staff 7, PTA/wound Care Specialist) was not needed at that time. On 12/10/15 the therapist noted a new blister on left dorsal foot and the physician ordered [MEDICATION NAME] of [MEDICATION NAME]. Nursing notes dated 12/26/15 described the area on Resident 68's coccyx as worsened with two black spots the size of quarters. A fax would be sent to the physician to request an assessment by the wound care specialist. On 1/13/16 at 10:01 am with Resident 68's permission an RN surveyor observed the dressing change to the coccyx. Staff 5 (LPN) stated she usually was the one who remembers to measure wounds and was not aware of weekly wound rounds. On 1/13/16 at 11:07 am Staff 2 (DNS) stated the weekly wound rounds were done by herself with Staff 7 (PTA/Wound Care Specialist) Staff 2 had no record of Resident 68's weekly wound monitoring in her skin book. She stated that was probably due to the resident being on hospice (entered hospice on 1/4/16). Staff 2 stated Resident 68 and Resident 3 were in same room and both had Stage III sacral pressure ulcers and heel wounds, on admission. She thought staff were getting confused. On 1/13/15 a nurses note indicated the coccyx wound was 7.6 cm long, 6.7 cm wide with periwound reddened, the wound bed with firmly adhered with black and tan covering and had a foul odor indicating the pressure ulcer was unstagable. On 1/15/16 at 10:35 am Staff 7 (PTA/Wound Care Specialist) stated she had her own skin notebook with wound measurements, but she stated she had not followed Resident 68 and had no record of the wounds. Staff 7 stated she kept wound notes in the electronic health records under therapy notes. She said the facility was working on changing the system as documenting skin issues had been a challenge to go from paper to electronic health records. On 1/15/16 at 12:50 pm Staff 8 (Regional RN) stated staff were to send him all the skin monitoring sheets each week and he reviewed the progress or lack of and recommended changes when needed. Staff 8 had no evidence of Resident 68's pressure ulcers. He stated all new residents were reviewed by RD for nutritional needs and would need to know of any skin breakdown. He stated when a pressure ulcer was acquired in the facility they would be referred to Nutritional At Risk (NAR) to be followed. A note by the RD dated 1/10/15 indicated the resident was referred to the NAR committee on 1/10/16. On 1/15/16 at 10:34 am Staff 2 (DNS) said she looked at Resident 68's dorsal foot the day before and Resident 68 told her it was a hard callous that was chronic for a long time and told Staff 2 sometimes the doctor would grind it off. She said the resident would be referred to the wound care specialist for the coccyx wound even though the resident was now on hospice. 3. Resident 41 was admitted to the facility in 12/2015 with [DIAGNOSES REDACTED]. The resident's 12/21/15 Admission Profile revealed the resident had [MEDICAL CONDITION] of both lower extremities, required extensive assistance with bed mobility, and was noted to have two skin conditions. The resident's coccyx was noted as red and intact and very tender to touch. There was no measurement of the coccyx red area. The resident's right heel was noted as very soft and dry skin 2.5 cm by 2.5 cm. The resident's 12/21/15 Admission Note indicated the right heel was soft and scabbed and indicated it was a high risk condition but did not identify the measures implemented. The resident's red coccyx was not identified. The resident's 12/28/15 Admission MDS indicated the resident was at risk for pressure ulcers but did not indicate the resident had a pressure ulcer on admit. The Pressure Ulcer CAA (Care Area Assessment) included a note of boggy right heel and referred to a history and physical dated 12/16/15. There was no supporting documentation, analysis or assessment of the resident's existing pressure ulcer or the resident's risk factors for pressure ulcers. The history and physical dated 12/16/15, five days before admission to the facility, included a Review of Systems that identified the resident's skin was Negative. The physical exam indicated the resident's skin was warm and dry but did not identify the right heel pressure ulcer. The resident's full care plan, initiated 12/28/15, identified the resident had a self-care deficit and directed staff to monitor/document/report any signs and symptoms of immobility such as skin breakdown. The care plan also identified the resident had potential for skin breakdown due to immobility and interventions included for staff to float heels. A progress note dated 1/10/16 at 11:53 am, indicated the resident had a 1 1/4 x 1 inch sore on the outer left heel. Staff 3 (LPN) wrote she put a boot on the resident's left foot and put wheel chair leg lifts on the wheelchair. The sore was noted to look old, the resident denied pain, and had [MEDICAL CONDITION] to both feet. Staff 3 also wrote she left a note for the Nurse Practitioner (NP). There was no identification of the type or stage of the wound. On 1/10/16 at 4:30 pm the resident was observed lying flat on her/his bed covered with a blanket. On 1/11/16 the resident was observed in a wheelchair with elevated foot rests wearing a left foot boot while at breakfast and lunch. On 11/11/16 at 3:15 pm Staff 2 (DNS) inaccurately stated during interview the resident did not have a pressure ulcer. On 1/13/16 at 11:54 am Staff 5 (LPN) stated she applied [MEDICATION NAME] of [MEDICATION NAME] to the resident's heel in the morning. She verbally described the resident's left heel as dark in color, with a callus, and part of the skin peeled off today. Staff 5 showed this surveyor the note written to the NP on 1/10/16 hanging on a clipboard in the nurse's station. Staff 5 stated it was the facility's routine process to put notes on the clipboard for notifying the NP since he visited the facility weekly. Review of the resident's medical record on 1/14/16 indicated there was no physician order for [REDACTED]. On 1/14/16 the resident's bedside care plan, dated 12/30/15, included directions to float the resident's heels and have her/him up for meals but did not include the left foot boot or wheel chair leg lifts. On 1/14/16 at 10:35 am the treatment to the resident's left lateral/posterior heel was observed with Staff 5. Staff 5 removed a pillow-type boot that was strapped on the resident's foot/ankle. The boot had a gel-like firmer surface on the interior of the back. The resident had a pillow under her/his left foot that extended past and in direct contact with the resident's heel. The wound had a dark tissue covering and was irregular in shape. Staff 5 cleansed the area, applied [MEDICATION NAME] of [MEDICATION NAME] and a dressing. Staff 5 verified the resident's heel was directly on the pillow and not being floated as directed in the care plan. Staff 5 also verified the firmer gel-like surface in the boot rested directly on the resident's wound. The facility's Skin & Wound Care protocol included descriptions and identified treatments for skin care. The use of [MEDICATION NAME] of [MEDICATION NAME] was not in the protocol for any skin or wound treatment. On 1/14/15 at 4:00 pm Staff 2 (DNS) verified the new ulcer noted on 1/10/16 should have been called to the Nurse Practitioner for treatment orders and not just a note left on the clipboard. Staff 2 also verified the facility protocol for new wounds was not followed, there was no physician order to treat the resident's left heel wound and the use of [MEDICATION NAME] of [MEDICATION NAME] was not part of the Skin & Wound Care protocol. 4. Resident 52 was admitted to the facility in 12/15 with [DIAGNOSES REDACTED]. A progress note on 1/1/16 at 11:50 am indicated the resident had a 1/2'' by 1/8 skin tear above her/his coccyx. The area was cleansed and a gauze dressing applied. The resident also had a red swollen scrotum. There was no indication the physician was notified and no further assessment of the area. A 1/4/15 progress note indicated the facility initiated weekly skin checks that directed staff to document progress notes and complete a skin documentation form when a new condition was present. The resident's 1/5/16 Admission MDS indicated the resident had no pressure ulcers but was identified at risk for development of pressure ulcers. The only documentation in the pressure ulcer CAA was a referral to a 12/24/15 History and Physical that had no information about or assessment of the resident's skin or risk for breakdown. The resident's care plan, dated 1/8/16, identified the resident was at risk for pressure ulcers related to diabetes and directed staff to educate the resident/family/caregivers as to causes of skin breakdown including: transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. It also directed staff to follow facility policies/protocols for the prevention/treatment of [REDACTED]. On 1/14/16 at 9:06 am the resident was observed on top of her/his lowered bed in a darkened room. The bed had a trapeze bar, the head of the bed was slightly elevated and the resident was watching TV located at the foot of the bed. Staff 5 completed the dressing change and described the open area as 0.6 cm Stage II crater with macerated moist white edges. On 1/14/16 the resident's 1/2016 treatment record included no new skin condition or treatment orders. On 1/14/16 at 11:33 am there was no assessment of the resident's coccyx Stage II pressure ulcer in the resident's medical record or physician order to treat the area. On 1/14/16 at 4:00 pm Staff 2 (DNS) verified the pressure ulcer was not assessed, the physician had not been notified, and the resident's care plan had not updated.

Based on observation, interview and record review it was determined that the facility failed to assess the potential for skin breakdown related to wearing a back brace and to implement interventions to prevent a pressure ulcer for 1 of 2 sampled residents (#8) who had pressure ulcers. Resident 8 acquired an unstageable pressure ulcer on her spine. Findings include: Resident 8 had been in the facility for one week prior to the survey. She was there for physical therapy following a fall that resulted in a fracture to her spine. The admitting orders dated 11/10/10 indicated a back brace was to be worn at all times. According to the resident's Bedside Care Plan dated 11/10/10 she was alert and oriented, walked with assistance and used a front-wheeled walker. The Pressure Ulcer Risk Evaluation dated 11/13/10 identified the resident to be at low to moderate risk for pressure ulcers. There was a check-off list with risk factors, that included wearing a cast or splint, which was blank. There was no assessment of the brace. Interventions included a pressure reduction mattress, weekly skin assessment, weekly weights, meal monitoring and position changes as "the resident would allow." Her skin was intact at that time. On 11/16/10 at 3:55 pm Resident 8 was in her bed with the head of her bed up. Her spouse was at her side. She had a soft Velcro back brace around her torso. She stated she wore the brace all the time. She stated she had a shower the other day and staff removed her brace. She stated that she was receiving good care and had no complaints. She stated that a sore was found on her spine the day before and staff were aware and treating it. She knew the sore was caused by having to wear the back brace all the time and from sliding up and down in bed. She stated she wore a hospital gown over the brace. Resident 8's November 2010 TAR had an entry directing nursing staff "Brace on at all times pad back with ABD pad (a padded gauze dressing)." The instruction was listed as "information only." On 11/17/10 at 10:55 am Staff 4 (LPN) stated she made the entry in the TAR to put ABD pads under the back brace. She said she should have written for each shift to check the ABD pad for placement and document if it had been done rather than to write "information only." She agreed the padding was not being applied and the brace caused the resident's skin to break down. On 11/17/10 at 11:05 am Staff 9 (CNA) stated that she regularly assisted the resident on and off of the bed pan. She stated she had not seen any padding under the back brace. At 12:50 pm Staff 6 (RN) stated that she assessed Resident 8 after she was admitted . She did not assess the back brace as a potential for skin breakdown. She stated she now realized the problem (in not assessing the brace). She stated the ABD dressing was not being monitored. On 11/17/10 at 2:05 pm Staff 3 (RN) stated she saw an ABD pad on Resident 8's back from the hospital. The pad had not been taped down and had moved around. She stated the nursing order in the TAR should have indicated the ABD pad was to be checked each shift. On 11/17/10 at 10:15 am Staff 1 (DNS) stated she heard about the pressure ulcer the day before. She spoke to the physical therapist about the brace needing to come off. She described the ulcer as deep tissue with a 2 cm open area that she thought was a stage 3. Staff 1 stated the brace had a steel rod running down the back. On 11/17/10 at 10:05 Witness 1 (spouse) stated that he stayed by the resident's side from morning until night every day. He stated he did not see any pad nor was he aware of staff putting any padding on the resident's back. He stated three days (or so) ago he brought in the tee-shirts she could wear instead of the the hospital gown so the resident's skin would not be against the brace. Witness 1 stated after he brought the tee-shirts in staff removed the brace every other day to change her tee-shirt.