Every finding on record at Legacy Nursing and Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to properly thaw ground beef and turkey in the sink, under running water, in its kitchen on 02/10/2026.2. The facility failed to properly store, label, and date all food items located in the facility refrigerators, freezers and in the dry food pantry area on 02/10/2026 and 02/11/2026. 3. The facility failed to discard outdated food items located in the refrigerator and dry food pantry on 02/10/2026 and 02/11/2026. 4. The facility failed to ensure that dietary staff wore hair restraints (e.g. beard restraints) to prevent hair from contacting food, according to the current Food Code on 2/11/2026. 5. The facility failed to properly handle raw chicken while thawing in the sink without a container on 02/11/2026. 6. The facility failed to ensure the cook used proper hand sanitizing after removing gloves in the kitchen. 7. The facility failed to ensure trash cans had lid covers. 8. The facility failed to ensure ADON sanitized or washed her hands prior to touching contaminated surfaces (wheelchair, chair and clothes) prior to touching Resident #66's food and prior to feeding Resident #66 on 02/10/2026. These failures could place residents who received meals from the kitchen at risk of foodborne illnesses.Observation during the initial tour of the kitchen on 02/10/2026 beginning at 8:54 AM revealed the following: Kitchen area: 3 trash cans no lids 1 large bin of sugar no discard/use by date in kitchen food preparation area 1 large bin of flour, no discard/use by date in kitchen food preparation areaWalk in Refrigerator: 1 storage bag of deli style turkey, no name, no date, no discard/use by date 1 storage bag of shredded yellow cheese, no name, no date, no discard/use by date 1 opened bag of white sliced cheese, no date, no discard/use by date 1opened bag of yellow sliced cheese, no date, no discard/use by date 1 storage bag of boiled eggs, no date, no discard/use by date 1 storage bag with unknown product that resembled icing, no name, no date, no discard/use by date 1 storage bag of tortillas dated 12/3/25 no discard/use by date 1 storage bag of tortillas dated 2/8 no discard/use by date 1 half gallon of expired buttermilk 1 container of enchilada sauce, receive date of 10/23, no discard/use by date 1 open gallon of coleslaw dressing, no discard or use by date 1 storage bag with items covered in foil, no name or discard dateWalk in Freezer: 1 storage bag of chicken, no open date, no discard/use by date 1 open bag of breaded item resembling biscuits, no label, no open date, no discard/use by date Dry Food Pantry area: 3 large bags of brand cereal that expired on 11/15/2025 2 large bags of fruity cereal removed from original packing, dated 1/12, no discard/use by date 3 large, dented cans of carrots Observation and interview conducted on 02/10/2026 at 9:30 AM. Observed 2 large turkey breasts and a storage bag of ground beef sitting in a sink thawing, with no running water. The Dietary Aide was asked if that was the way the dietary department thawed their meat and she responded, I think that is how they thaw meat.Observation during the follow up tour of the kitchen on 02/11/2026 beginning at 11:26 AM, revealed the following:Kitchen area: 1 trash can with no lid 1 large bin of sugar, no discard/use by date in kitchen food preparation area 1 large bin of flour, no discard/use by date kitchen food preparation area Raw chicken thawing in the sink not in a container [NAME] was observed not washing her hands after removing her gloves following her contact with the raw chicken and before she handled the next food item. Walk in Refrigerator: 1 storage bag of deli style turkey, no name, no date, no discard/use by date 1 container of enchilada sauce, receive date of 10/23, no discard/use by date 1 open gallon of coleslaw dressing, no discard or use by date Walk in Freezer: 1 open bag of breaded item resembling biscuits, no label, no open date, no discard/use by date Dry Food Pantry area: 3 large bags of brand cereal that expired on 11/15/2025 2 large bags of fruity cereal removed from original packing, dated 1/12, no discard/use by date Observation/Interview conducted on 02/11/2026 at 3:01 PM. Observation revealed the dishwasher with approximately 2-inch beard without a beard restraint. The dishwasher stated he was aware that hair restraints should be worn in the kitchen area upon entering. However, he said no one informed him about beard restraints. He stated that a few months ago beard restraints were available, but he has not seen any recently. He acknowledged that a potential risk to residents is that hair could fall into food, which could lead to contamination or choking hazards.Interview conducted with the [NAME] on 02/11/2026, at 1:13 PM. The [NAME] stated she has worked at the facility for 4 years. The [NAME] stated she has been trained on the food handling policy and proper hand hygiene in the kitchen. The [NAME] was asked whether she believed the chicken observed in the kitchen sink earlier that day had thawed properly. The [NAME] stated the raw chicken was supposed to be in a container and not just lying in the sink. The cook stated she knows that she was supposed to wash her hands after removing her gloves. The [NAME] stated she was in a hurry to complete tasks and it slipped her mind. In regard to the labeling, dating, and discarding of food items, the [NAME] stated the food is labeled with the name, date received, date opened and discard date of 3 days past the open date. The [NAME] stated they dispose of expired foods when they expire, and she stated the DM checks for all the expired foods. The [NAME] stated all the trash cans should have lids, but they do not have lids for all the trash cans. The [NAME] stated that if residents eat outdated food or food that is not properly handled, they could become sick.Interview conducted with DON on 02/12/2026, at 9:45 AM. DON stated she was not familiar with the facility's policy on food labeling in the kitchen. She stated she knows items should be labeled but was unsure what information is required on the label. She believed labels may include the date, the item name, or the date the item was prepared, and that expired food should be discarded daily. She further stated that dietary staff should perform hand hygiene and sanitize their hands when changing gloves in the kitchen. She also stated she did not believe raw chicken should be placed bare in the kitchen sink. She stated that potential harm to residents from consuming expired food, improper food handling and improper hand hygiene in the kitchen, could lead to a resident getting very sick.Interview conducted with the DM on 02/12/2026, at 11:09 AM. DM stated she had just returned to the facility 3 weeks ago. The DM stated that the kitchen protocol requires trash cans to have lids. She reported that during the last inspection, no concerns were raised regarding the trash cans. The DM stated that the food labeling and dating protocol requires food items to be labeled with the received date and that staff must monitor expiration dates. She explained that cooked food has a three-day hold time and is labeled with the received date, the opened or prepared date, and the discard date. She stated that food is typically kept in the walk-in refrigerator for 48-72 hours for thawing and may also be thawed under running cold water. She reported that expired food is discarded every two days. The DM added that there is a designated area in the kitchen for dented cans and that she was taking photographs on Tuesday when the surveyor arrived to document dented cans for credit. The DM stated she spoke to the dietary staff on Tuesday regarding the meat not being thawed under running water. She further stated that raw chicken observed in the sink should have been placed in a container or thawed in the walk-in refrigerator. Surveyor showed DM pictures of expired food items that remained in the dry pantry that were not discarded. The DM stated the items should have been discarded, and she would throw them out. The DM stated that she is trying to bring the kitchen back up to correct standards, now that she has returned. The DM stated that potential harm to residents from consuming expired food or improper food handling and not wearing hair restraints could lead to a resident getting sick or salmonella poisoning. In an interview conducted on 02/12/2026 at 11:55 AM, the Administrator stated he expects his dietary staff to follow all kitchen policy and protocols regarding trash cans, proper food handling, labeling and dating foods, and hand hygiene in the kitchen. Administrator stated that each of the above issues could lead to infection control issues and a resident could become ill.Record review of the facility's policy not dated, named Preventing Foodborne Illness-Employee Hygiene & Sanitation Policy and Procedure revealed: Purpose:To guide the facility on the policy to ensure service employees are trained on proper procedures toprevent spread of foodborne illness.Policy:Food and nutrition services employees will follow appropriate hygiene and sanitary procedures toprevent the spread of foodborne illness.Procedure:1. All employees who handle, prepare, or serve food will be trained in the practices of safe foodhandling and preventing foodborne illness. Employees will demonstrate knowledge andcompetency in these practices prior to working with food or serving food to residents.6. Employees must wash their hands:d. Before coming in contact with any food surfaces;e. After handling raw meat, poultry or fish and when switching between working with rawfood and working with ready-to-eat food;f. After handling soiled equipment or utensils;g. During food preparation, as often as necessary to remove soil and contamination and toprevent cross contamination when changing tasks; and/or7. Antimicrobial hand gel CANNOT be used in place of handwashing in food service areas.8. Contact between food and bare (ungloved) hands is prohibited.10. Gloves are considered single-use items and must be discarded after completing the task forwhich they are used. The use of disposable gloves does not substitute for proper handwashing. 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens.Record review of Resident #66's face sheet, dated 02/12/2026, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, unspecified severity (person has clear symptoms of decline in memory loss, but the specific cause has not been determined and is not clearly defined or documented by the provider), age related osteoporosis (a condition where bones become progressively thinner and fragile due to aging, significantly increasing the risk of fractures) generalized anxiety disorder (a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life).Record review of Resident #66's Quarterly MDS Assessment, dated 01/06/2026 reflected Resident #66 had a BIMS score of 1 which indicated her cognition was severely impaired. Resident #66 required supervision or touching assistance (helper provides verbal cues and assistance may be provided) with eating. Resident #66 required substantial/ maximal assistance (helper does more than half the effort) with the following: personal hygiene and dressing. Resident #66 did not have a weight loss or weight gain.Record review of Resident #66's Care Plan revised on 02/04/2026 reflected Resident #66 required staff assistance for all ADLs related to impaired mobility and dementia. Intervention: Resident #66 required assistance from staff with feeding.Observation on 02/10/2026 at 12:45 pm reflected ADON grabbed the arms of a chair and pulled the chair next to Resident #66. ADON touched her right side of her top. She touched Resident #66's clothes, Resident #66's right arm, and the back of Resident #66's wheelchair. ADON did not sanitize or wash her hands. ADON sat in the chair and turned Resident #66's plate around between her and Resident #66. When she pulled Resident #66's plate the top part of her middle finger and fore finger touched inside her plate and touched the cornbread dressing. ADON continued to feed Resident #66 and never sanitized or washed her hands. She picked up the napkin with her small finger, middle finger, and ring finger on her right hand and wiped Resident #66's mouth. She picked up the spoon and touched the oval part of the spoon designed to hold food with her middle finger and ring finger on her right hand. ADON placed cornbread dressing in the oval part of the spoon she had touched and fed Resident #66 without sanitizing or washing her hands.In an interview on 02/10/2026 at 1:30 pm ADON stated she pulled up a chair and touched the arms of the chairs. ADON stated she pulled Resident #66's plate around to feed her, and she did touch the inside of the plate, the inside of the spoon and she may have touched the cornbread dressing. She stated she did not wash or sanitize her hands. ADON stated she did touch inside of the spoon where she placed the cornbread dressing to feed Resident #66. ADON stated there was a possibility she may have cross contaminated Resident #66's plate and her food with her hands. She stated the expectation when touching anything considered contaminated was to wash or sanitize hands prior to feeding any resident and she did not wash or sanitize her hands. She stated she had been in serviced on sanitizing hands prior to feeding a resident, however, she did not recall the date of the in-service. ADON stated if a resident ingested any type of bacteria there was a possibility a resident may become ill with some type of food borne illness. She stated a resident may have stomach issues such as nausea and vomiting.In an interview on 02/12/2026 at 7:45 am the Director of Nurses stated the staff was expected to sanitize their hands prior to feeding a resident. She stated if the staff touched the arms of a chair, their clothes, the resident's chair, the staff was expected to wash or sanitize their hands prior to feeding a resident. She stated the facility never had a resident to become ill from any type of bacteria. The Director of Nurses stated there was always a possibility of someone becoming ill from bacteria and may need to be assessed at the hospital. She stated a resident may become physically ill such as diarrhea, vomiting or nausea. The Director of Nurses stated the staff had been in-serviced to wash or sanitize their hands prior to feeding a resident. She stated she did not recall the date of the in-service. She stated if staff touched any silverware and placed food in the area of the silverware, they touched the silverware would be considered contaminated and the staff was to replace that particular silverware and not use it to feed the resident.In an interview on 02/12/2026 at 8:45 am LVN Charge Nurse C stated if staff touched the arms of a chair while moving the chair to the table next to a resident, the chair was considered contaminated, and the staff was expected to wash or sanitize their hands prior to feeding a resident. LVN Charge Nurse C stated if the staff touched the resident's food with her hands after she touched the chair and clothes the staff cross contaminated the food from the bacteria on the staff's hands. She stated there was a possibility the resident could become ill such as food borne illness with symptoms of vomiting or diarrhea. She stated she had been in-serviced on hand hygiene and to wash or sanitize your hands prior to feeding a resident. LVN C stated she did not recall when she had been in-serviced on washing hands when in the dining room feeding residents. In an interview on 02/12/2026 at 8:59 am CNA B stated if staff pulled up a chair and sat in the chair the chair would be considered contaminated. She stated the staff must sanitize or wash hands prior to feeding any resident even if they did not touch a chair. CNA B stated if staff touched their clothes and touched the wheelchair these items would be considered contaminated. She stated if staff touched the resident's food without washing or sanitizing their hands, the bacteria from the staff's hands may transport from the hands or fingers to the resident's food. She stated a resident could become sick if they swallowed any type of bacteria from the staff's hands if the hands were not sanitized. CNA B stated the resident could become ill with vomiting stomach issues and may have diarrhea. CNA B stated she had been in-serviced on hand hygiene when feeding but did not recall the date and had been in-serviced on sanitizing hands when feeding a resident.Record review of the facility's policy not dated, named Food Safety and Sanitation Policy and Procedure revealed: Food Storage1. Food that is stored is protected from contamination and growth of any pathogenic organisms.7. Perishable ingredients are refrigerated when they are not being used.9. All time and temperature control for safety (TCS) leftovers are labeled, covered, and dated whenstored.a. They are used within 72 hours (or discarded).10. Foods with expiration dates are used prior to the use by date on the package.A record review of the 2022 U.S. Food and Drug Administration Food Code reflected the following:Working trash cans are clean, covered, and not overflowing while in use.Food items in the refrigerator(s) are covered/sealed, labeled, dated, and shelved to allow air circulation.Food items in the freezer(s) are covered/sealed, labeled, dated, and shelved to allow air circulation.Frozen foods are thawed under cool running water, in the refrigerator, using a microwave, or as part of the cooking process. Food is discarded on or before the expiration date.Record review of the Facility's Policy on Hand Washing/ Hand Hygiene, not dated, reflected Purpose: To reduce the spread of infection throughout the facility.Policy: All personnel shall perform hand washing/ hand hygiene when working with residents.Procedure:Before and after direct contact with residents.Before and after assisting resident with meals.After contact with resident's intact skin.

Based on interview and record review the facility failed to ensure residents had a right to organize and participate in resident groups for six of six confidential residents reviewed for resident council. The facility failed to provide monthly Resident Council meetings for the month of October 2025 and January 2026. This failure could place residents at risk of not being able to exercise their rights to meet as a group. Findings include:Record review of the Resident Council minutes from 09/2025 to 02/2026 reflected the Resident Council did not meet during the months of October 2025 and January 2026. During a confidential group interview at an undisclosed date and time the group of six residents stated they wanted to be invited to Resident Council and wanted to have Resident Council meetings once a month. The group stated they had not been having Resident Council meetings monthly and they were not given a reason of why they were not having Resident Council meetings on a regular basis.During an interview on 02/11/2026 at 11:30 am The Activity Director stated she was unsure how many times Resident Council was required to meet. She stated she would need to review the facility policy and would continue the interview after she reviewed the facility policy. She did not get with surveyor and finish the interview prior to exit.During an interview on 02/12/2026 at 9:40 am The Administrator stated the Facility Policy indicated the Resident Council was to meet on a monthly basis. He stated this was his expectations. The Administrator stated the Resident Council President was not feeling well when it was scheduled on the Activity Calendar in January 2026. He stated the Resident Council meeting could have been changed to another date. He stated someone in the Activity Department could have informed the residents of the change of the Resident Council meeting. The Administrator stated it was the Activity Director's responsibility to ensure the Resident Council meets monthly.Record review of the Facility's Policy on Resident Council, not dated, reflected The Resident Council will meet monthly. Those who are unable to attend or do not want to attend can submit their concerns to the resident council liaison.

Based on observation, interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 (Residents #41, #50 and #69) of 8 residents reviewed for activities. The facility failed to provide activities for Resident #41, Resident #50, and Resident #69 for the months of January and February 2026.This failure could place residents at risks of boredom, depression, and diminished quality of life and decreased cognitive function. Findings include:Record review of Resident #41's face sheet, dated 02/12/2026, reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #41 had diagnoses of anxiety disorder (involve more than occasional worry or fear, does not go away, is felt in many situations, and can get worse over time), depression, unspecified ( individuals experiencing significant, impairment such as sadness or hopelessness- not enough information for a specific diagnosis), dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance ( decline in memory caused by underlying, medical condition. The severity is not defined as mild, moderate, or severe, and it may include behavioral issues like agitation), and chronic pain syndrome ( a condition where pain persists for 3 to 6 months or longer, often outlasting the initial injury or illness).Record review of Resident #41's admission MDS assessment dated [DATE], reflected the MDS Assessment was in progress.Record review of Resident #41's Baseline Care Plan, dated 01/04/2026 reflected Resident #41 would prefer to attend activities of her choice. Intervention: Review with Resident #31 of the activities she enjoys. Encourage Resident #31 to attend different activities.Record review of Resident #41's Activity Participation records reflected Resident #41 had not been provided any activity by the activity staff in her room or in group since Resident #31 was admitted to the facility.Observation and interview on 02/10/2026 at 9:30 am revealed Resident #41 was in her room sitting in a wheelchair. She was yelling help me and pulling on her hearing aids. Resident #41 did not respond appropriately to conversation when asked about needing help. She did not respond appropriately to questions about her activity preferences. Resident #31 continued to yell help whenever a question was asked. The Business office Manager entered the room and began to assist Resident #31 with her hearing device. Resident #41 had the television on, however, she was not watching Price Is Right rerun on the television.Observation and interview on 02/10/2026 at 10:45 am revealed Resident #41 was in her room sitting in a wheelchair. She was yelling help, rubbing her hands, and had a frown on her face ( corners of her mouth turning downward). Resident #41 continued to yell when the surveyor attempted to speak to her. She repeated yelling my hearing aids. Resident #41 hearing aids were in her ears. She did not respond to any questions related to being in pain, activities, if she was hungry or thirsty. Observation throughout the day on 02/10/2026 thru 02/12/2026 revealed Resident #41 would be in her room sitting in her wheelchair and yelling help me or yelling strange sound. Resident #41 television would always be on Price is Right - a re-run of Price is Right, however, Resident #41 was never observed watching television. She always had a frown on her face, wringing hands ( a common body language cue signaling intense worry, anxiety, or helplessness). In an interview on 02/11/2026 at 11:30 am the Activity Director stated she had not asked Resident #41 about her activity preferences. She stated Resident #41 sometimes came to an activity. The Activity Director stated Resident #41 needed to be on in-room activities. She stated with her behaviors she would probably benefit more with one-on-one activity ( activity provided in the resident room with the activity staff) instead in a group. The Activity Director stated she began working at the facility in January 2026. She stated Resident #41 did need some type of activity to divert her attention and to help with her being anxious. She stated she did not have an excuse of why Resident #41 was not provided any type of activity item or activity program. The Activity Director stated she had not asked Resident #31 or Resident #41's family about what type activities she enjoyed. She stated Resident #41 had not been provided activities during the months of January 2026 and February 2026.Record review of Resident #50's face sheet, dated 02/12/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #50 had diagnoses of major depressive disorder, single episode, severe without psychotic features ( a low mood or loss of pleasure or interest in activities lasting at least two weeks), anxiety disorder (involve more than occasional worry or fear, does not go away, is felt in many situations, and can get worse over time), and unspecified dementia, unspecified severity, with other behavioral disturbance ( when a person shows significant memory decline- affecting thinking and daily functioning. However, the specific cause and severity are not yet determined with behaviors such as wandering increased confusion and restlessness in the late afternoon or night, pacing, or verbal outbursts). Record review of Resident #50's Annual MDS Assessment , dated 05/07/2025 reflected Resident #50 had a BIMS score of 7 which indicated his cognition was severely impaired. Resident #50 enjoyed doing his favorite activities and this was very important to him.Record review of Resident #50's MDS assessment dated [DATE], reflected Resident #50 had a BIMS score of 7 which indicated his cognition was severely impaired. Record review of Resident #50's revised care plan dated 02/06/2026, reflected Resident #50 would prefer to attend activities of his choice. Intervention: Encourage Resident #50 to attend different activities. Review with Resident #50 of the activities he enjoys.Observation and interview on 02/10/2026 at 9:45 am revealed Resident #50 was lying in bed. His television was turned off, and he was staring toward the wall near the door. He never smiled and had a worried expression on his face ( corners of mouth turned downward). Resident #50 stated he did not enjoy going to group activities. He stated he would prefer for someone to come to his room and talk to him and maybe play cards with him in his room.In an interview on 02/11/2026 at 11:30 am the Activity Director stated she had not asked Resident #50 about his activity preferences. She stated Resident #50 will walk in the hall sometimes. The Activity Director stated Resident #50 did need in room activities related to him and did not enjoy being around a group of people. She stated there was not any participation records of Resident #50 receiving any type of activities for the month of January 2026 and February 2026. She stated she was in process of developing a new system to record resident activity participation. The Activity Director stated Resident #50 did need activities to prevent boredom, depression and improve his quality of life. She stated Resident #50 did not attend group activities or have in room activities for the months of January 2026 and February 2026.Record review of Resident #69's face sheet, dated 02/12/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #69 had diagnoses of anxiety disorder (involve more than occasional worry or fear, does not go away, is felt in many situations, and can get worse over time), and unspecified dementia, unspecified severity, with other behavioral disturbance (when a person shows significant memory decline- affecting thinking and daily functioning. However, the specific cause and severity are not yet determined with behaviors such as wandering increased confusion and restlessness in the late afternoon or night, pacing, or verbal outbursts) and type 2 diabetes mellitus with other diabetic kidney complication ( prolonged high blood sugar has damaged the small blood vessels and filtering units in the kidneys). Record review of Resident#69's admission MDS Assessment, dated 09/07/2025, reflected Resident #69 had a BIMS score of 9 which indicated his cognition was moderately impaired. Resident #69 was assessed, and the following activities were very important to him: have books, newspaper, and magazine to read, listening to music, being around pets, keep up with the news, doing favorite activities, go outside to get fresh air when weather permitted and participating in religious services and practices.Record review of Resident #69's MDS assessment dated [DATE], reflected Resident #69 had a BIMS score of 9 which indicated his cognition was moderately impaired. Record review of Resident #69's care plan revised on 02/03/2026 reflected Resident #69 would prefer to attend activities of his choice. Intervention: Encourage Resident #69 to attend different activities. Remind Resident #69 of the upcoming activities. Review with Resident #69 his activity preferences. Observation and interview on 02/10/2026 at 9:00 am revealed Resident #69 was sitting in a recliner in the common area across from the nurses station. He was attempting to take off his shirt and pants. Resident was yelling and attempting to stand up from the recliner. Observation from 02/10/2026 until 02/12/2026 revealed Resident #69 was sitting either in a recliner or his wheelchair in the common area yelling constantly, attempting to remove clothes, yelling at other residents, was frequently agitated such as fidgeting, clenched fists, hand wringing, rapid speech, etc.In an interview on 02/11/2026 at 11:30 am the Activity Director stated Resident #69 was at risk for falls and he did yell out frequently. She stated he sat in a recliner a lot in the common area near the nurses desk on south wing. She stated he did not always enjoy being in a group activity and sometimes would be disruptive. The Activity Director stated Resident #69 would benefit having some type of activity to do independently to divert his attention. She stated he would also need in-room activities. The Activity Director stated she was not aware of Resident #69 attending group activities in the months of January 2026 and February 2026. She stated he did not receive in-room activities, and an activity item was not provided for him to attempt to divert his attention from yelling and taking his clothes off in the public area. She stated if Resident #69 was not provided any type of activities there was a potential his cognition would decline, he may become depressed and have increased behaviors. She stated also his quality of life may decline. She stated the Administrator was her supervisor. Activity Director stated they were in the process of changing the activity programming for each resident to receive person center activities.In an interview on 02/12/2026 at 1:02 pm the Activity Assistant stated she was not aware of Resident #41, Resident #50 or Resident #60 attending group activities during the months of January 2026 and February 2026. She stated she did not provide any activity items for these residents ( Resident #41, #50 and #69) or provide in-room activities. Activity Assistant stated if a resident was not receiving activities there was a possibility they would increase isolating themselves from others, become depressed, and increase behaviors. She stated she did not know why these residents were not provided activities. Activity Assistant stated she had been working at the facility as the Activity Assistant since August 2025. She stated her job description was reviewed with her, and she signed her job description. Activity Assistant stated the activity programs were going to change for each resident and the activity department would be working on changing activities. She stated the Activity Director was her supervisor.In an interview on 02/12/2026 at 9:40 am the Administrator stated he expected a variety of activities to be provided for all residents. He stated each resident's activity preference needed to be assessed, and each resident's activity was expected to be planned according to their activity preferences. He stated activities such as independent, in-room, and/or group activities were to be documented on participation records. The Administrator stated he expected all residents to be interviewed, and their activity preferences updated and all care plans to be revised to reflect each resident's activity preferences. He stated if a resident was not receiving activities there was a potential a resident would have a decline in their cognition, mental status, physical status and quality of life. He stated a resident with a history of depression may become depressed and isolate themselves in their rooms. The Administrator stated the Activity Director was responsible for the activity programming and documentation of all activities department including participation records. He stated he was the Activity Director's supervisor. Record review of the Activity Director Job Description, signed on 01/26/2026 by the Activity Director , reflected the Activity Director will work to develop meaningful activities designed to meet the needs and interests of all residents. Activity Director will lead and assist with group activities, individual activities, and/or one on one activities, including activities for residents who are bed bound, cognitively impaired, and residents with behaviors. The Activity Director will evaluate the effectiveness of the activity programs and take initiative to try new methods and use best practices. The Activity Director will document resident activity participation. Record review of the Activity Assistant Job Description, signed on 08/15/2025 by the Activity Assistant, reflected the purpose of the Assistant Activity Director is to provide support for the Activity Director in developing and carrying out activities that enhance the residents' quality of life. The activity department orchestrated group, individual, and one-on-one activities. The goal of the Activity Department is to maintain self confidence in residents, provide a sense of community, encourage socialization, use mental and sensory stimulations, encourage participation in leisure activities, and develop a plan of care to improve and/ or maintain each residents' psychosocial well-being. Record review of the Activity Policy and Procedure, not dated, reflected All residents shall be provided activities according to their preferences and needs. The facility shall provide an activities program that is appropriate to the needs and interests of each resident that will encourage self-care, resumption of normal activities, maintenance of optimal self-functioning, and contact with the environment. As a part of the Activities Program:Each resident's interests and needs shall be identifiedThe resident shall be involved in an ongoing program of activities that is designed to appeal to his/her interests and to enhance the resident's highest practicable level of physical, mental, and psychosocial well-being.Upon admission, individualized care planning goals and activities for each resident shall be developed.The information gathered through the assessment process shall be used to develop the activities component of the comprehensive care plan.The ongoing program of activities shall match the skills, abilities, needs, and preferences of each resident with the demands of the activity and the characteristics of the physical, social and cultural environments. Activities should be included in the care planning for each resident.The activities program provided by the facility shall accomplish the following:Encompasses both small groups with similar cognitive levels and one-to-one opportunities.Matches the resident's cognitive , sensory , and physical disabilities.Matches resident's past and current interestsA variety of supplies and equipment shall be maintained in a safe and functional order and shall be easily accessible to residents where feasible.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 5 medication carts (Medication Cart #1 and Medication Cart #2) reviewed for medication storage.The facility failed to ensure Medication Cart #1 and Medication Cart #2 were locked and medications were secured and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the counter medications.Findings included:Observation on 02/10/2026 at 9:00 a.m. revealed the locking mechanism protruding outward (indicated the medication cart was unlocked) on Medication cart #1 located partially in hallway on 200 hall and partially behind the nurse's desk (South Wing). ADON was sitting at the nurse's desk with her back turned away from the unlocked Medication Cart #1 and was unable to view Medication Cart #1. In an interview on 02/10/2026 at 9:02 a.m. ADON stated she did not realize the medication cart was unlocked. She stated all medication carts were to be locked except when a nurse was obtaining medications from the cart. ADON stated if a resident did ingest medications the resident was allergic to there was a possibility the resident may have a reaction and possibly die. She stated a resident also had a potential of overdosing on medications or giving the medications to another resident. ADON stated she had been in-serviced on locking medication carts; however, she did not recall the date of this in-service. She stated there were all types of medications prescribed by the physician in Medication Cart #1 except for narcotics.Observation on 02/11/2026 at 9:45 a.m. revealed on Medication Cart #2 the locking mechanism protruding outward (indicated the medication cart was unlocked) between the nurse's desk on South Hall and the medication room. RN Supervisor E was approximately 50 feet away from the unlocked Medication Cart #2 standing in a foyer in the hall between South side and North side of the facility. He was unable to view the unlocked Medication Cart #2 from where he was standing. In an interview on 02/11/2026 at 10:00 a.m. RN Supervisor E stated the medication cart was to always be locked except when he was dispensing medications from the medication cart. He stated a surveyor could observe the medication cart being unlocked and this would be the potential harm. He did not respond to any further questions about the unlocked medication cart such as what could possibly happen to a resident if a resident ingested another resident's medications or if it was possible for a staff or a visitor to obtain the medications from the unlocked Medication Cart #2.In an interview on 02/12/2026 at 7:50 a.m. the Director of Nurses stated her expectation was for all medication carts to be locked when the nurse was not administering medications. She stated the staff had been in-serviced on securing the medication carts when not in use. The Director of Nurses stated she did not know the exact date of the in-service. She stated residents, other staff, and visitors would have access to the medications in the unlocked medication cart. She stated if a resident ingested medications not prescribed to them; there was a potential the resident may have an allergic reaction or may need to be admitted to the hospital. She stated it was the nurse or Medication Aide's responsibility to ensure the medication cart was locked when not dispensing a resident's medication. The Director of Nurses stated she was responsible for monitoring the nurse supervisors.In an interview on 02/12/2026 at 8:40 a.m. LVN C stated all medication carts were to be locked when the nurse was not administering medications. LVN C stated if residents had accessed the medication cart they could have overdosed, taken wrong medication, had an allergic reaction, and could require admission to the hospital. She stated she had previously been in-serviced on locking the medication carts and could not recall the specific date. She stated any unauthorized staff or visitors would have access to the medications. LVN C stated a resident may give medications to another resident. She stated if a resident became severely sick and the staff was not aware the resident had ingested another resident's medication it would be difficult to determine what was physically wrong with the resident. Record review of the facility's Policy on Storage of Medications, not dated, reflected Ensure that medications are stored in a safe, secure, and orderly manner. Compartments containing medications are locked when not in use:Trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes).

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three of eight residents (Resident # 57 and Resident #59) reviewed for ADL care.The facility failed to ensure Resident #10, Resident #50 and Resident #69's nails were cleaned and did not have any rough edges on 02/10/2026.This failure could place residents at risk of not receiving services or care, diminished quality of life , and decreased self-esteem. Findings included: Record review of Resident #10's face sheet, dated 02/12/2026, reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side ( this condition causes left-sided, one-sided, muscle weakness- general lack of strength, and loss of motor control- the partial or total inability to voluntarily control body movement, muscle coordination, and balance), cerebral infarction ( brain tissue death caused by a sudden, prolonged lack of blood flow due to a blocked artery), and lymphedema ( a chronic condition causing persistent swelling, usually in the arms or legs, due to a blockage or damage that prevents proper fluid drainage). Record review of Resident #10's Quarterly MDS Assessment, dated 12/08/2025, reflected Resident #10 was assessed to have a BIMS score of 15 indicating cognition was intact. Resident #10 did not refuse care. Resident #10 required substantial/maximal assistance- helper who does more than half the effort with personal hygiene, showers, upper body dressing, toileting hygiene, chair to bed transfers and toilet transfers. She was dependent on staff for lower body dressing and tub/shower transfers. Record review of Resident #10's Comprehensive Care Plan, dated 12/08/2025, reflected Resident #10 had arthritis in joints. Interventions: notify physician of any significant changes. Administer medications as ordered. Resident #10 had required staff assistance with some of ADLs. Intervention: Assist with hygiene and grooming tasks. Assist with bathing.Observation and interview on 02/10/26 at 09:58 AM revealed Resident #10 was lying in bed in her room. Her nails on her right hand were not smooth around the edges and there was a blackish/brownish substance underneath her middle and fore fingernails on her right hand. She stated she asked someone over the weekend to file and clean her nails and the person stated they would sometime during the week. Resident #10 stated she did not recall the staff's name. She stated she believed the staff worked in nursing but did not recall if the staff was a CNA or a Nurse. Resident #10 stated she did not recall seeing a name badge on the staff's clothes.Record review of Resident #50's face sheet, dated 02/12/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #50 had diagnoses of major depressive disorder, single episode, severe without psychotic features ( a low mood or loss of pleasure or interest in activities lasting at least two weeks), anxiety disorder (involve more than occasional worry or fear, does not go away, is felt in many situations, and can get worse over time), and unspecified dementia, unspecified severity, with other behavioral disturbance (when a person shows significant memory decline- affecting thinking and daily functioning. However, the specific cause and severity are not yet determined with behaviors such as wandering increased confusion and restlessness in the late afternoon or night, pacing, or verbal outbursts). Record review of Resident #50's MDS assessment dated [DATE], reflected Resident #50 had a BIMS score of 7 which indicated his cognition was severely impaired. Resident #50 did not refuse care. Resident #50 required supervision or touching assistance with the following: personal hygiene, showers, and transfers from sit to lying position, sit to stand, and chair to bed and bed to chair.Record review of Resident #50's revised care plan dated 02/06/2026, reflected Resident #50 required staff assistance for all ADLs. Intervention: Assistance with hygiene, grooming, bathing and adjusting clothing.Observation and interview on 02/10/2026 at 9:10 AM revealed Resident #50 was lying in bed. Resident #50's fingernails on his right hand underneath his middle and ring fingernails had a blackish/brownish substance. Resident #50 had rough edges around his fingernails on his right hand and had blackish/brownish substance underneath his middle and fore fingernails on his left hand. Resident #50 stated he did not like his nails to be dirty. He stated he did not remember if he asked someone to help him with his nails.Record review of Resident #69's face sheet, dated 02/12/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #69 had diagnoses of anxiety disorder (involve more than occasional worry or fear, does not go away, is felt in many situations, and can get worse over time), and unspecified dementia, unspecified severity, with other behavioral disturbance (when a person shows significant memory decline- affecting thinking and daily functioning. However, the specific cause and severity are not yet determined with behaviors such as wandering increased confusion and restlessness in the late afternoon or night, pacing, or verbal outbursts) and type 2 diabetes mellitus with other diabetic kidney complication ( prolonged high blood sugar has damaged the small blood vessels and filtering units in the kidneys). Record review of Resident #69's MDS assessment dated [DATE], reflected Resident #69 had a BIMS score of 9 which indicated his cognition was moderately impaired. Resident #69 did not refuse care. Resident #69 required supervision or touching assistance with the following: personal hygiene, toileting hygiene, and oral hygiene. He required partial to moderate assistance - helper does less than half the effort with the following: showers, upper and lower body dressing, and shower transfers.Record review of Resident #69's care plan reflected his care plan revised on 02/03/2026 reflected Resident #69 required assistance with personal hygiene.Observation and interview on 02/10/2026 at 9:30 am revealed Resident #69 was sitting in a recliner in the common area across from the nurses station. Resident #69's fingernails on his left hand underneath his middle and ring fingernails had a blackish/brownish substance. Resident #69 had rough edges around his fingernails on his left hand. Resident #69 stated he did not like his nails to be dirty. He did not respond to any other questions about when was the last time his nails were cleaned or trimmed.In an interview on 02/12/26 at 7:45 am, the DON stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become ill with stomach issues such as vomiting and nausea if they ingested the blackish/ brownish substance. She stated the CNAs were responsible for all residents' nails such as cleaning, trimming, and filing except for the residents with diabetes. She stated for any resident with a diagnosis of diabetes the nurse was responsible for these residents' fingernails. The DON stated the nurse supervisor was responsible for monitoring CNAs giving ADL care which included nail care, and the ADON and DON were responsible for monitoring the nurse supervisors.In an interview on 02/12/2026 at 8:30 am, CNA A stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA A stated the residents' nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA A stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 50 , Resident #10 and Resident #69, and they did not refuse nail care. CNA A stated she did not know the last time these residents' nails were trimmed or cleaned and she would need to check the medical records. She stated if a Resident's nails were rough around the edges there was a possibility the resident could scratch themselves and cause a skin tear. CNA A stated anytime a resident refused any type of care she reported it to the charge nurse.In an interview on 02/12/2026 at 8:45 am, LVN Charge Nurse C stated the nurses were responsible for residents with a diagnosis of diabetes with nail care such as trimming, cleaning, and filing. She stated the CNAs were responsible for all other residents' nail care. LVN Charge Nurse A stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill, such as stomach problems nausea and vomiting. She stated she would need to ask staff questions for the reason nail care was not completed on Resident #10, Resident #50 and Resident #69. LVN Charge Nurse C stated no one reported to her that Resident #10 or Resident #50 or Resident#69 refused nail care. She stated anytime a resident refused care it was documented in the nurses' notes.In an interview on 02/12/2026 at 8:59 am, CNA B stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA B stated the residents' nails were usually cleaned on Sundays, their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as vomiting and diarrhea. She stated if a resident had rough edges around the fingernails there was a potential a resident may scratch another resident or themselves and obtain a skin tear. She stated a resident could get their nail caught on something and pull their nail off their finger. CNA B stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident #10, Resident #50 and Resident #69, and they did not refuse nail care. Record review of the Facility's Policy on Nail Care, not dated, reflected Policy:To prevent infection.To prevent irritation.To prevent break in skin integrity.To promote cleanliness.To relieve pain.Procedure:Care of fingernails and toenails is part of the bath.Be certain nails are clean.If nails are difficult to cut, inform the charge nurse.Nails are to be clipped and filed smoothly.Cut across the nails.Residents who refuse nail care should be reported to the nurse.

Based on interviews and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for one (1) of five (5) residents (Resident #64) reviewed for accuracy of assessments. The facility failed to ensure the MDS dated [DATE] was updated to reflect active dialysis for Resident #64 The facility failed to ensure the MDS dated [DATE] was updated to reflect active dialysis for Resident #64 This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.Record review of Resident #64's Face sheet dated 02/10/2026, reflected he was a [AGE] year-old male, who was admitted to facility on 10/25/2025 with readmission on [DATE]. He was diagnosed with Hypertensive heart disease and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease. (heart and kidney complications due to chronic high blood pressure), Type II diabetes mellitus with Diabetic Chronic Kidney Disease (high blood sugar and high blood pressure damaging kidneys), and Acute osteomyelitis, left ankle and foot (bone infection).Review of Resident #64's latest MDS assessment dated [DATE] reflected a BIMS of 15, indicating the resident was cognitively intact. The MDS assessment did not reflect dialysis in Section O.Review of Resident #64's MDS assessment dated [DATE] did not reflect dialysis in Section O.Record review of Resident #64's care plan dated 2/10/2026 reflected there was a focus care plan area for dialysis on Monday, Wednesday, and Fridays.Record review of the facility's 802 Resident Matrix (document that indicates resident care areas) dated 2/10/2026 did not list Resident #64 for dialysis.Interview conducted 2/11/2026, at 3:50 PM, with Resident #64. Resident #64 stated he was receiving dialysis at the time of admission and he attends dialysis on Monday, Wednesdays, and Fridays.Interview conducted 2/12/2026, at 9:42 AM, the DON stated she has been employed at the facility since the end of December. She reported that the corporate MDS nurse is responsible for updating the MDS. She stated the MDS should reflect current, correct information on residents. The DON stated she did not know why dialysis information was missing from Resident #64's MDS.She stated she was unsure why the resident was not listed on the matrix but later explained that the matrix pulls information from the MDS, which is why Resident #64 did not appear on the matrix. The DON stated she was unaware of any potential harm to the resident, noting that the dialysis orders were in the chart and the resident had been receiving the necessary services. She stated the only potential concern she could identify at this time was related to payment. She added that the matrix is intended to reflect residents with higher care needs or triggers. Interview conducted 2/12/2026, at 11:38 AM with corporate MDS Nurse, she stated she updates the MDS at the facility. The MDS nurse was asked whether she had been informed at any time that Resident #64 was receiving dialysis treatments. She responded that she oversees 11 facilities and would need to review the chart. She stated that she typically verifies whether a resident receives dialysis by the MAR and reviews the chart before coding the MDS. When asked why Resident #64 does not have dialysis on his MDS, the MDS nurse responded, I am human. I don't have a better answer as to why it is not on there. The MDS nurse stated that the missing dialysis information on the MDS should not have any effect on the residents. When asked whether missing dialysis information could affect the resident's care plan or monitoring, she stated that it could, since the MDS is typically used to guide the care plan.Interview conducted 2/12/2026, at 11:38 AM with Administrator. Administrator stated The MDS nurse is responsible for entering dialysis information on the MDS, with input from other interdisciplinary team members. The Administrator stated that communication regarding dialysis is typically based on physician dialysis orders. He reported he did not know why Resident #64 was not listed on the 802 and did not know why dialysis was not documented on the resident's MDS. The Administrator stated that potential effects of not documenting dialysis on the MDS include breakdowns in team communication and possible reimbursement issues.Record review on 2/12/2026 of the facility's policy, undated named MDS Policy and Procedure reflected: Purpose:The Minimal Data Set (MDS) is an assessment tool used to identify the residents care problems that will be addressed in an individualized care plan, SNF PPS Medicare reimbursement system, State Medicaid reimbursement systems, and monitoring the quality of care provided to residents. Policy:All Minimal Data Set (MDS) are to be completed and transmitted according to the most current Resident Assessment Instrument (RAI) manual. Procedure:The Interdisciplinary Team will assess the resident and document during the 7 day look back and accurately complete the MDS according to the RAI manual. Equipment:1. Computer2. Resident Chart 3. Resident Assessments4. Current RAI manual.

Based on interview and record review, the facility failed to have sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for one cook (Cook B) of three dietary cooks reviewed for qualified dietary staff in that:Cook B had not received the Texas food handler certificate to carry out the functions of the food and nutrition services department.This failure could place residents at risk of not having their nutritional needs met and place them at risk of food borne illness.Findings included:Record review of [NAME] B's personnel file revealed a hire date as a cook on 11/25/2025 and there was no food handler's license certificate on file.During an interview on 02/02/2026 at 2:42 PM the Dietary Manager stated she started back at the facility on 01/26/2026 as the Dietary Manager and [NAME] B texted her on 02/01/2026 to let her know that she did not have a food handler's license and she was taking the class on 02/02/2026. The Dietary Manager stated that she was not aware [NAME] B did not have her food handler's license and had been preparing meals in the kitchen. The Dietary Manager stated it was expected for her to have checked to see if [NAME] B had her food handler's license. The Dietary Manager stated it was expected for [NAME] B to have her food handler's license prior to preparing food. The Dietary Manager stated it was important for [NAME] B to have her food handler's license for proper handling of the food to avoid foodborne illness.During an interview on 02/02/2026 at 3:15 PM the HR stated that [NAME] B started at the facility on 11/25/2025 as a cook. The HR stated that [NAME] B's orientation was 11/26/2025 and the food handler's class was scheduled right after the hire date 11/25/2025, actual date not recalled. The HR stated she did not know the reason [NAME] B did not take the food handlers course when it was scheduled. The HR stated she had failed to verify if [NAME] B had taken the food handler's course. The HR stated [NAME] B would have been responsible for giving the food handlers certificate to her so she could file it. The HR stated it was expected for [NAME] B to have food service license class to be completed before handling food.During an interview on 02/02/2026 at 7:30 PM the ADM stated the Dietary Manager started working at the facility on 01/26/2026 and was responsible for making sure [NAME] B had her food handler's license. The ADM stated HR would have been responsible for filing the food handler's certificate for [NAME] B. The Adm stated it was important to have food handlers course completed to make sure food was distributed safely.During an interview on 02/03/2026 at 12:20 PM [NAME] B stated that she started the facility at the end of November 2025 and could not recall the exact date as a cook. [NAME] B stated that she thought her food service certificate was still active. [NAME] B stated she could not recall when her food handler's license expired, and she had failed to check to see if it was still active. [NAME] B stated it was expected for her to have active food hander's license while preparing food to make sure food was prepared safely. [NAME] B stated that she had just finished up her food handler's course today 02/02/2026 and sent to the Dietary Manager.Record review of the facility's policy titled Preventing Foodborne Illness Food Handling Policy and Procedure not dated revealed Purpose to provide guidance on proper food handling to avoid foodborne illness.3. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.

Based on interview and record review, the facility failed to immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition for 1 of 3 residents (Residents #1) reviewed for hospice services.The facility failed to immediately notify resident's hospice provider of COC, transport by EMS, and discharge to hospital. This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included:Record review of Resident # 1 admission face sheet dated 7.14.25 reflected a [AGE] year old female admitted on 2.7.17 and readmitted on 6.18.25 with a diagnosis of acute respiratory failure with hypoxia and hypercapnia( a serious condition where the lungs cannot adequately oxygenate the blood and /or remove carbon dioxide), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), bronchiectasis (a condition in which the lungs airways become damaged making it hard to clear mucus), Crohn's disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract), hypothyroidism ( underactive thyroid), hyperlipidemia (increased fat particles in the blood), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), osteoporosis (brittle bones), anemia )lack of iron rich blood), generalized muscle weakness, anxiety disorder, hypertension (elevated blood pressure), personal history of transient ischemic attack (mini stroke) and cerebral infarction (stroke), R hip fracture, and pain.Review of Resident # 1 Comprehensive MDS dated 6.21.25 reflected a BIMS score of 00 indicating severe cognitive impairment. Further review indicated Resident # 1 required supervision touching assist for dressing, partial moderate assist for bathing, substantial maximum assist for transfers, and total assist for toileting. Review of section O Special treatments, Procedures, and Programs reflected Resident #1 receiving hospice care while a resident.Record review of Resident # 1 Care Plan dated 5.5.23 reflected Resident # 1 had and advance directive DNR code status with interventions of needing the nursing staff to have knowledge of my advance directive and a goal of the staff will adhere to my choices made in my advance directive. Review reflected Resident # 1 had chosen to receive hospice care dated 6.30.25 with goal of remain comfortable throughout hospice care and interventions of assist resident with setting up hospice care, coordinate care with hospice team, coordinate with hospice team to assure resident experiences as little pain as possible, provide resident and resident family with grief and spiritual counseling if desired.Record review of Resident # 1 nursing progress note dated 7.4.25 at 6:23 pm reflected this nurse was called by CNAs to come to this resident room. When arriving to this resident room this resident was observed lying in the bed gasping for air and continuously stating Help Me, Help Me. This nurse then immediately reapplied this resident nasal cannula back in her nares and raised her head. At this time a blood pressure was unable to be obtained and this resident O2 sat was 55%. After applying the nasal cannula 02 raised to 82%. Resident stated call 911, Help Me. This nurse then contacted EMS services and the arrived at 6:29 pm. Resident was transferred to stretcher and exited the facility with 3 attendants at 6:43. Resident RP and DON was also notified of situation. Signed by LVN A.Record review of Resident # 1 nursing progress note dated 7.5.25 at 5:51 am reflected Received report of resident returning to facility from an ER visit following cardiac arrest. No new orders, oxygen via NC at 6L. Resident arrived at facility via EMT services, with 2 EMT personnel, and [family]present. Resident is awake, alert answering few questions.No s/s of pain or distress noted. Resident remains on hospice, DNR, and wishes from RP of no lifesaving interventions. Signed by LVN B.Record review of Resident # 1 hospice binder reflected outside front of binder with sheet stating Call the Nurse First. We may be able to help you avoid unplanned hospitalizations if we know you need our help. Call the nurse first at the number listed below. Hospice provider name and contact number listed. On call 24 hours a day, seven days a week, including holidays. Further review reflected copy of OOH-DNR dated 6.17.25 accurately completed. Review reflected a red sheet of paper with a stop sign symbol stating hospice patient Do Not Resuscitate hospice provider name and contact information. Review of hospice certification and plan of care dated 6.18.25 reflected under orders of discipline and treatment heading:*SN TO INSTRUCT FACILITY STAFF ON HOSPICE RESPONSIBILITIES, 24/7 AVAILABILITY, HOW TO CONTACT HOSPICE, AND FACILITY STAFF RESPONSIBILITIES RELATED TO PATIENT CARE NEEDS AS DELINEATED ON THE HOSPICE PLAN OF CARE *SN TO EDUCATE FACILITY STAFF THAT HOSPICE APPROVAL IS NEEDED PRIOR TO ANY NEW ORDERS AND TO CONTACT HOSPICE STAFF FOR ANY CHANGE IN PATIENT CONDITION.*SN TO INSTRUCT PATIENT/CAREGIVER ON MEDICATION REGIMEN AND SIDE EFFECTS. *SN TO INSTRUCT PATIENT/CAREGIVER ON HOW TO MAINTAIN A MEDICATION ADMINISTRATION RECORD. *SN TO ASSESS EFFECTIVENESS OF TREATMENT REGIMEN.SN TO ASSESS FOR PAIN AND POTENTIAL CAUSES*SN WILL INSTRUCT PATIENT/CAREGIVER ON ADMINISTRATION OF INHALATION THERAPIES AND CARE OF EQUIPMENT.*SN TO INSTRUCT PATIENT/CAREGIVER ON RESPIRATORY DISEASE PROGRESSION, COMMONS SIGNS/SYMPTOMS, AND MANAGEMENT OF DISEASE PROCESS/SYMPTOMS.*SN TO ASSESS PATIENT FOR SIGNS AND SYMPTOMS OF IMPAIRED RESPIRATORY FUNCTION, DIFFICULTY BREATHING AND DISEASE PROGRESSION.*SN TO ASSESS FOR SAFE AND APPROPRIATE USAGE OF OXYGEN.*SN TO ASSESS FOR ANXIETY AND POTENTIAL CAUSES. SN TO ASSESS EFFECTIVENESS OF TREATMENT REGIMEN.Record review of hospice provider call log dated 7.4.25 at 6:56 pm reflected patient complained of SOB and her respirations slow and unable to get blood pressure. Patient sent to hospital. Observation of camera recordings of Resident # 1 incident on 7.4.25 reflected 4 facility staff in Resident # 1 room observation of vitals being taken and Resident # 1 being assessed by facility staff. Further review reflected 3 EMS staff observed coming into Resident # 1 room chest compressions being initiated and Resident # 1 being prepped for transport.Interview on 7.14.25 at 10:20 am with Resident # 1's RP revealed they felt the facility was unsure of their own policy and procedures concerning hospice residents and residents with DNR's. RP stated when Resident #1 was unresponsive that the facility called EMS and treated her and sent her to the hospital prolonging her suffering even with a DNR in place. RP stated she; nor hospice; nor the DON were called until Resident #1 had left the facility with EMS. RP felt Resident #1 suffered thru living extra days because of actions taken by the facility. Interview on 7.14.25 at 3:10 pm LVN A stated she works 7a-7p shift. Been working at the facility 10 months. Received ANE and Resident Right trainings via CBT monthly training and in person monthly staff meeting as well as management team bringing off cycle in-service trainings around. LVN stated advance directives are in the electronic record keeping system. LVN A stated if a resident has a COC, then the nurse obtains vitals and assesses the resident. LVN A stated the nurse calls the doctor if the resident was not hospice to obtain further instructions, if the resident was on hospice services, then the nurse calls the hospice company to obtain further instructions. LVN stated for Resident # 1 COC she obtained vitals and assessed then she called hospice and got the on-call reception. LVN A stated she waited fifteen minutes for the hospice nurse to return call during the wait LVN A stated she contacted the facility doctor who advised the nurse to contact EMS. LVN A stated she contacted EMS for transport. LVN A stated while resident was still in the parking lot with EMS, LVN A called hospice again and spoke to hospice nurse and hospice nurse told the LVN A she would meet resident at the hospital. LVN A acknowledged that the progress note in resident electronic record does not state hospice was contacted prior to contacting EMS and transferring resident from facility. Interview on 7.14.25 at 3:34 pm with Hospice on-call nurse revealed Hospice nurse stated she received a call from the hospice triage line on 7.4.25 at 7:00 pm stating that Resident # 1 was SOB and unable to obtain a BP and that resident was sent out to the hospital. Hospice nurse stated she then contacted the facility and confirmed from LVN A that the resident had a COC was found SOB and unable to locate a BP and at that time EMS was called and resident was sent out. Hospice nurse inquired if the RP had given permission for transport. Hospice nurse stated charge nurse was unable to give an answer as to why resident was sent out prior to receiving authorization from hospice or RP. Attempted telephone interview on 7.14.25 at 4:15 pm with facility doctor no answer message left awaiting return call.Interview on 7.14.25 at 5:00 pm the DON stated she has worked at facility 3 1/2 years. DON stated if a resident has a COC, then the charge nurse was to go down and assess the resident. DON stated if the resident was on hospice the charge nurse was to notify the hospice company to attain further instructions. DON stated if the matter was emergent then the charge nurse does not transfer a resident until instructed by hospice. DON further stated that the charge nurse was to perform any treatments or give any medications the resident has that can be beneficial until transfer can be arranged, or further instruction was received from the MD, NP, or hospice. DON stated after notifying the MD, NP, or hospice then the nurse was to notify the DON, and RP of a COC. DON stated if a hospice resident was transported to the hospital prior to receiving approval from hospice it could negatively affect a resident emotionally, and psychologically due to having to endure unnecessary treatment and trips. DON stated nursing was to document everything patient related in the electronic record keeping system. DON stated if something was not documented then there was no proof it occurred. DON stated she was responsible for ensuring the nursing staff document resident information accurately. Interview on 7.14.25 at 6:05 pm with ADM revealed ADM stated he expected the nurse to attend the resident first, then notify hospice as soon as possible. ADM stated he does not feel the situation was handled wrong or right. ADM stated EMS was called for resident treatment and EMS make the decision to transport. ADM stated he does not feel the resident was transported unnecessarily as the resident just needed stabilizing and suffered no ill effects. ADM stated he feels hospice residents should have hospice contacted first. ADM stated he feels the nurse made the right decision in a split-second type of situation. ADM stated his expectation was that nursing document resident information. ADM stated he feels the facility systems did not fail but that the processes just need to be fine-tuned. ADM stated ultimately the responsibility of nursing training and documentation was the ADM responsibility. Record review of in-service dated 7.8.25 titled Guidelines/Parameters related to When to send hospice resident to the ER and when not to. Calling hospice service conducted by hospice provider with 9 staff attendance signatures. Supporting documentation provided from hospice provider. Record review of supporting documentation from in-service dated 7.8.25 reflected:Call Hospice, not 911Supporting hospice patients with dignity in the nursing homeWhen hospice patient declines call hospice first. If a resident is under hospice care is physically declining, calling 911 may not align with their end-of-life goals. We are available 24/7 to manage symptoms and provide guidance at the bedside, helping patients remain in comfort and dignity right where they are-home.Why not call 911? Hospital transfers are often painful and disorienting.ER visits can prolong suffering and may lead to interventions the patient didn't want.Calling 911 may go against the patients wishes and care plan.What to do instead:Call hospice provider first:-Our nurses will triage the situation and come to the facility if needed.-We manage most symptoms directly in the nursing home.Call the family:-Keep them informed and calm.Treat symptoms if appropriate:- Use hospice approved PRN medications.- Follow the hospice plan of care and consult with hospice nurse as needed.Record review of facility Residents Receiving Hospice Services policy undated reflected under heading procedure:1. When a facility resident has also elected the Medicare hospice benefit, the hospice, and the nursinghome must communicate, establish, and agree upon a coordinated plan of care for both providers which reflects the hospice philosophy, and is based on an assessment of the individual's needs and unique living situation in the facility.2. The plan of care must include directives for managing pain and other uncomfortable symptoms andbe revised and updated as necessary to reflect the individual's status.3. This coordinated plan of care must identify the care and services which the nursing facility and hospicewill provide to be responsive to the unique needs of the resident and their expressed desire forhospice care.4. The nursing facility and the hospice are responsible for performing each of their respective functionsthat have been agreed upon and included in the plan of care.5. The hospice retains overall professional management responsibility for directing the implementationof the plan of care related to terminal illness and related condition.Record review of facility Hospice benefit care requirements policy undated reflected under heading procedure:For a resident receiving hospice benefit care4. The plan of care must include directives for managing pain and other uncomfortable symptoms [NAME] revised and updated as necessary to reflect the resident's status.6. The hospice and the facility will communicate with each other when any changes are indicated to theplan of care. Record review of facility Advance directives policy undated reflected under purpose:To ensure every resident has the opportunity to make an informed decision regarding their advanced directives.Under heading policy:Advance directives will be respected in accordance with state law and facility policy.Under heading procedure:15. In accordance with current OBRA definitions and guidelines governing advance directives, our facility hasdefined advanced directives as preferences regarding treatment options and include, but are not limited to:e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legalguardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonaryresuscitation (CPR) or other life-sustaining treatments or methods are to be used.

Based on observation, interview and record review, the facility failed to ensure the right to be free from Misappropriation of Resident Property for 3 of 5 residents (Residents #1, #2 and #3) The facility failed to prevent the misappropriation of Resident #1's discontinued Hydrocodone/ Tylenol 7.5mg/ 325mg when 10 tablets could not be accounted for and Resident #2's hydromorphone liquid 1mg/ml when 120 ml could not be accounted for, and Resident #3's Hydrocodone/ Tylenol 10 mg/ 325mg when 56 tablets could not be accounted for. The noncompliance was identified as PNC. The past noncompliance began on 05/29/2025 and ended on 06/04/2025. The facility had corrected the noncompliance before the investigation began. This failure had the potential to affect the residents in the facility by placing them at risk for misappropriation of resident medication and drug diversion. Findings included: Review of Resident #1's face sheet reflected she was admitted on [DATE] and discharged from the facility on 05/29/2025 with the following diagnoses COPD (disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.), and left femur fracture (fracture of left hip). Review of Resident #1's Medicare 5-day MDS assessment reflected she was assessed to have a BIMS score of 14 indicating she was cognitively intact. Resident #1 was assessed to have pain and be on an opioid. Review of Resident #1's comprehensive care plan reflected Resident #1 was discharged from the facility with her family member on 05/29/2025. Further review of Resident #1's care plan reflected she had a focus area related to chronic pain syndrome. Interventions included administer pain mediation as ordered. Review of Resident #1's physician's orders reflected an order for Hydrocodone-Acetaminophen 7.5mg/ 325mg every 6 hours as needed for pain with the start date 05/13/2025 and discontinued on 05/29/2025. Review of Resident #2's face sheet reflected she was admitted on [DATE] and readmitted on [DATE] and discharge date of 05/26/2025. Resident #2's diagnoses included cerebral infarction (the pathologic process that results in an area of necrotic (dead tissue) tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia).) and vascular dementia (A group of symptoms that affects memory, thinking and interferes with daily life.). Review of Resident #2's discharge MDS (death in facility) reflected Resident #2 was assessed to be on hospice services. Review of Resident #2's comprehensive care plan reflected Resident #2 had a plan of care for pain and hospice with interventions that included pain medication. Review of Resident #2's physician's orders reflected an order hydromorphone HCL liquid 1mg/ml every 2 hours as needed for pain with a discontinuation date of 05/26/2025. Review of Resident #3's face sheet reflected she was admitted on [DATE] with the following diagnoses cerebral infraction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia).) and diabetes mellitus type 2 (A condition results from insufficient production of insulin, causing high blood sugar.). Review of Resident #3's Quarterly MDS assessment reflected a BIMS score was not conducted indicating she had severe cognitive impairment. Resident #3 was assessed to have scheduled pain medication regimen. Review of Resident #3's comprehensive care plan reflected a focus area for hospice care and routine pain medication. Review of Resident #3's physician's orders reflected Resident #3 Hydrocodone-Acetaminophen 10 mg/ 325mg with a discontinuation date of 05/30/2025. Review of the facility's investigation report dated 05/29/2025 reflected on 05/29/2025 the ADON took Resident #1's discontinued medication Hydrocodone-Acetaminophen 10 mg/ 325mg off the medication cart from the charge nurse LVN A. LVN A was concerned regarding the way the ADON took the discontinued medication off her cart without signing for it. LVN A informed her DON. When the DON requested the ADON produce the discontinued mediation, the count sheet had been modified from the last accurate count of 49 (which was documented with two nursing signatures at morning shift change on 05/29/2025) to 39. The ADON had no explanation for the discrepancy except that she did not follow the facility's procedure. Further review of the facility's investigation report reflected that during an audit of all discontinued medications the facility found 2 additional medications missing for Resident #2 and Resident #3 (Resident #2's hydromorphone liquid 1mg/ml when 120 ml could not be accounted for, and Resident #3's Hydrocodone/ Tylenol 10 mg/ 325mg when 56 tablets could not be accounted for). The facility terminated the ADON because she did not follow narcotic policies and procedures that she knew. She stated that in her statement and she was the last in chain of custody for Resident #1's discontinued medication. It was also decided to in -service all staff to not release medications without a signature or give keys to anyone, no matter their position (ADON follows same policies and procedures and everyone else.) LVN A, even though she identified the concern was counseled individually by the DON because she released the medications without proper procedures being followed. The facility further put a new policy in place that two signatures were required when placing discontinued medications in storage that are waiting for destruction. The facility's investigation team decided that this drug diversion was confirmed because the ADON was in possession as the last in the chain of custody and the count was off. She validated that she did not follow the facility policy and took full responsibility. The ADON was terminated 06/04/2025 while on suspension for not following proper narcotic policy and procedures. Review of the facility's individual patient's antibiotic/ narcotic record for Resident #1's hydrocodone reflected the count for the medication was documented as 49 on 05/29/2025, then there were an additional three entries on the narcotic log dated 05/28/2025 with one-tab documented. However, the ending count was 39. With a total of 10 pills missing. Review of Resident #1's MAR dated May 2025 reflected the last dose given to Resident #1 was given at 1:00 am on 05/29/2029. Review of Resident #1's narcotic record log for the medication (not dated ongoing log) reflected three entries after that with the count going down 10 pills. The signature on the form was not readable. In an interview on 06/17/2025 at 1:00 PM the ADON stated she took Resident #1's narcotics off the medication cart and took them to her office and put them in a drawer because she did not think the resident was supposed to take narcotic medication home with them once they discharged . She stated she did not count the medication when she removed them from the cart. She stated she had worked at other facility's where the residents were not able to take the medication home. The ADON denied taking any of the medication and stated she did not know about the other missing discontinued narcotics. She stated all she did was remove the medication and put it in a locked drawer in her office. She stated she did not have a chance to take it to the discontinued drug drawer that was why it was in her office. She stated she knew she was supposed to take all discontinued meds to the discontinued lock up which had two locks and a log for the medication. In an interview on 06/17/2025 at 1:20 PM LVN A stated she was discharging Resident #1 when the ADON came to her and stated she needed the keys to her medication cart and did not say what she needed the keys for. LVN A stated she followed the ADON to her medication cart and saw she took Resident #1's narcotic medication and stated to her that the resident could not take them home with her. LVN A stated the ADON took the medication to her office. LVN A stated it did not sit well with her that the ADON did not sign the medication out. LVN A further stated she always sent all the resident's medications home on discharge. LVN A stated once the DON came in, she went and told her what the ADON did. She stated the DON told her that yes, the medications were supposed to go home with the resident. She stated her and the DON went to the ADON's office to get the medication. LVN A stated the ADON was fumbling around like she did not know where the medications were and then finally, she took them out of a drawer where they were in the back of the drawer. Observation on 06/17/2025 at 1:25 pm of the narcotic count and signature sheets of south side nurse cart revealed no discrepancies and the medications were counted at shift change. In an interview on 06/17/2025 at 1:30 pm the DON stated when she came in to work on 05/29/2025 LVN A came to her and told her the ADON removed medications from her cart, and she felt like it was not right. The DON stated she went with LVN A to the ADON's office to get the medications. The DON stated when they got to her office the ADON at first acted like she did not have the medication, then removed them from the back of her desk drawer from behind some files. The DON stated the ADON told her she knew the procedure for discontinued medications and that they were supposed to go to the discontinued drug file cabinet. The DON stated the ADON did tell her that she did not think the medications could go home with the resident. The DON stated she did not have an explanation of why the count was not correct or who's signature was on the narcotic sheet for the last three sign outs that were not given. In an interview on 06/17/2025 at 1:35 pm the DON stated she did not recognize the signature on Resident #1's narcotic record. The DON stated she compared the signature with all her nurse signatures, and they did not match. Observation on 06/17/2025 at 1:40 pm of the discontinued medication file cabinet revealed the cabinet was double locked. Review of the medication count reflected no discrepancies. Review of the facility's Disciplinary report dated 06/04/2025 reflected the ADON was terminated on 06/04/2025 related to failure to follow the facility's narcotic policy and procedures. Review of the facility's Inservice training dated 05/29/2025 reflected staff were in serviced on the facility's narcotics policy and procedure, prevention of drug diversion and safe medication practices. In an interview on 06/17/2025 at 1:50 PM LVN B stated she was in serviced on narcotics policy and procedures to ensure you always have two nurses signing for narcotics and to make sure when drugs are discontinued the medications are given to the DON and placed in the discontinued storage with two nursing signatures. In an interview on 06/17/2025 at 1:50 PM LVN C stated she was in serviced on narcotics policy and procedures to ensure you always have two nurses signing for narcotics and to make sure when drugs are discontinued the medications are given to the DON and placed in the discontinued storage with two nursing signatures. In an interview on 06/17/2025 at 2:51 pm the Administrator stated moving forward the facility would have two nurses sign out discontinued medications. The Administrator further stated the ADON told him that if he drug tested her that she would be positive because she had a prescription. The Administrator stated she would not tell him what her prescription was. The Administrator stated he reported the incident to the police, but no report was provided to him the police stated to him that without further evidence they would not be able to do anything. Review of the ADON's personnel file reflected a background check was conducted prior to hire on 03/26/2025. Further review of the ADON's personnel file reflected her RN license was checked. Review of the license checked from the BON website reflected the ADON's RN license was current and had formal charges filed as of 11/18/2024. In an interview on 06/17/2025 at 3:00 pm the DON stated that when the ADON was hired, and her license was checked it did not say she had formal charges filed. The DON stated she ran her license again after the incident and saw the formal charges filed statement. The DON stated she called the BON, and they told her the ADON license did not have stipulations as the charges were still under investigation and they were not able to tell her what they were. Review of the facility's policy Narcotics policy and procedure (not dated) reflected All controlled substances shall be counted at the change of each shift. The amount of each controlled substance on hand shall be listed on the Narcotic Count Sheet. PROCEDURE: 1. One (1) licensed nurse from the off-going shift and one (1) licensed nurse from the oncoming shift must count and sign the Narcotic Count Sheet in front of the narcotic box.2. The off-going nurse shall write and observe counting; the counting nurse shall count each shift.3. If the count is wrong, the off-going nursing staff member must stay until the discrepancy is found,4. The cart and medication sheets shall be reviewed to recover the narcotic. 5. The total of each drug found in the controlled substance drawer shall be listed on the Narcotic Count Sheet. 6. The oncoming nurse shall sign his/her name on the count sheet. 7. The off-going nurse shall sign his/her name on the count sheet . All discrepancies shall be reported immediately to the Nurse Manager/Charge Nurse, who will advise the Director of Nursing. 10. The Nurse Manager/Charge Nurse shall assist the nurses in determining what happened to the controlled substance, by following these steps: a. Review controlled substance storage b. Review resident records c. Review controlled substance records d. Each specific fact-finding task shall be listed on the Controlled Substance Discrepancy Record by the Charge Nurse or the designee . Review of the facility's undated Abuse prevention and probation policy reflected Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals .7. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. At least one of the following elements must be present for an incident to be reportable: Identity theft. Theft of money from the resident's bank account. Unauthorized purchases on the resident's credit card or from the resident's funds. A resident who provides a gift to staff in order to receive ongoing care, based on staff's persuasion. A resident who provides monetary assistance to staff, after staff had made residents believe that staff was in a financial crisis, and Drug Diversion: Diversion of resident medication, including, but not limited to, controlled substances for staff use or personal gain .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's kitchen and nourishment room. -The facility failed to ensure food and beverages stored in the walk-in cooler were labeled and dated. -The facility failed to remove the scoop for dry goods stored in large bins for sugar, flour, and thickener powder on [DATE]. -The facility failed to clean and sanitize the resident nourishment room refrigerator which had expired foods and an unknown brown substance in a bag. These failures could place residents who ate food from the kitchen, nourishment refrigerator and ice machine at risk of foodborne illness. Findings included: An observation in the kitchen on [DATE] at 9:10 AM reflected unlabeled salad dressing in small containers, opened juice and milk in cups with lids with no label and date in the walk-in cooler. An observation in the kitchen on [DATE] at 9:15 AM reflected a scoop in the container with sugar in it. In addition, there was a scoop in the flour container and thickener meeting. An observation on [DATE] at 2:42 PM reflected expired yogurt in the nutrition refrigerator on the 100 hallway. In addition, there was a plastic bag with a brown substance inside that was not labeled and dated. In an interview on [DATE] at 10:05 AM the DM stated all foods in the walk-in cooler should be labeled and dated when added to the walk-in cooler. She stated they only keep leftovers three days from the date it was added to the cooler. She stated if a food or drink was not labeled and dated, it could expose residents to food borne illness if served to a resident. She stated the scoops should not be in the bulk foods in bins like the flour, sugar and thickener powder. She stated leaving the scoops in the food could expose residents to germs on the staff's hands and cause food borne illness. She stated the nursing staff maintain the refrigerators in the nutrition rooms on the hallway. She stated there should not be expired foods or unlabeled/dated foods. She stated if these undated, unlabeled liquids and food were served to a resident it could cause food borne illness. In an interview on [DATE] at 11:15 AM, the DON stated the scoops in the bulk food bins could cause food borne illness. She stated the scoops should not be stored in the container with the sugar, flour and thickened powder. She stated the foods in the walk-in cooler and nutrition refrigerator on hallway 100 should not be expired and should be thrown out if they are expired. She stated serving expired foods could cause food borne illness in residents. She stated staff should label and date foods according to policy. She stated expired or outdated foods should be thrown away immediately. She stated floor staff were responsible for cleaning and maintaining the nutrition refrigerator on the hallway and should have removed the expired food and the unlabeled/undated foods. In an interview on [DATE] at 11:30 AM, the ADMIN stated staff should follow the policy for labeling and dating foods stored in the kitchen and nutrition refrigerators. He stated the scoops should not be stored in the bulk foods as it would cause food borne illness in residents. He stated the nutrition refrigerator on hallway 100 was cleaned and the expired foods were thrown away. Review of Food Safety and Sanitation Policy and Procedure (undated) revealed for food storage All time and temperature control for safety (TCS) leftovers are labeled, covered and dated when stored. They are used within 72 hours (or discarded). In addition, Foods with expiration dates are used prior to the use by date on the package. Review of FDA Food Code 2022 revealed scoops may be stored in a clean, protected location if the utensils such as ice scoops, are used only with a food that is not time/temperature control for safety food.

Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one resident (Resident #50) of 23 residents reviewed for nutrition. The facility failed to ensure Resident #50 maintained acceptable parameters of nutritional status as demonstrated by Resident #50 experiencing a 10.98% weight loss in less than 60 days. These failures could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization . Findings included: Review of Resident #50 face sheet dated 11/14/2024 revealed Resident #50 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses on Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Ulcerative colitis (a chronic, inflammatory bowel disease that causes inflammation in the digestive tract), bilateral below the knee amputation, End Stage Renal Disease requiring hemodialysis, congestive heart failure, high blood pressure, anxiety and depression. Review of Resident #50's quarterly MDS assessment dated [DATE] revealed Resident #50 to have a BIMS score of 14 to indicate intact cognition. Resident #50 was noted to require assistance with eating. Resident #50 was not noted to have a swallowing disorder and had no recent weight loss. Resident #50 required a mechanically altered diet and therapeutic diet. Review of Resident #50's Care Plan dated 04/11/2023 revealed Resident #50 required help with my tray set up and verbal cues to help prompt Resident #50. Resident #50 was noted to be at risk for weight loss on 04/11/2023 due to excess fluids being pulled off me at dialysis 3x/week. Interventions included have the dietitian re-evaluate my nutritional status as needed, need my meal served as ordered by my physician, provide me with an attractive setting with socialization opportunity for my meals and weigh me as appropriate. On 10/10/2024, Resident #50 was noted I have altered diet needs I am on a full liquid diet. Interventions included dietitian to evaluate my current nutritional status, I need my diet served to me as ordered, I need my physician and family notified for significant changes and maintain my current listing of food likes and dislikes. Review of Resident #50 Weight records dated 11/13/2024 revealed: 11/07/2024 - 178.4 lbs 10/29/2024 - 187.8 lbs 09/12/2024 - 196.2 lbs 08/15/2024 - 200.4 lbs 05/23/2024 - 194.0 lbs 30 days change (10/29/2024 to 11/07/2024): 9.07% decrease - to indicate severe weight loss 90 days change 9/12/2024 to 11/07/2024): 10.98% decrease - to indicate severe weight loss 6 month change (5/23/2024 to 11/07/2024): 8.04% decrease - to indicate significant weight loss In an observation and interview on 11/12/2024 at 10:24 AM, Resident #50 stated she was in pain related to a fractured leg and back that she sustained in October 2024 after the transportation company (not related to facility) dropped her out of the transport van. She complained of decreased appetite and did not feel like eating. Resident #50 stated the nurse brought her pain medication as scheduled which helped with the pain. Resident #50's breakfast tray was observed on her bed side table with none of the food eaten. In an interview on 11/14/2024 at 9:30 AM, LVN G stated Resident #50 has had decreased intake and poor appetite since she broke her leg and back after the transport van dropped her. She said they encourage her to eat and offer her an alternative if she did not eat the main entree. She said she was not sure if Resident #50 has lost weight in the last few months. She stated the restorative aides were in charge of resident weights and alert the DON to changes. When asked if she was aware Resident #50 lost 22 pounds since August 2024, she said no. She said she was not aware of any new nutrition interventions put into place for Resident #50. She stated they could offer alternative foods or a nutrition supplement shake. She stated other nurses have not brought the weight loss to her attention. She stated she was not sure if the dietitian had evaluated Resident #50. She stated Resident #50 was non-compliant with her diet and would eat food if her family brought her food from outside sources. In an interview on 11/14/2024 at 9:45 AM, the DM stated she was not aware of any diet interventions for weight loss for Resident #50. She stated Resident #50's diet was liberalized by her physician because of decreased intake. She stated she was not aware of supplements of fortified foods being ordered. She stated in the past Resident #50 refused health shakes or other supplements. She stated she was not aware of anyone offering Resident #50 a health shake for the current weight loss. She stated they did not have renal friendly health shakes at this time. In an interview on 11/14/2024 at 10:30 AM, CNA H stated Resident #50 had decreased appetite over the last month or so. She stated Resident #50's blood sugar has been running low due to decreased oral intake. She stated Resident #50's doctor decreased her insulin and liberalized her diet from renal to no concentrated sweets regular diet. She stated she did not know if Resident #50 started eating more when her diet was liberalized. She stated Resident #50 was offered a health shake in the past and refused. She said it had been months since Resident #50 tried a health shake. She stated she was not aware of Resident #50's weight loss and that the nurses would address weight loss. She stated she encouraged Resident #50 to eat her food and offered her a sprite when she didn't want anything else to eat or drink. She was not aware of any other interventions that have been put into place to prevent further weight loss in Resident #50. In an interview on 11/14/2024 at 10:40 AM, the DON stated she was not aware of 20+ pound weight loss in the last two months for Resident #50. She stated they discuss weight loss daily at the morning meeting and Resident #50 had not triggered. She stated the dietitian should have evaluated Resident #50 when the weight loss was discovered. She stated the dietitian has not evaluated Resident #50 for weight loss or made any new recommendations. She stated normally if a resident triggers for weight loss, the dietitian will evaluate them and make recommendations. She stated they then speak with the resident's physician for orders and then start a new intervention like health shakes, fortified foods and/or double portions. She stated the dietitian comes to the facility monthly to review all residents and then weekly the dietitian looks at the weight variance report. She stated if a resident triggers on the weekly report, the dietitian will make recommendations remotely and forward to the facility staff. She stated she did not know why the dietitian did not note the severe weight loss in Resident #50. She stated the DM will also address weight loss by looking a food-preferences, likes and dislikes, of residents to increase intakes. She stated the weight loss should be addressed as soon as its noted by re-checking the weight, asking for a dietitian assessment and notifying the physician for order changes. She stated these had not been done for Resident #50 and she was not sure why the dietitian had not evaluated Resident #50. In an interview on 11/14/2024 at 11:30 AM, the RD stated she had not evaluated Resident #50 for weight loss. She was not aware of Resident #50's recent weight loss of 22 pounds since August 2024. She stated normally she would pick up on weight loss from the weight variance report she reviews weekly. She stated she was at the facility on 11/07/2024 and did not note the weight loss from 10/29/2024 and/or 11/07/2024. She stated the restorative aide that did the weights must not have put the new weight in the system when she was at the facility. She stated the restorative aide does all of the monthly weights so the weights were consistent. She stated she reviewed the weights for everyone monthly and then she reviewed them weekly remotely. She stated she will make recommendations and notify the nursing staff. She stated the physician will order interventions based on her recommendations. She stated for Resident #50 interventions for weight loss might include a renal friendly health shake, fortified foods with meals, snacks, ice cream with lunch and dinner, med pass supplementation and/or double portions. She knew Resident #50 had decreased appetite due to pain from Resident #50's fractured leg and back. She stated she thought Resident #50's nutrition needs were increased due to the healing fractures and the decreased intake might slow her healing time. Review of Resident #50's Dietary Managers Nutritional Review, dated 09/18/2024 revealed Resident #50 had unplanned weight loss in the past 3-6 months of greater than 10% to indicated Resident #50 was at high risk. High risk indicated Resident #50 should be treated for weight loss. Resident #50's diet order was noted to be no concentrated sweets with a good appetite with regular textured food and regular fluids. Resident #50 was noted to be allergic to tomatoes, potatoes, citrus and bananas due to her renal diet. The DM noted Resident #50 was on dialysis on M-W-F she takes a snack lunch meal with her each treatment. She is on a NCS diet but does no [sic] adhere to her diet. She a BLE amputee Her weight in Oct was 198.4 [DATE] & [DATE].6. Review of Resident #50's Annual Dietician Nutritional Assessment evaluations dated 12/07/2023 revealed an assessment. Review of nursing progress noted dated 11/01/2024 revealed Resident #50's blood sugars have been running low lately and resident's appetite has been poor. Notified [PHYSICIAN]. Received new order from [PHYSICIAN] to decrease Semglee (insulin) to 18 units daily. MAR updated to reflect changes. Review of nursing progress note dated 11/01/2024, 10/31/2024, 10/28/2024 (same note all three days) revealed Resident #50 appetite and fluid intake vary. Mainly fair and requires multiple reminders and offerings of her favorite foods to ensure she is taking in enough to maintain her blood sugar. Review of Diet Orders Policy and Procedure (undated) revealed when there is a nutritional indication, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of the resident to achieve outcomes/goals of care. Review of Diet Changes Policy and Procedure (undated) revealed nursing and therapy services is responsible for notifying the dietary department of any changes in the resident's diet, meal service, eating habits, and/or changes in the resident's condition. The policy further noted Nursing or therapy service staff is responsible for notifying the dietary manager when a nutritional problem has been identified (e.g., weight loss, pressure ulcer, eating problems, etc.).

Based on observations, interviews, and record reviews the facility failed to ensure that the medication error rate was not five percent or greater when the facility had a medication error rate of 9.68% based on 3 of 31 opportunities, which involved 2 of 5 residents (Resident #39, and Resident #63) and 1 of 2 MA's (MA D) observed during medication administration. A) Resident #39 had physician orders for Lisinopril 20 mg one tablet by mouth two times a day hold if BP is below 100/60 mm/hg and Metoprolol Tartrate 25 mg give 0.5mg tablet by mouth two times a day to keep pulse in normal range of 60 to 60 and to hold if BP was below 100/60 or pulse 55 bpm. MA D did not check Resident #39's vital signs prior to administering her medication on 11/13/2024 and no blood pressures were documented for November 2024. B) Resident #63 had a physician order for Midodrine HCL 2.5mg by mouth two times day and hold for BP greater than 140/80 mm/hg. MA D did not check Resident 63's vital signs prior to administering her medication on 11/13/2024. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs. Findings included: A) Review of Resident #39's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses essential hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body.), and tachycardia (an irregular electrical signal, called an impulse, starts in the upper or lower chambers of the heart. This causes the heart to beat faster.). Review of Resident #39's annual MDS dated [DATE] reflected she was assessed to have a BIMS score of 4 indicating severe cognitive impairment. Resident #63 was assessed to have hypertension and atrial fibrillation or other dysrhythmias. Review of Resident #39's comprehensive care plan reflected a focus area dated 05/23/2023 I have diagnosis of hypertension. Interventions included, administer my antihypertensive medication as ordered, and obtain and evaluate my blood pressure as appropriate. Further review reflected a focus area I have coronary artery disease . Interventions included, administer my medications as ordered by my physician .I need my vital sings watched as ordered by my physician and as needed . Review of Resident #39's consolidated physician orders reflected an order dated 10/08/2024 Lisinopril 20 mg one tablet by mouth two times a day related to essential hypertension hold if BP is below 100/60 mm/hg. Further review reflected an order for Metoprolol Tartrate 25 mg give 0.5mg tablet by mouth two times a day related to essential hypertension to keep pulse in normal range of 60 to 60. Hold if BP is below 100/60 or pulse 55 bpm. Review of Resident #39's MAR dated November 2024 reflected an entry for Lisinopril 20 mg give one tablet by mouth two times daily hold if BP is below 100/60 mg/hg. No blood pressures were documented on the MAR. Further review reflected an entry for Metoprolol tartrate 25 mg give 1/2 tablet two times daily to keep pulse in normal range of 60 to 60 bpm; hold if BP is below 100/60 or pulse 55 bpm. No BP or pulse were documented on the MAR. Observation on 11/13/2024 at 8:12 AM revealed MA D preparing to administer medications to Resident #39. MA D prepared her morning medications that included her Lisinopril 20 mg and Metoprolol Tartrate 25 mg. MA D administered her medication without taking her vital signs. B) Review of Resident #63's face sheet dated 11/13/2024 reflected a [AGE] year-old female admitted to the facility 03/20/2023 with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), traumatic subarachnoid hemorrhage with loss of consciousness and syncope and collapse. (Bleeding in the space below one of the thin layers that cover and protect your brain.) and syncope (also known as fainting). Review of Resident #63's quarterly MDS dated [DATE] reflected Resident #63 was assessed to have a BIMS score of 3 indicating severe cognitive impairment. Resident #63 was further assessed to have cardiac implants. Review of Resident #63's comprehensive care plan dated 03/20/2023 and revised 07/31/2024 reflected no entry related to syncope or orthostatic hypotension (decreased blood pressure upon standing). Review of Resident #63's consolidated physician orders reflected an order dated 05/24/2024 Midodrine HCL (This medication is used for certain patients who have symptoms of low blood pressure when standing.) 2.5mg by mouth two times day for traumatic subarachnoid hemorrhage with loss of consciousness hold for BP greater than 140/80 mm/hg. Review of Resident #63's MAR dated November 2024 reflected an entry for Midodrine HCL 2.5mg by mouth two times day for traumatic subarachnoid hemorrhage with loss of consciousness hold for BP greater than 140/80 mm/hg. No blood pressure readings were documented on the MAR. Observation on 11/13/2024 at 8:10 AM revealed MA D preparing to administer medications to Resident #63. MA D prepared her morning medications that included her Midodrine HCL 2.5mg. MA D administered Resident #63's medication without taking her vital signs. In an interview on 11/13/2024 at 9:11 AM MA D stated she did not take Resident #39 or Resident #63 blood pressure or pulse prior to administrating their medication because the MAR did not indicate their vital signs needed to be taken. She stated Resident #39 and #63's orders indicated she needed to take Resident #39's blood pressure and pulse prior to giving the medications Lisinopril and Metoprolol and she should have taken Resident #63's blood pressure prior to administering the Midodrine. MA D stated when the orders were put in by the nurses. They did not put in the orders right (correctly) and the vital sign indicator did not show up on the system and that was why she missed it. In an interview on 11/13/2024 at 10:50 AM the DON stated that staff should absolutely be checking the blood pressures and vital signs on resident with parameters in their orders. She stated she would check all the orders to see that the orders were put in, so the vital sign indicators show up when staff are administering the medications. In an interview on 11/14/2024 at 12:46 PM the DON stated it was her expectation that staff give residents their medications per MD orders and that they follow medication parameters. She stated the failure of staff to do so could cause negative outcomes in residents such as blood pressure drops, or heart rate changes. Review of the facility's policy Medication Regimen review not dated that was provided by the facility reflected .9. Each resident's medication regimen shall be reviewed to ensure it is free from unnecessary medications. A medication shall be considered unnecessary when it is used: .c. Without adequate monitoring . The facility's provided policy did not address medication administration using vital signs parameters.

Based on observations, interviews, and record reviews, the facility failed to develop a comprehensive care plan for one resident (Resident #31) of 23 reviewed, in that: The facility failed to ensure Resident #31's Comprehensive Care Plan reflected a revision of care for his current skin condition and wound care. This failure could place a resident at risk for errors in provider care, and wound tracking. Findings included: Review of Resident #31's face sheet dated 11/04/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses hemiplegia and hemiparesis following a cerebral infarction and pressure ulcer of other site, unstageable. Review of Resident #31's quarterly MDS dated [DATE] reflected Resident #31 was assessed to have a BIMS score of 1 indicating severe cognitive impairment. Resident #31 was assessed to be at risk of developing pressure ulcers/injuries. Resident #31 was assessed to not have pressure ulcers or venous and arterial ulcers. Resident #31 was further assessed to not have open lesions on the foot. Review of Resident #31's comprehensive care plan reflected a focus area dated 09/02/2024 I have an arterial status ulcer to my right great toe. Interventions included Watch my venous stasis ulcer for signs and symptoms of worsening . Review of Resident #31's consolidated physician orders dated 11/2024 revealed no physician order for treatment of a right great toe ulcer. Observation on 11/13/2024 at 3:45 PM revealed Resident #31 in room in bed. The ADON/ Treatment nurse stated Resident #31 did not have any open areas to his right foot. The ADON/ Treatment removed Resident #31's covers to his feet to reveal no open areas to his right great toe. Review of Resident #31's skin and wound evaluation dated 11/12/2024 reflected his arterial, right dorsum hallux ulcer was resolved. In an interview on 11/14/2024 at 9:55 AM the MDS Coordinator stated he was in charge of updating resident care plans. He stated he gets the wound notes from the treatment nurse on Mondays, and he updates the care plans. The MDS Coordinator stated Resident #31's care plan should have been updated after his toe healed. He stated by not updating the care plan it could have a negative effect on the resident cares and affect his wound care. In an interview on 11/14/2024 at 12:46 PM the DON stated she expected staff to update residents plans of care with any changes to their care. The DON stated the staffs' failure to do so could result in residents not receiving proper care. Review of the facility's policy Care planning policy and procedure (not dated) reflected .Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals and approaches Resident's care plan will be reviewed with the resident, responsible party and interdisciplinary team quarterly and as needed 44174

Based on observations, interviews, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 34 and Resident #75) reviewed quality of life. 1. The facility failed to ensure Resident #34 nails were cleaned and did not have any rough edges on 11/12/2024. 2. The facility failed to ensure Resident #75 facial hair was removed on 11/12/2024. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident # 34's Face Sheet dated, 11/13/2024, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes mellitus with diabetic polyneuropathy (occurs when high blood sugar levels over time damage nerves), chronic pain ( a long term pain condition that lasts longer than the normal recovery period for an injury or illness ), and peripheral vascular disease ( a condition that occurs when the blood vessels outside of the heart and brain narrow or become blocked, reducing blood flow to the body). Record review of Resident #34's Quarterly MDS Assessment, dated 10/08/2024, reflected the resident had a BIMS score of 8 indicating his cognition was moderately impaired. Resident #34 required partial/moderate assistance ( helper does less than half the effort) with personal hygiene, lower and upper body dressing, showers, and transfers. Record review of Resident #34's Comprehensive Care Plan, with a completed date on 10/25/2024 reflected Resident #34 required staff assistance for all ADLs. Intervention: Assist Resident #34 with hygiene and grooming tasks. Resident #34 had diagnosis of type 2 diabetes. Record review of Resident #34's nurses notes from 10/01/2024 to 11/13/2024 Resident #34 did not refuse nail care. Observation on 11/12/2024 at 9:37 AM, Resident #34 was lying in bed. Resident #34 had blackish / brownish substance underneath his all his nails on his right hand. He had rough edges around his nails on his right hand. In an interview on 11/12/2024 at 9:45 AM, Resident #34 stated he bites his nails when they are long and he was unable to keep them from being rough. Resident #34 stated he asked staff few days ago to cut his nails and clean them. He did not recall the staff name. He stated when his fingernails needed to be cut he would bite them. Resident #34 stated he had few nails to bite for all of his nails to be shorter. He stated when he bites his fingernails they never were straight. Observation on 11/13/2024 at 8:10 AM, Resident #34 was lying in bed. Resident #34 had blackish / brownish substance underneath his all his fingernails on his right hand. He had rough edges around his fingernails on his right hand. In an interview on 11/13/2024 at 8:13 AM, Resident #34 stated he requested his fingernails to be cut and cleaned on Saturday (11/09/2024 and Sunday (11/10/2024) and the staff told him someone would come to his room and do nail care sometime that day. He stated he did not recall the staff name. He stated when he was unable to get someone to cut his nails he would bite them off and that was the only way he could get his nails trimmed. Resident #34 stated his nails would be sharp when he was not able to bite them straight. He stated he would get hang nails sometimes and was afraid his nails would become infected. Resident #34 stated he was a diabetic and his nails needed to be trimmed with nail clippers instead of him biting his nails. Resident #34 stated he sometimes would refuse a shower but never refused having his nails trimmed or cleaned. 2. Record review of Resident #75's Face Sheet, dated 11/13/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of adult failure to thrive ( a syndrome that describes a decline in physical and psychological health in older adults), age-related osteoporosis without current pathological fracture ( when bones become less dense and more likely to break), and weakness ( lack of strength). Record review of Resident #75's Quarterly MDS Assessment, dated 08/27/2024, reflected Resident #75 had a BIMS score of 15 indicating her cognition was intact. Resident #75 required assistance with partial/moderate assistance ( helper does less than half the effort) with personal hygiene, upper body dressing, and toileting hygiene. She required substantial/maximal assistance with showers and lower body dressing. Record review of Resident #75's Comprehensive Care Plan completed on 09/17/2024 reflected Resident #75 required staff assistance for all ADLs. Intervention: assist Resident #75 with hygiene and grooming tasks. Record review of Resident #75's nurses notes from 09/28/2024 to 11/14/2024 reflected Resident #75 did not refuse for facial hair to be removed from face. Observation on 11/12/2024 at 1:31 PM, Resident #75 was sitting in her wheelchair near her bed. She had approximately 1 inch of hair on her chin, on the left and right side of mouth and on her upper lip. In an interview on 11/12/2024 at 1:33 PM, Resident #75 stated she was embarrassed to have hair on her face. She stated she asked the staff yesterday to remove the hair on her face. Resident #75 stated the staff stated they would sometime that afternoon. Resident #75 stated no one came back to her room and removed the hair from her face. She stated she asked someone today to remove the hair from their face and the staff told her they were busy and would do it sometime this weekend. Resident #75 did not recall the staff name or their position. She stated she was so embarrassed to be around people. Resident #75 stated she had always had a lot of pride in her appearance and would never want anyone to see her with hair on her face. In an interview on 11/14/2024 at 8:15 AM, RN A stated the CNAs (Certified Nursing Assistant) was responsible for cleaning, trimming, and filing all residents' nails except for the residents with diagnosis of diabetes. She stated the nurses was responsible for all residents' nails with diagnosis of diabetes. RN A stated residents nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting, diarrhea and dehydration. RN A stated a resident may cause a skin tear on their skin or another resident's skin if the nail was not filed. She stated she had been in-serviced on cleaning, filing and trimming residents' nails but she did not recall the date. She stated the nurses checked the residents with diabetes nails at least 1-2 times per week. She stated the CNAs would report to the nurses if they observed dirty or long nails of any resident with diagnosis of diabetes. RN A stated Resident #34 refused showers and sometimes medications, however, she was not aware of him refusing nail care. She stated if a female resident had facial hair on their face there was a possibility the resident may isolate themselves in their room. RN A stated she was not aware of Resident #75 refusing facial hair to be removed. In an interview on 11/14/2024 at 8:33 AM, CNA B stated the nurses completed all diabetic fingernails, and the CNAs were responsible for all other residents' nails. She stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails during showers. CNA B stated if a resident's nails needed to be cleaned, trimmed, or filed and it was not their shower day, the staff were expected to do any type of nail care as needed. CNA B stated if a resident had blackish substance underneath their nails, it was probably some type of bacteria. CNA B stated if a resident swallowed bacteria it was a potential the resident may become ill such as vomiting. CNA B stated if a resident had rough edges around their fingernails, it was a possibility the resident may scratch themselves or scratch their eyes and develop an infection. CNA B stated if a female resident had facial hair on their chin or upper lip, a resident may not want to leave their room. She stated a female resident may become embarrassed over their appearance. CNA B stated she was not aware of Resident #75 refusing for staff to remove facial hair. She also stated the staff would usually remove female's facial hair in shower and/or as needed. CNA B stated Resident #34 had refused showers in the past. She stated she was not aware of Resident #34 refusing nail care. She stated he was a diabetic and the nurses would complete nail care on Resident #34. She stated if all CNAs were required to report to the nurse if they noticed any changes including long and dirty nails to the nurse of the residents with diagnosis of diabetes. In an interview on 11/14/2024 at 8:50 AM, CNA C stated the CNAs was responsible for cleaning, trimming, and filing all residents' nails except for the residents with diagnosis of diabetes. She stated the nurses was responsible for all residents' nails with diagnosis of diabetes. CNA C stated residents' nails were usually cleaned , filed, and trimmed on their shower days. She stated if a resident had a hang nail or their nails were dirty, nail care was expected to be completed as needed. CNA B stated if a resident had nails that were rough around the edges, there was a possibility a resident may scratch themselves and develop a skin tear. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues such as diarrhea. CNA B stated if she saw a resident with a diagnosis of diabetes needed their nails cut or cleaned, she would report it to the nurse. CNA B stated she had been in-serviced on cleaning, filing, trimming residents' nails, and grooming of female residents. She stated she did not remember the date of the in-service. CNA B stated she was not aware of Resident # 34 refusing nail care. She stated sometimes Resident #34 would refuse clothes to be changed. CNA B stated if a female resident had facial hair the female resident may be humiliated if around people. She stated there was a potential for a female resident not wanting to socialize with others outside of her room. CNA B stated she was not aware of Resident #75 refusing any care including removing facial hair. In an interview on 10/24/2024 at 10:45 AM, Director of Nurses stated if a resident ingested blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria. She stated there was a possibility a resident may develop vomiting or diarrhea. She stated all residents was expected to receive nail care during showers and as needed. Director of Nurses stated the CNAs completed nail care on all residents except for the residents with diagnosis of diabetes. She stated all residents with diagnosis of diabetes, the nurse was responsible for their nail care. The Director of Nurses stated she did expect the CNAs to report any changes in all residents' nails to the nurse supervisor. She stated if a resident had rough nails, there was a potential a resident may scratch themselves or someone else and cause a skin tear. The Director of Nurses stated if a female resident had facial hair the resident may become humiliated when around other people. She stated a resident may want to stay in their room to prevent others from seeing her with facial hair. She stated she was not aware of Resident #75 refusing hair to be removed from her face. She stated it was the nurse supervisor responsibility to monitor ADL care. The Director of Nurse stated Resident #34 did refuse showers; however, she was not aware of him refusing nail care. She stated if a resident with a diagnosis of diabetes refused nail care, the nurse was responsible to document the nail care refusal in the nurses' notes. The facility Policy on Nail Care, dated 11/11/2021, reflected the following: Policy: 1. To prevent infection. 2. To prevent irritation. 3. To prevent break in skin integrity 4. To promote peripheral (an infection that occurs in the outer tissues of the body) circulation. 5. To promote cleanliness 6. To relieve pain. Procedure: 1. Care of fingernails and toenails is part of the bath. 2. Be certain nails are clean. 3. If nails are difficult to cut, inform the charge nurse. 4. Nails are to be clipped and filed smoothly. 5. Cut straight across the nails. The podiatrist or licensed nurse clip nails for all diabetic residents and residents with peripheral vascular disease. 6. Residents who refuse nail care should be reported to the nurse. 7. Apply lotion to skin as needed.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident # 61) of four residents reviewed for accidents and hazards. The facility failed to ensure Resident #61 intervention of a fall mat was placed on the side of the bed on 11/13/2024. This failure could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life. Findings included: Record review of Resident #61's face sheet, dated 11/14/2024, reflected an [AGE] year-old female was admitted to the facility on [DATE] with the following diagnoses of syncope and collapse ( sudden loss of consciousness), unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (dementia [a general term for a decline in mental abilities that affects memory, and reasoning, and can interfere with daily life] where the specific type of dementia cannot be clearly identified and the person does not exhibit any behavioral disturbances), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #61's Quarterly MDS, dated [DATE], reflected Resident # 61 had a BIMS score of 3 indicating her cognition was severely impaired. Resident #61 required supervision with transfers. She required partial/moderate assistance (helper did less than half the effort). Resident #61 Record review of Resident #61's Comprehensive Care Plan of a start date, 09/17/2024 and a completion date of 10/01/2024 reflected Resident #61 was a risk for falls related to impaired mobility, cognitive deficit and functional incontinence, and history of falls. Resident #61 had a fall on 1/11/2024, 3/31/2024, and 4/08/2024. Interventions: low bed with fall mat. Staff to encourage assistance with transfers and toileting. Resident #61 required staff assistance for all ADLs related to cognitive deficit (affects a person's mental processes, including learning, thinking, remembering, and decision-making). Interventions: Resident #61 required assistance with transfers, assistance with ambulation, and bed mobility. Observation and interview on 11/13/2024 at 8:26 AM Resident #61 were lying in bed with eyes opened. A fall mat was located against the chest of drawers on the wall in front of her bed. Resident #61 bed was in low position. Resident #61 was not interview able. In an interview on 11/14/2024 at 8:15 AM, RN A stated the CNA's (certified nurses assistant) were responsible to ensure fall mats was placed beside Resident #61's bed after assisting Resident #61 from wheelchair to bed. She stated Resident #61 did require assistance with transfers most of the time. RN A stated Resident #61 was a fall risk and had a history of falls. RN A stated Resident #61 required a fall mat beside her bed. RN A stated if Resident #61 fell on to the floor without the fall mat beside her bed, there was a possibility Resident #61 may sustain a broken hip, head laceration, broken arm, etc. She stated it was on the Kardex for Resident #61 to have a fall mat beside her bed. RN A stated it was the CNAs responsibility to place fall mat beside bed and the nurse supervisor's responsibility to ensure all fall protocols including fall mat was in place. In an interview on 11/14/2024 at 8:33 AM, CNA B Resident #61 was a fall risk. She stated Resident #61 had a history of falling. CNA B stated she had given care to Resident #61 and it was on Resident #61's Kardex ( a medical record the CNAs refers to and the information is gathered from the comprehensive care plan) to have a fall mat beside Resident #61's bed. CNA B stated Resident #1 would attempt to get out of bed without any assistance. She stated Resident #1 required a fall mat beside her bed as a precaution for falls. CNA B stated Resident #61 had a potential to fall out of bed. She stated if Resident #61 fell out of bed and there was not a fall mat beside his bed, she could break a bone, hit her head on something and cause her head to bleed. CNA B stated there was a possibility Resident #61 injury would be serious and require to be assessed at a hospital. She stated she had received a fall protocol in-service within the past 7 or 8 months. She did not recall the date of the in-service. In an interview on 11/14/2024 at 8:50 AM, CNA C stated Resident # 61 was a fall risk and she had given care to Resident #61. She stated Resident #1 was required to have a fall mat beside her bed whenever Resident #61 was lying in bed. CNA C stated if Resident #61 had fallen off the bed and there were not any floor mats beside his bed, there was a possibility Resident #61 may break a hip, leg, arm or have a head injury. She stated the CNAs reviews the Kardex in the electronic medical records to confirm what type of care a resident needed. CNA C stated on Resident #61's Kardex reflected Resident #61 required fall mat beside her bed. CNA C stated when Resident #61 was assisted to bed the fall mat was to be placed beside her bed. She stated she had been in-serviced on falls and fall protocol; however, she did not recall the date. In an interview on 10/24/2024 at 10:45 AM, Director of Nurses stated Resident #61 was required to have a fall mat beside her bed when she was lying in bed. The Director of Nurses stated having fall mat beside Resident #61 bed was on the care plan the CNAs Kardex record ( a record in computer system to alert CNAs on what type of care each resident needed). The Director of Nurses stated if the fall mat was not beside Resident #61's bed there was a potential if she fell from bed onto the floor, she may sustain injury such as broken leg or a broken arm. The Director of Nurses stated it was the nurse supervisor to ensure all fall devices was in place for all residents assessed to be a fall risk. Facility Policy and Procedure on Fall Protocol, dated 06/20/2204, reflected the following: Purpose: To identify residents at risk for falls, initiate preventative approaches, and provide appropriate strategies and interventions. Policy: Each resident will be assessed on admission, re-admission, quarterly, annual, any significant change in condition, and as needed for potential risk for falls in order to initiate preventative approaches, Discussion regarding the acceptable level of risk must be based on individual assessment with input from the resident and/or interdisciplinary team. Procedure: 1. Care Plan will be updated. Interventions: 2. Low Bed with fall mat.

Based on record review and interview the facility failed to transmit resident assessments within the required time frames for 2 of 10 Residents (#27 and #34) reviewed for MDS assessments. A) The facility failed to complete and submit a discharge MDS for Resident #27. B) The facility failed to submit a Quarterly MDS for Resident #34. These failures could place residents at risk of not having their resident specific information submitted for payment and quality measure purposes. Findings included: A. Review of Resident #27's Face Sheet dated 09/28/23, reflected a [AGE] year-old female who was discharged on [DATE]. Review of Resident #27's MDS assessment history, reflected no discharge MDS was completed. Review of Resident #27's undated care plan, reflected Resident #27 was care planned for receiving long term care. Review of Resident #27's progress notes, reflected Resident #27 was sent to the hospital on 05/31/2023. In an interview on 09/28/2023 at 9:50 AM the MDS Coordinator stated a discharge MDS should have been completed for Resident #27 due to her being admitted into the hospital before she passed away. He further stated a discharge MDS should have been completed within 24 hours of a resident being discharged from the facility and Resident #27's discharge MDS was in progress and would be completed. In an interview with the DON on 09/28/2023 at 11:06 am, DON stated Resident #27 should have discharge MDS are completed within 14 days of a resident being discharge home or admitted to the hospital. DON stated that if the discharge MDS is not completed within 14 days then the facility would be out of compliance. B. Review of the undated Face Sheet for Resident #34 reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems), Chronic Respiratory Failure with Hypoxia (low blood oxygen levels), and personal history of other Malignant Neoplasm (cancer) of Bronchus (central passageway into the lung) and Lung. Review of the Care Plan for Resident #34 dated 05/01/2023 reflected she was at risk for falls related to cognitive deficit, unsteady balance, history of falls, psychotropic [affect a person's mental status] medications and generalized weakness. Falls 4/3/23, 5/27/23, 6/23/23, 8/10/23, 9/19/23 and 9/26/23. Goal: I will not experience any injuries related to falls. Interventions/Tasks: 5/27/23 Staff will encourage me to call for assistance with all transfers. 09/26/23 Remind me to ask for assist with all ambulation. Review of the quarterly MDS for Resident #34 dated 08/06/2023 reflected she had BIMS score of 2 indicating severe cognitive impairment. Her functional status reflected she required staff assistance for transfer. In an interview on 09/28/2023 at 10:26 AM the MDS Coordinator stated he sent an MDS spreadsheet to the DON at the end of each week and she signed the assessments. He further stated he forgot to submit the MDS assessment for Resident #34 dated 08/06/2023. In an interview on 09/28/2023 at 10:33 AM the DON stated she looked online every week and signed MDS assessments. She stated the MDS for Resident #34 dated 08/06/2023 was not submitted as it should have been. In an interview on 09/28/2023 at 11:00 AM the ADM stated the facility follows the RAI Manual guidelines to submit MDS assessments and did not have a separate policy. Review of the RAI Manual Version 1.17.1 dated October 2019 reflected Discharge Assessments - return not anticipated should be transmitted at the MDS Completion Date plus 14 calendar days. The RAI Manual reflected the Quarterly MDS non-comprehensive assessment should be transmitted no later than the MDS completion date plus 14 calendar days.

Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 1 of 10 Residents (#34) reviewed for accommodation of needs, in that:. Resident #34 was observed in her room with her call light not in reach. This failure could affect residents who needed assistance and could result in needs not being met. Findings included: Record review of the undated Face Sheet for Resident #34 reflected she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems), Chronic Respiratory Failure with Hypoxia (low blood oxygen levels), and personal history of other Malignant Neoplasm (cancer) of Bronchus (central passageway into the lung) and Lung. Record review of the Care Plan for Resident #34 dated 05/01/2023 reflected she was at risk for falls related to cognitive deficit, unsteady balance, history of falls, psychotropic [affect a person's mental status] medications and generalized weakness. Falls 4/3/23, 5/27/23, 6/23/23, 8/10/23, 9/19/23 and 9/26/23. Goal: I will not experience any injuries related to falls. Interventions/Tasks: 5/27/23 Staff will encourage me to call for assistance with all transfers. 09/26/23 Remind me to ask for assist with all ambulation. Record review of the quarterly MDS for Resident #34 dated 08/06/2023 reflected she had BIMS score of 2 indicating severe cognitive impairment. Her functional status reflected she required staff assistance for transfer. Observation on 09/28/2023 at 9:00 AM revealed Resident #34's was in her bed and her call light was not in her reach. The call light was hanging off the side of the bed near the floor. In an interview on 09/28/2023 at 9:02 AM CNA A stated she had been working at the facility since March 2023. She stated she did not put Resident #34's call light in her reach after she assisted her with breakfast. She stated it could increase her risk of having a fall if she could not call for help and she had been trained to put call lights in reach. In an interview on 09/28/2023 at 9:10 AM LVN B stated the call light should have been in reach for Resident #34 because she was a high fall risk. In an interview on 09/28/2023 at 10:41 AM the ADON stated she had been working at the facility since May of 2023. She stated call lights should always be in reach for all residents as their needs might not be met. She stated Resident #34 was a high fall risk and could be in danger if she could not reach her call light. In an interview on 09/28/2023 at 10:47 AM the DON stated call lights should be in reach for all residents as the potential risk is their basic needs might not be met. Review of the facility's undated policy and procedure titled Call Light, Use of Policy and Procedure reflected Procedure: When providing care to residents be sure to position the call light conveniently for the resident to use. Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand.

Based on observation, interview and record review, the facility failed to develop and implement a person-centered care plan to maintain a resident's practicable wellbeing for one of two residents (Resident #43) reviewed for restraints and one of one resident (Resident #41) reviewed for bed rails. A) The facility failed to ensure Resident #43 who was physically restrained in a wheelchair with a Velcro seat belt without a plan of care for the device. B) Resident #41 was observed in bed with full bed rails on both sides of the bed. Resident #41 did not have a plan of care for the full bed rails. This deficient practice could place residents who were at risk for falls and/or wandered at risk of unnecessary confinement and could place residents at risk for entrapment. Finding Included: A) Review of Resident #43's Face Sheet dated 09/27/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Osteoporosis (A condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist, or spine.), Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.) and Atrial Fibrillation (A disease of the heart characterized by irregular and often faster heartbeat.). Review of Resident #43's Quarterly MDS dated [DATE] reflected Resident #43 was assessed to have a BIMS score of two indicating severe cognitive impairment. Resident #43 was assessed to require limited to extensive assist with ADLs. Further review of Resident #43's MDS assessment reflected she was assessed to not have restraints in chair or that her chair prevented rising. Review of Resident #43's Comprehensive Care Plan reflected a focus area initiated on 05/04/2023 and revised on 08/11/2023 I am at risk for falls related to frequent incontinence, dementia, impaired mobility. Intervention included an intervention dated 07/25/2023 Self-releasing seatbelt to my wheelchair. Further review of Resident #43's care plan reflected no plan of care for the use of the seatbelt. Review of Resident #43's Consolidated Physician orders reflected an order dated 08/03/2023 Observe placement and positioning of Soft, Velcro, Self-Releasing Seat Belt when in wheelchair Q shift and PRN. (Reposition device as needed and assess resident's ability to self-release the device Q shift and PRN). Review of Resident #43's TAR dated September 2023 reflected an entry to Observe placement and positioning of Soft, Velcro, Self-Releasing Seat Belt when in wheelchair Q shift and PRN. (Reposition device as needed and assess resident's ability to self-release the device Q shift and PRN). The entry was signed at 7:00 AM and 7:00 PM daily. Observation and interview on 09/26/2023 at 10:12 AM revealed Resident #43 up in wheelchair wheeling self in the hall. Resident #43 was observed to have a Velcro type seat belt on her wheelchair. When Resident #43 was asked what the device was and if she could take it off Resident #43 did not answer and smiled and continued to wheel herself down the hall. Observation on 09/27/2023 at 8:00 AM revealed Resident #43 up in wheelchair in hall with seat belt in place. Review of Resident #43's Safety Device Consent form dated 08/03/2023 reflected verbal consent was obtained from her responsible party for a Velcro self-releasing seat belt for poor balance and poor safety awareness. Review of Resident #43's Safety Device Reduction/ Elimination assessment dated [DATE] reflected Resident #43 was a poor candidate for device reduction related to Medical symptoms include frequent attempts to self-transfer without asking for assistance. The resident has very poor Safety awareness related to Dementia. In an interview on 09/28/2023 at 9:29 AM the DON stated Resident #43 could remove her seat belt. She stated the resident did not have a specific care plan for the use of her seat belt and Resident #43's care plan should include a release schedule and specific interventions for the use of the seat belt. Review of the facility's undated policy Restraint Devices, Physical Policy and Procedure reflected Purpose: . To prevent the resident from injuring himself or others. Restraints of any type will not be used as punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff . Develop or review resident care plan for type of restraint device, reason for use, alternate methods to be used and method of application. List medical symptoms to be treated and methods to reduce and eliminate the restraint device .add the safety device and/ or skin device to the resident's care plan . B)Review of Resident #41's Face sheet dated 09/27/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), Vascular Dementia (A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), Chronic Kidney Disease, Stage 3 (kidneys are damaged, but they still work well enough that you do not need dialysis or a kidney transplant. Kidney disease often cannot be cured in Stage 3, and damage to your kidneys normally is not reversible.), and Spinal Stenosis (A condition where spinal column narrows and compresses the spinal cord.) Review of Resident #41's Quarterly MDS dated [DATE] Resident #41 was assessed to have a BIMS score of one indicating severe cognitive impairment. Resident #41 was assessed to require extensive to dependent assist with ADLs. Resident #41 was assessed to not have Bed rails. Review of Resident #41's Consolidated Physician Orders reflected an order dated 05/25/2023 Provide fall matt at bedside side rails x 2. Further review reflected an order dated 05/05/2023 for hospice services. Review of Resident #41's Comprehensive Care plan reflected a focus area initiated on 04/24/2023 and revised on 06/18/2023 I am at risk for falls r/t weakness, Alzheimer's, poor impulse control 6/18/23- Unwitnessed fall, no injuries. Interventions included 6/18/23- staff to evaluate me for a scoop mattress .Provide Fall [NAME] at my Bedside to minimize risk of injury. Further review of care plan reflected no entries related to siderails. Review of Resident #41's Safety Device Consent form dated 07/31/2023 reflected consent for siderails to maintain body alignment and increase resident sense of safety and security. Observation and interview on 09/26/2023 at 10:15 AM revealed Resident #41 in room in bed. Resident #41 was not interviewable. Resident #41 had full side rails that enclosed both sides of the bed with approximately 6 inches of space and the head and foot of the bed. Resident #41 was further noted to be in a low bed with a bolster mattress with a fall matt noted underneath the bed. Resident #41#s Responsible Party was in the room. Resident #41's RP stated the bedrails were used whenever Resident #41 was in bed. When asked if she had ever tried to climb out of the bed over the siderails he stated yes, she had but she was not able to get out of the bed. Observation on 09/27/2023 at 7:51 AM revealed Resident #41 was in bed with both full bed rails up. In an interview on 09/27/2023 at 2:00 PM AM LVN A stated Resident #41 did have full bed rails and were used whenever she was in bed. When asked why she had them on her bed she stated she was not sure, but they were on the bed that hospice brought in. When asked if she could put the bed rails down on her own, she stated no. In an interview on 09/28/2023 at 9:00 AM CNA D stated Resident #41's bedrails were used when she was in bed, so she did not fall out of bed. In an interview on 09/28/2023 at 9:29 AM the DON stated Resident #41 did have full bedrails and Resident #41 was not able to put them down on her own. The DON stated the use of the bedrails should be care planned. The DON further stated the full bedrails should not be used since they prohibited Resident #41 from getting out of bed on her own making them a restraint. Review of the facility's undated policy Restraint Devices, Physical Policy and Procedure reflected Purpose: . To prevent the resident from injuring himself or others. Restraints of any type will not be used as punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff . Develop or review resident care plan for type of restraint device, reason for use, alternate methods to be used and method of application. List medical symptoms to be treated and methods to reduce and eliminate the restraint device .add the safety device and/ or skin device to the resident's care plan . The facility did not provide a policy for the use of bed rails. Review of the facility's undated policy Care Planning Policy and Procedure reflected To provide a comprehensive plan of care addressing resident's needs, strengths, goals, and approaches. Policy: Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches . 45957 Resident #26 Accidents Resident [NAME] is a smoker. Resident [NAME] has been assessed for smoking. Resident [NAME] is not care planned for smoking 09/28/23 - 09:50 [NAME] Martinize - MDS Coordinator - stated that the care plan is a projection of care for the resident rather long or short term, list of diagnose and preventions. Care plan also assist with a overview of the care that should be provided to the resident. [NAME] stated that if a resident is smoker then that resident should be care plan for smoking. [NAME] stated if a resident is not care planned for smoking then the resident may not be identified as a smoker, or there could side effects from the medication and smoking. The smoker have instruction in PPC for the residents. 09/28/23 - 11:06am DON Waldene Herring stated that the purpose of the care plan so staff can know what care the resident should be receiving. if a resident is a smoker then they should be care planned. DON stated if a resident is not care planned for smoking that the resident could be a harm to them or others, and harm.

32452 Based on observation, interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of two (Resident #22) residents reviewed for pressure ulcers. The facility failed to ensure Resident #22 received his physician ordered pressure ulcer preventative measures routinely. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections. Findings included: Review of Resident #22's Face Sheet dated 09/27/2023 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Hemiplegia and Hemiparesis (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body.), Cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia).) and Aphasia (A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain.) Review of Resident #22's Annual MDS dated [DATE] reflected Resident #22 was assessed to have a BIMS score of four indicating severe cognitive impairment. Resident #22 was assessed to be dependent on staff for ADL assistance. Resident #22 was assessed to be at risk for developing pressure ulcers, to not currently have pressure ulcers and to have pressure reducing devices for bed. Review of Resident #22's Comprehensive Care Plan reflected a focus area initiated on 04/25/2023 I am at risk for skin breakdown related to impaired mobility, incontinence of bowel and bladder, and CVA with Left Hemiplegia. Listed under interventions was an intervention dated 05/24/2023 Provide Bilateral Heel Protectors. Review of Resident #22's Consolidated Physician orders reflected an order dated 05/24/2023 to float heels when in bed. Further review reflected an order dated 05/24/2023 for bilateral heel protectors. Review of Resident #22's TAR dated September 2023 reflected an entry for Bilateral Heel protectors every shift and an entry to float heels when in bed (suspending the heels in order to prevent pressure points.) Observation and interview on 09/26/2023 at 10:45 AM revealed Resident #22 in room in bed. Resident #22 was not interviewable. Resident #22 was noted to not have heels floated or heel protectors on, his feet were pressed against the foot board. Observation on 09/27/2023 at 8:15 AM revealed Resident #22 in bed. His heels were not floated, and he did not have heel protectors on. Observation on 09/27/2023 at 9:45 AM revealed Resident #22 being Hoyer lift transferred to bed after his shower. Skin check revealed multiple healed scars to his left ankle and left side of foot. Observation on 09/27/2023 at 10:02 AM revealed Resident #22 in bed dressed his heel protectors were not on. Observation and interview on 09/28/2023 at 9:09 AM revealed Resident #22 in bed with floating boots on. In an interview with LVN A she stated Resident #22 was supposed to have his floating boats on at all times when in bed. LVN A stated she did not know why they were not on yesterday. In an interview on 09/28/2023 at 9:29 AM the DON stated she expected residents who had pressure ulcer prevention interventions in place for those interventions to be in place. The DON further stated Resident #22 did have a history of skin breakdown and his heels should be floated when he is in the bed. Review of the facility's undated policy Skin care Policy and Procedure reflected Purpose: To maintain and prevent further skin breakdown. The facility will accomplish these goals through prevention, assessment, and treatment . Use pressure reducing or relieving devices as necessary . Position with appropriate surfaces to protect bony prominences .

32452 Based on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to be free from any physical or chemical restraints imposed for purposed of discipline or convenience and not required to treat the resident's medical symptoms and, when the use of restraints was indicated, to use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for one of two residents (Residents #43) reviewed for restraints, in that: Resident #43 was physically restrained in a wheelchair with a Velcro seat belt without a plan of care for the device. These deficient practices could place residents who were at risk for falls and/or wandered at risk of unnecessary confinement. Finding Included: Review of Resident #43's Face Sheet dated 09/27/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Osteoporosis (A condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist, or spine.), Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.) and Atrial Fibrillation (A disease of the heart characterized by irregular and often faster heartbeat.). Review of Resident #43's Quarterly MDS dated [DATE] reflected Resident #43 was assessed to have a BIMS score of two indicating severe cognitive impairment. Resident #43 was assessed to require limited to extensive assist with ADLs. Further review of Resident #43's MDS assessment reflected she was assessed to not have restraints in chair or that her chair prevented rising. Review of Resident #43's Comprehensive Care Plan reflected a focus area initiated on 05/04/2023 and revised on 08/11/2023 I am at risk for falls related to frequent incontinence, dementia, impaired mobility. Intervention included an intervention dated 07/25/2023 Self-releasing seatbelt to my wheelchair. Further review of Resident #43's care plan reflected no plan of care for the use of the seatbelt. Review of Resident #43's Consolidated Physician orders reflected an order dated 08/03/2023 Observe placement and positioning of Soft, Velcro, Self-Releasing Seat Belt when in wheelchair Q shift and PRN. (Reposition device as needed and assess resident's ability to self-release the device Q shift and PRN). Review of Resident #43's TAR dated September 2023 reflected an entry to Observe placement and positioning of Soft, Velcro, Self-Releasing Seat Belt when in wheelchair Q shift and PRN. (Reposition device as needed and assess resident's ability to self-release the device Q shift and PRN). The entry was signed at 7:00 AM and 7:00 PM daily. Observation and interview on 09/26/2023 at 10:12 AM revealed Resident #43 up in wheelchair wheeling self in the hall. Resident #43 was observed to have a Velcro type seat belt on her wheelchair. When Resident #43 was asked what the device was and if she could take it off Resident #43 did not answer and smiled and continued to wheel herself down the hall. Observation on 09/27/2023 at 8:00 AM revealed Resident #43 up in wheelchair in hall with seat belt in place. Review of Resident #43's Safety Device Consent form dated 08/03/2023 reflected verbal consent was obtained from her responsible party for a Velcro self-releasing seat belt for poor balance and poor safety awareness. Review of Resident #43's Safety Device Reduction/ Elimination assessment dated [DATE] reflected Resident #43 was a poor candidate for device reduction related to Medical symptoms include frequent attempts to self-transfer without asking for assistance. The resident has very poor Safety awareness related to Dementia. In an interview on 09/28/2023 at 9:29 AM the DON stated Resident #43 could remove her seat belt. She stated the resident did not have a specific care plan for the use of her seat belt and Resident #43's care plan should include a release schedule and specific interventions for the use of the seat belt. Review of the facility's undated policy Restraint Devices, Physical Policy and Procedure reflected Purpose: . To prevent the resident from injuring himself or others. Restraints of any type will not be used as punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff . Develop or review resident care plan for type of restraint device, reason for use, alternate methods to be used and method of application. List medical symptoms to be treated and methods to reduce and eliminate the restraint device .add the safety device and/ or skin device to the resident's care plan .

Based on observation, interview and record review the facility failed to ensure that a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for four (4) of four (4) residents reviewed for pressure injuries (Residents #11, #10 and #12 and #5). A.) Resident #11 had a pressure injury on her left heel that was first identified as a Stage I boggy area on 08/17/16. The pressure injury was not assessed, measured, or staged from 08/30/16 until 09/14/16, after surveyor intervention; and had progressed to an Unstageable pressure injury with a separate area 2 cm x 2 cm area of Suspected Deep Tissue Injury. B. Resident #10 had a Stage 2 pressure injury on her left foot 2nd toe that declined to Unstageable eschar and the facility was not aware of the decline. She developed a second pressure sore to her left foot on 09/09/16 and the facility was not aware of it. Three additional pressure sores were discovered with surveyor intervention on 09/14/2016. Resident #10 did not have a pressure reduction mattress or wheelchair cushion in place. C. Resident #12 had a blister; Stage 2 pressure sore on her left heel that progressed to an unstageable pressure injury with a surrounding area of redness, the facility ADON was unaware of the new pressure sore and did not notify the physician and family until surveyor intervention. D.Resident #5 had pressure sores to her foot and did not have a pressure reduction surface on her bed until surveyor intervention. These failures further resulted in an identification of an Immediate Jeopardy (IJ) on 09/14/2016. While the IJ was removed on 09/18/2016, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could affect a facility census of 8 residents with current pressure sores and 35 residents identified by the facility as requiring preventative skin care by placing them at risk for unidentified pressure sores, complications of new and/or worsening pressure injuries with delayed treatments and interventions to include need for mechanical debridement and could cause local and systemic infections, pain and amputations. The Findings Include: A. Resident #11 was [AGE] years old and admitted to the facility on [DATE] and a readmission on 03//04/16 with [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] reflected Resident #11 was at high risk for pressure sore and had a pressure relieving device for the chair and an overlay mattress for the bed. Review of a Care plan for Resident #11 dated 08/22/14 and updated on 06/22/16 reflected the following: This resident will have intact skin, free from redness, blisters, or discolorations through 09/22/16. The resident's pressure sore will show signs of healing and remain from infection through 09/22/16. Interventions: Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD. Keep Responsible Party informed (RP). {The care plan did not specify the frequency of assess/record/monitor wound healing.} Monitor/document/report as needed any changes in skin status, appearance, color, wound healing, signs and symptoms of infections, wound size (length x width x depth) and stage. Keep RP informed. Review of physician orders for Resident # 11 reflected the following: 08/17/16 Cleanse Stage I to the right heel with normal saline, pat dry apply skin prep and baby powder and insert heel in protector. Change dressing three times a week and as needed. (The National Pressure Ulcer Advisory Panel defines a Stage I as intact skin with a localized area of non-blanchable redness www.NPUAP.org) Review of a facility Wound Assessment Worksheets dated 08/17/16, 08/24/16, and 08/3016 for Resident and completed by ADON reflected the following: Wound Location- Left heel Treatment to be used: Skin prep, baby powder, padded heel. Stage 1, Length 2.0 cm x 1.5 cm, no depth Wound base- Red, Drainage None, No odor, No Eschar (dead tissue), Peri-wound- scaley Review of the facility's weekly Decubitus Log for the following dates, 08/25/16, 09/01/16, and 09/08/16 reflected there was no documentation of Resident #11's pressure sore to her left heel. An observation on 09/14/16 at 4:35 PM of a head to toe skin assessment of Resident #11 conducted by LVN A and assisted by CNA M reflected the following (the ADON joined the skin assessment to confirm the findings of the left heel ) : Left Heel: Medial Left heel an area of necrotic/eschar (black in color and dead) tissue measuring 4.5 cm x 2.3 cm. with 2 cm x 2 cm area of boggy tissue located below the necrotic/eschar area. In an interview on 09/14/16 at 5:20 PM, LVN A stated she felt the area of eschar on Resident #11's left heel had been present for approximately a month and there had been no changes in the treatment orders. LVN A stated she didn't say anything about the change in Resident #11's left heel because she thought the ADON was measuring and assessing weekly. In an interview on 09/14/16 at 5:00 PM, the ADON stated she had assumed the responsibilities of the treatment nurse in April when the full-time treatment nurse resigned. The ADON went on to say the new responsibilities were in addition to those of the ADON position, and she also works the floor when charge nurses are unavailable. The ADON added, the charge nurses were responsible for the residents' weekly skin assessments performed on a shower day; and signing off on the CNAs Skin Monitoring records completed for each shower day indicating they had been reviewed for any concerns. In a continued interview on 09/14/16 at 5:00 PM, the ADON confirmed she had not done weekly wound assessments and measurements on Resident #11 since 08/30/16. The ADON stated she must have been working the floor and was unable to perform them due to time constraints. The ADON stated she had not informed the DON she had not completed the weekly wound assessments, but she should have. The ADON stated she thought she had seen the pressure sore on Resident #11's left heel about a week ago, but couldn't be certain and was unaware of the area of eschar. The ADON did not have an explanation for why the pressure sore on Resident #11's left heel was not reviewed in the facility's weekly Skin Conditions meeting, other than she thought because the area on her right heel was resolved and there were no other pressure sore areas. According to the ADON, she participates in the weekly meetings with the DON, MDS nurse and the Medical Director and felt strongly all of the wounds/pressure sore were thoroughly reviewed. Review of nurses' notes for Resident #11 dated 09/15/16 and completed by the ADON reflected the following: Resident has dark area to left heel. Appears as dark blood under the eschar. Unstageable at this time. Nurse Practitioner removed dry skin from left heel and found soft pink skin under the eschar. New orders to keep socks off resident use [MEDICATION NAME] lotion to moisturize, and use floatation device for heels at all times. In an interview on 09/16/16 at 3:20 PM, the Nurse Practitioner (NP) stated she was requested by the facility to assess Resident #11's feet. The NP stated after seeing the area of eschar on Resident #11's left heel it was mechanically removed and found old blood underneath and fairly healthy tissue; but she didn't address the bogginess of the left heel other than instructions to monitor. The NP added she discontinued the current orders for skin prep and baby powder because the powder was drying out all the skin on her feet and she was concerned the skin may crack open. She further stated the new orders for Resident #11 were to apply [MEDICATION NAME] cream, no socks, and to float her heels at all times. The NP stated to date she had not been informed Resident #11 had not been assessed for new or worsening pressure sores since 08/30/16. The NP added we rely on them (licensed staff) to assess and inform us (physicians and NPs) if skin conditions are worsening or there is no improvement so appropriate measures can be taken. In a continued interview on 09/14/16 at 5:00 PM, the ADON stated the process of the weekly Skin meetings is she brings her documentation (Wound Assessment Worksheets) to use as a reference and the rest of the team uses the weekly Decubitus Log documentation. The ADON stated the two forms of documentation are not reconciled during the meeting to possibly identify missing wounds or changes in them. The ADON also confirmed she does not bring the weekly skin assessments completed by the charge nurses to review for changes or new areas of suspicious pressure sores. In an interview on 09/16/16 at 11:10 AM, the ADON was asked about the training she received when she assumed the duties of the treatment nurse. The ADON stated prior to April 2016 the facility had a treatment nurse and a wound care physician that cared for the residents; but the wound care nurse resigned and the wound care physician retired. The ADON stated her training consisted of using the National Pressure Ulcer Advisory Panel's poster as a reference for staging; the facility's Wound Care Policy, and in-services she has had attended during her nursing positions in the past. The ADON stated the facility will now have a wound care certified nurse consultant available to her through an outside agency. In an interview on 09/16/16 at 11:45 AM, the DON stated the ADON had not informed her she was unable to do weekly wound assessments on residents. The DON stated there were times when she was told by the ADON that she didn't think she was going to be able to do them; but there wasn't any follow up on her (the DON) part. The DON stated she felt like the ADON was doing a good job with managing wounds in the facility. The DON added she does not review the ADON's documentation during the weekly skin meetings or review the charge nurses weekly skin assessments. The DON also stated she was unaware the ADON was not reviewing them as well. The DON added she is ultimately responsible for ensuring residents receive the care they need, including all aspects of pressure sore management. B. Review of Resident #10's Face Sheet reflected a [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Quarterly MDS dated [DATE] reflected Resident #10 was assessed as having short and long term memory problems with severely impaired decision making. Resident #10 was assessed as requiring limited assistance of one person for bed mobility and transferring and she had no episodes of continent voiding. She was assessed as being at risk for developing pressure sores, and marked as having a pressure relieving device for her bed and her chair. Review of Resident #10's Care Plan reflected she was to receive assistance of one person with her ADLs including bathing and hygiene. Resident #10 was care planned for pain, weight loss and Hospice. In an observation on 09/14/2016 at 2:20 PM Resident #10 warned the CNAs about to transfer her to bed that she had a sore toe and it was a son of a gun. Resident #10 warned the CNAs before they removed her pink house shoes and during the transfer not to hurt her foot. She stated it really hurt and she must have banged it up. CNA K completed the gait belt transfer, covered Resident #10 with her linens and turned the light out on her way out of the room. Surveyor requested CNA K return to the room and remove the socks to see the toes. Resident #10's left sock had bloody drainage on it on the bottom. Upon removal of the left sock it was noted Resident #10 had bloody drainage between every toe and on the bottom of her foot at her toes. There were no foam pads between her toes. Resident #10 was on a vinyl mattress with no pressure reduction surface on the bed or in her wheelchair. In an interview on 09/14/2016 at 2:20 PM CNA K stated she didn't know Resident #10 had any wounds on her toes. In an interview on 09/14/2016 at 2:35 PM CNA L stated she was Resident #10's aide and Resident #10 was up in her wheelchair and dressed when she arrived for work at 6:00 AM and the Hospice Aide, CNA J had bathed Resident #10 earlier in the shift and she had not spoken to her about Resident #10 or her toes. Review of Resident #10's CNA Skin Monitoring Form dated August 2016 reflected Hospice CNA J bathed and assessed Resident #10 each time she was bathed. She noted Toe in the rash column next to abrasions on the days of 08/19 Friday, 08/20 Saturday, 08/24 Wednesday, and 08/26/2016 Friday. Review of Resident #10's CNA Skin Monitoring Form dated September 2016 reflected Hospice CNA J assessed Resident #10 on 9/07/16 Wed., 9/09 Fri., 9/12 Mon, and 9/14/16 Wed. Each assessment had a check mark in the columns labeled bruises, abrasions and scabs. There was not a location described and the picture at the bottom of the form was not marked. Review of Resident #10's Weekly Skin Monitoring performed by the Charge Nurse reflected on 08/16/16 Tues., 08/23 Tues. and 08/30 Tues. the charge nurse for the day wrote Left 2nd toe on the open [MEDICAL CONDITION] line no on the pressure area line. There was no wound description area on the form. Review of Resident #10's Weekly Skin Monitoring (which was photo-copied on 09/19/2016) performed by the Charge Nurse reflected on Tuesday 09/06/16 there was an entry that stated Left 2nd medial toe. On Tuesday 09/13/2016 there was an entry Left 2nd, 3rd, 4th toe. The entry dates of every Tuesday in September were highlighted. LVN A signed the two entries. In an interview on Wednesday 09/14/2016 at 2:40 PM LVN A Resident #10's charge nurse for the day shift stated it was Resident #10's skin assessment day and she had not done a skin check or a dressing change on Resident #10 because she was waiting on the Hospice CNA J to come to the facility and give Resident #10 a bath so she could do her skin assessment. LVN A stated as far as she knew Resident #10 had one pressure sore on her second toe. LVN A stated she was supposed to give report and go on to the other side of the building and take charge for the evening shift which started at 3:00 PM. Review of Resident #10's Nurse Notes dated from 09/01/16 until 09/11/16 did not mention the pressure sore or any prevention measures. An entry dated 09/12/16 reflected RN T recorded; Treatment completed to toes right foot, tender to touch, no sign of infection noted. 09/13/16 9:15 AM Treatment completed to toes right foot, no change noted, no sign of infection noted, very tender to touch will continue to monitor. There was no note of pressure sore declining to eschar or the four additional pressure sores found on 09/14/2016 by the surveyor. In an observation on 09/14/2016 at 3:24 PM after Resident #10 had pain medicine so the ADON could assess her left foot, Resident #10 was found to have: 1) the existing stage 2 on the left medial toe had declined to an unstageable eschar area 1.1 cm x 0.7 cm. 2) The lateral second toe was 0.5 cm x 1.0 cm stage 2. 3) Third medial toe 0.5 cm x 0.5 cm stage 2. 4) Fourth medial toe 0.5 cm x 0.8 cm stage 3. 5) Fourth lateral toe 0.6 cm x 1.2 cm stage 3. There were two abrasions to the base of the great toe; 1.3 and 1.0 cm long. The ADON stated Resident #10 should have been on a pressure reduction mattress. In an interview on 09/14/2016 at 2:35 PM the ADON stated she was to measure the wounds weekly on Wednesdays and whenever a new wound appeared. She further stated no one had informed her Resident #10's Stage 2 Pressure Injury to her second toe had declined to Unstageable eschar and she did not know there were any other wounds to the foot. She stated the Hospice Nurse RN U did not tell her there was a second area on the foot on 09/09/2016. The ADON further stated Resident #10 appeared to have [MEDICAL CONDITION] in her foot also because the top of the foot was red and puffy. Review of Resident #10's September 2016 Treatment Record reflected an entry for a wound dressing; Cleanse Stage 2 to right second medial toe with Normal Saline, pat dry, apply honey and foam insert between each toe. Change on shower days and as needed. Signed 09/06/2016 ADON. The form was signed that the treatment was completed on 09/06, 09/07, 09/09, 09/12 and 09/13/2016. The Treatment sheet reflected Resident #10 was previously receiving a dressing every day from 08/24/2016 until 09/06/2016 when the treatment changed and the frequency changed to shower days and as needed. In an interview on 09/14/2016 at 3:00 PM LVN A stated on 09/09/2016 in the morning hours she had placed foam between Resident #10's toes and wrapped all of her toes in gauze and then ran the gauze across the top of the foot, around the back of the ankle, across the top of the foot again and secured the gauze to the foot. She stated she didn't have an order to wrap the foot with gauze and she did it to make sure the foam stayed put. LVN A further stated she didn't realize wrapping around the ankle and toes could have caused decreased circulation and possibly more pressure from the dressing inside the shoe. She stated there was one ulcer when she did it on the morning of 09/09/2016. Review of Resident #10's Hospice Nurse Notes dated 09/09/2016 no time reflected, The right foot with open areas between great/2nd toe and 4th/5th toe. Dressing in place and pedal pulse. No concerns voiced by facility staff. RN U. In an interview on 09/14/2016 at 4:00 PM RN U, the Hospice Nurse stated on 09/09/16 Resident #10 had a gauze dressing wrapped around all of her toes, across the top of her foot around her ankle and back to the toes. RN U stated there was a piece of foam between the first and second toe and not between any other toes. She stated the order stated to put foam between each toe and she would have expected to find foam between each toe. RN U further stated there were two areas at that time just as she documented. RN U further stated she wrapped the foot in the same manner after she assessed it. She stated it was change of shift time from day to evening shift on Friday, 09/09/16 and she did not talk to either one of the facility charge nurses to inform them of the second wound. She stated Resident #10 did not have any pain on 09/09/2016 and did not flinch. RN U stated she did not believe the gauze was tight but stated she thought some of the pressure was the shoe. RN U further stated CNA J had called her today 09/14/2016 and told her Resident #10's foot seemed redder and she still has open areas on her foot. RN U stated CNA J did not explain to her Resident #10 had an ulcer between each toe on her left foot and CNA J had not told the charge nurse about the wounds, that Resident #10 had received her shower or that the dressing needed replacing. In an interview on 09/14/2016 at 4:45 PM CNA J stated she had arrived to the facility at 10:00 AM on Wednesday, 09/14/2016 and bathed Resident #10. She stated she removed the little foam pads from between her toes before bathing her. CNA J stated Resident #10 had one opening on her toes to begin with then last week she got a second one and today she had three openings. CNA J stated there were dark spots and dried blood and her foot was redder and had more tenderness than it had on Monday. She stated she did not tell the nurse or the aide at the facility. She stated she didn't feel she had seen anything urgent to tell the nurse about so she had called the Hospice Nurse, RN U. CNA J stated there was no gauze on her foot Monday. CNA J stated the skin assessment is done on Fridays and that is why she didn't get the nurse to go to the shower on Wednesday 09/14/2016. Review of Resident #10's Physician Order dated 09/14/2016 reflected she was started on an antibiotic with a [DIAGNOSES REDACTED]. Review of Resident #10's Individual Wound Assessment Sheets reflected: 08/14/2016 reflected a newly acquired pressure area stage 2 was found to the medial 2nd toe. It was 0.4 cm x 0.5 cm. 08/24/2016 (10 days later) Stage 2 left medial 2nd toe 0.4 cm x 0.5 cm with pain on touch and granulation 95% (new skin growth). 09/07/2016 (14 days later) Stage 2 left medial 2nd toe 0.7 x 0.8 cm pain meds required prior to assessment, new orders honey and foam insert between toes. Review of the ADON's handwritten notes dated 08/30/2016 reflected a note: Resident #10; Stage 2 left 2nd toe-improving continue same treatment. Review of the facility compiled pressure sore log dated 08/25/2016 (11 days after Resident #10's stage 2 was identified) reflected Resident #10 was not on the log. The Pressure Ulcer log dated 09/01/2016 reflected Resident #10 had an onset date of 09/01/2016 for a Deep Tissue injury (identified as a stage 2 by the ADON) to the left medial 2nd toe (there was no size documented) and the family and MD were notified on 09/01/2016. The Pressure Ulcer log dated 09/08/2016 reflected Resident #10's ulcer was a stage 2 and was increasing in size at 0.7 x 0.8 cm and there was a new treatment for [REDACTED]. In an interview on 09/14/2016 at 5:25 PM LVN A stated she would have expected RN U to have notified the charge nurse when she found the second opening on Resident #10's foot on 09/09/2016. LVN A stated it wasn't a problem to be interrupted during report at change of shift and she expected to be informed of new wounds. LVN A also stated expects CNA J to notify her of any changes in her residents such as new wounds and she wanted to be told when she could do her treatment to wounds for the day. In an interview on 09/14/2016 at 5:29 PM the ADON stated it was up to the charge nurse to notify the family and MD of new wounds and to get the treatment started. She further stated it was her responsibility to measure the wounds weekly and call the MD if she noticed a decline or the treatment wasn't working. The ADON stated she gave the weekly measurements to the MDS Coordinator who compiled the facility report for the skin meeting. She further stated she doesn't get a report for the meetings; she sits with her individual sheets and does not compare the report to what her individual sheets say. She stated she believed she had measured the wound weekly and didn't know why she didn't have a wound assessment sheet every seven days except that she had worked the floor as a charge nurse and didn't always have time to make them. In an interview on 09/14/2016 at 6:30 PM the Administrator stated he thoroughly believed every wound was being measured every week and he believed the weekly skin meeting document was correct and included every ulcer in the building. In an interview on 09/14/2016 at 8:30 PM the Administrator stated he expected the Hospice CNAs and Nurses to tell the charge nurse when there was a new wound or a decline in the identified wounds. He further stated he expected the treatments to be done as ordered. The Administrator also stated he expected the family and physician to be notified of new wounds and he expected the residents to be on pressure reduction surfaces as appropriate. Observation on 09/15/2016 at 10:00 AM reflected Resident #10 was in the lobby by her nurse station in her wheelchair and stated my leg feels like it is gonna fall off and my tail hurts from sitting in this chair. There was no cushion in Resident #10's chair. The nurse gave her some pain medication. In an interview on 09/19/2016 at 2:35 PM the DON stated the family had provided new shoes for Resident #10. C. Review of a Face Sheet for Resident #12 reflected she was [AGE] years old with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #12 dated 08/24/16 reflected she had severe cognitive impairment for decision making, required of assistance of 1 person for bed mobility, and she was always incontinent of bowel and bladder. Section M of the MDS indicated Resident #12 was at high risk for pressure sores, but there were no preventative measures listed. Review of a care plan for Resident #12 dated 06/29/16 and updated on 08/31/16 reflected the following: Focus- Resident had fragile skin due to alteration in skin integrity. Goal-The resident will maintain clean and intact skin. Interventions-Monitor/document as needed any changes in skin status, appearance, color, wound healing, signs and symptoms of infection, wound size and keep RP informed. Weekly skin review. Notify MD of any concerns. Wound care as ordered and monitor for effectiveness. Review of the Weekly Skin Monitoring assessment log for Resident #12 dated 09/02/16 and 09/09/16 reflected in the section for Blisters- left heel was documented and signed by LVN B. Review of a Treatment Administration Record for Resident #12 for the month of July reflected the following: 07/22/16 Feet in foot pillows while in bed. Apply skin prep and baby powder and heel protector to left lateral heel for Stage I pressure ulcer. Wrap ankle with gauze. Change three times a week on shower days and as needed until resolved. An observation on 09/15/16 at 11:30 AM revealed the ADON performing a head to toe skin assessment for Resident #12. Resident #12 had a pressure injury to her left heel. The ADON measured two areas. One area measured 1.5 cm x 1.5 cm of eschar (black, dead tissue) and a peri- wound of redness measuring 2 cm x 2.5 cm. During the observed skin assessment of Resident #12, the ADON stated she thought this area had healed on 08/24/16. In an interview on 05/1516 at 2:05 PM, LVN B stated she was treating the blistered area on Resident #12's left heel because she did not have an order to discontinue the treatments. LVN B stated she had not notified the physician or RP when she identified the blistered area because she thought it was the ADON's responsibility. Review of the facility ' s weekly Decubitus Logs from 0722/16 through 09/08/16 revealed documentation that Resident #12 had a boggy left heel. There was no documentation in the area on the Decubitus Logs that read 'Date Healed' to support the pressure sore on Resident #12's left heel had healed. In an interview on 09/16/16 at 11:10 AM, the ADON stated she had not reviewed the Weekly Skin Monitoring Sheets for Resident #12 indicating she had a blister on her left heel, but should have reviewed it. The ADON stated she didn't know she was supposed to get an order to discontinue a treatment when a pressure sore healed. Review of physician orders for Resident #12 dated 09/15/16 reflected the following: Cleanse wound to left heel with normal saline and pat dry. Apply skin prep and cover with heel protectors. Elevate heels on floating devices. Change dressing three times a week and as needed. Apply [MEDICATION NAME] cream to both feet and ankles daily for dry skin. D. Review of Resident #5's Face Sheet reflected an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Significant Change MDS dated [DATE] reflected she required total assistance for bed mobility, she was receiving pressure ulcer care and had a pressure reducing device in place on her bed. Review of Resident #5's Care plan dated 08/01/2013 reflected she had pressure ulcers and had interventions such as pressure relieving pad in geri chair and air mattress is in place on her bed. In an observation on 09/15/2016 at 4:25 PM Resident #5 did not have a pressure reduction surface on her bed and was sleeping on a vinyl mattress. In an interview on 09/15/2016 at 4:30 PM the ADON stated Resident #5 should have been on a pressure reduction mattress. She stated she didn't know of a system or who determines who should be putting on pressure reduction surfaces for the residents that are high risk for pressure ulcers or that have pressure ulcers. In an interview on 09/15/2016 at 4:45 PM the LVN F, who did the MDSs and Care Plans stated she completed the Braden Scale quarterly to determine who was at risk for developing pressure ulcers. She stated she does not notify anyone in maintenance or nursing to provide pressure reduction surfaces to the residents that were high risk. She stated there was no system and there was no person responsible for getting the pressure reduction surfaces in place. On 09/14/2016 at 8:28 PM the Administrator was informed an Immediate jeopardy situation had been identified due to facility failure to identify, assess, notify and treat new pressure sores and worsening of known pressure sores. In an interview on 09/14/2016 at 8:30 PM the Administrator stated he expected his CNAs and the Hospice CNAs and Nurses to tell the charge nurse when there was a new wound or a decline in the identified wounds. The Administrator stated he expected the family and physician to be notified of new wounds timely. He further stated he expected the wounds to be measured and documented every week. He expected the treatments to be done as ordered and for residents at risk for pressure injuries to have pressure reduction surfaces in place. Review of the facility policy: Wound Care with no date reflected: Accountability; The wound Management Program includes Medical Director, Administrator, DON, ADON, Wound Care Nurse and other nursing personnel. Wound Care Nurse is responsible for program oversight and coordination. Charge Nurse and CNAs involved in prevention and treatment. The policy further stated the wounds would be assessed weekly or more frequently and Braden Assessment would be completed. C.8. A. stated if the wound is not showing signs of healing, it is to be re-evaluated and documented in the medical record. D. Wound management principles reflected control or elimination of causative factors such as pressure. F. Documentation and Care Planning: Required comprehensive description of pressure ulcer weekly. Weekly meeting with Committee and report from Wound Care Nurse. Risk factors include b. Need for pressure relief such as support surfaces, repositioning, pressure relieving devices g. Orders from MD. G. Notification 1. A. Physician notification of pressure ulcer presence and response to treatment. D. Family notification of pressure ulcer presence, treatment plan, response to treatment, and changes in treatment due to wound deterioration. E. The Committee discusses the presence of a pressure injury and or deterioration in wound status weekly. F. Facility protocols for documentation and notification. The following Plan of Removal was submitted on 09/15/2016 at 1:28 PM. The final Plan of Removal was accepted by the survey team on 09/16/2016 at 4:00 PM. Plan of Removal Facility Will: Identify all residents at risk: 1. Resident #10 - All wounds will be assessed, measured and staged. Resident will be assessed for preventative measures by September 16, 2016 at 5:00 PM. Provide a pressure reduction mattress for her bed on September 16, 2016 at 5:00 PM. The Physician was notified of the four new pressure sores on her left foot on September 14, 2016 at 5:00 PM. Treatment orders were obtained. The wounds will measured and staged by a Registered Nurse weekly and each wound will be documented on an individual record. Family was notified of pressure sores on September 15, 2016 at 5:00 PM. 2. Resident #11 - Was assessed for pressure reduction intervention on September 16, 2016 at 9:00 AM. Pressure areas were assessed, measured and staged on September 16, 2016 at 9:00 AM. Physician was notified on September 15, 2016 at 5:00 PM for

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician; and notify the resident's legal representative or an interested family member when; a significant change in the resident's physical status (i.e., a deterioration in health, or clinical complications); or there was a need to alter treatment significantly occurred for three (3) of eight (8) residents reviewed for pressure sores (Residents #10, #11 and #12). A) Resident #10 had a documented Stage 2 pressure sore on her left foot 2nd toe and it declined to an Unstageable pressure sore. Resident #10 developed a second pressure injury to her left foot on 09/09/16 and three (3) additional pressure sores were discovered on 09/14/2016 by the surveyor, which the facility had not identified or notified the MD and family prior to surveyor intervention on 09/14/2016. B) Resident #11 had a pressure sore on her left heel that was first identified as a Stage I boggy area on 08/17/16. The pressure sore was not assessed, measured, or staged from 08/30/16 through 09/14/16, until after surveyor intervention; and had progressed to an Unstageable pressure injury with a separate area of Deep Tissue Injury. The physician was not consulted and the family was not notified until 09/15/16. C) Resident #12 had a blister on her left heel that progressed to an unstageable pressure injury with a surrounding area of redness. The facility ADON was unaware of the new pressure injury and did not notify the physician and family until surveyor intervention. These failures further resulted in an identification of an Immediate Jeopardy (IJ) on 09/14/2016. While the IJ was removed on 09/18/2016, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice had the potential to place 35 residents identified by the facility as receiving preventive skin care at risk for developing new or worsening Pressure Injuries, [MEDICAL CONDITION] (skin infection), Osteomylitis (bone infection),[MEDICAL CONDITION] (blood infection), and severe pain due to delayed identification of changes and delayed physician interventions and treatments. Findings Included: A) Review of Resident #10's Face Sheet reflected a [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Quarterly MDS dated [DATE], reflected Resident #10 was assessed as having short and long term memory problems with severely impaired decision making. Resident #10 was assessed as requiring limited assistance of one person for bed mobility and transferring, and she had no episodes of continent voiding. Review of Resident #10's Care Plan, reflected she was to receive assistance of one person with her ADLs, including bathing and hygiene. Resident #10 was care planned for pain, weight loss and Hospice care. Review of Resident #10's Physician Orders, reflected an order dated 09/06/2016; Cleanse Stage 2 to 2nd medial toe with Normal Saline, pat dry, apply honey and foam insert between each toe. Change on shower days and as needed. There were no other current treatments for skin wounds on the Orders. (Stage 2 - loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough www.NPUAP.org) In an observation on 09/14/2016 at 2:20 PM, Resident #10 warned the CNAs about to transfer her to bed that she had a sore toe and it was a son of a gun. Resident #10 warned the CNAs before they removed her pink house shoes and during the transfer not to hurt her foot. She stated it really hurt and she must have banged it up. Resident #10's left sock had bloody drainage on the bottom of it. Upon removal of the left sock it was noted Resident #10 had bloody drainage between every toe and she had black eschar (Eschar - Full thickness skin or tissue loss - depth unknown actual depth of the ulcer is completely obscured by slough and/or eschar (tan, brown or black) in the wound bed www.NPUAP.org) on her second toe and multiple sores on the other toes. There were no foam pads or dressing in place between her toes. Review of Resident #10's August 2016 Weekly Skin Monitoring performed/documented by the Charge Nurse, reflected on Tuesdays 08/16, 08/23 and 08/30, the charge nurse for the day wrote Left 2nd toe on the open [MEDICAL CONDITION] line. There was no wound description area on the form. Review of Resident #10's September 2016 Weekly Skin Monitoring performed by the Charge Nurse, reflected on Tuesday 09/06/16 there was an entry that stated Left 2nd medial toe. Review of Resident #10's Hospice Nurse Notes dated 09/09/2016, no time, reflected, The right foot with open areas between great/2nd toe and 4th/5th toe. Dressing in place and pedal pulse. No concerns voiced by facility staff. RN U. Review of Resident #10's Nurse Notes dated 09/12/16 no time recorded, reflected RN T recorded; Treatment completed to toes right foot, tender to touch, no sign of infection noted. An entry dated 09/13/16 at 9:15 AM, Treatment completed to toes right foot, no change noted, no sign of infection noted, very tender to touch will continue to monitor. The entries did not reflect the second pressure sore found by RN U on 09/09/2016. The previous Nurse Notes did not reflect any entries regarding Resident #10's Pressure Sore or if she had pressure reduction devices in her chair or bed from 09/01/16 until 09/12/16. In an interview on Wednesday, 09/14/2016 at 2:40 PM, LVN E, Resident #10's charge nurse for the day shift, stated it was Resident #10's skin assessment day and she had not done a skin check or a dressing change on Resident #10, because she was waiting on CNA J to come to the facility and give Resident #10 a bath. LVN A stated as far as she knew Resident #10 had one pressure sore on her left foot second toe and no others. In an interview on Wednesday, 09/14/2016 at 2:35 PM, the ADON stated she was to measure the wounds weekly on Wednesdays; and whenever a new wound appeared. She further stated no one had informed her Resident #10's Stage 2 Pressure Injury to her second toe had declined to Unstageable eschar, and she did not know there were any other wounds to the foot. She stated the Hospice Nurse, RN U, did not tell her there was a second pressure sore on the foot on 09/09/2016. The ADON further stated Resident #10 appeared to have [MEDICAL CONDITION] in her foot also because the top of the foot was red and puffy. In an observation on 09/14/2016 at 3:24 PM, after Resident #10 had pain medicine so the ADON could assess her left foot, Resident #10 was assessed to have: 1). the existing stage 2 on the left medial toe had declined to an unstageable eschar area 1.1 cm x 0.7 cm. 2). The lateral second toe was a 0.5 cm x 1.0 cm stage 2. 3). Third medial toe 0.5 cm x 0.5 cm stage 2. 4). Fourth medial toe 0.5 cm x 0.8 cm stage 3. (Stage 3 - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss www.NPUAP.com). 5). Fourth lateral toe 0.6 cm x 1.2 cm stage 3. There were two abrasions to the base of the great toe; 1.3 and 1.0 cm long. Review of Resident #10's September Treatment Record, reflected an entry for a single wound dressing; Cleanse Stage 2 to right second medial toe with Normal Saline, pat dry, apply honey and foam insert between each toe. Change on shower days and as needed. Signed 09/06/2016 ADON. The form was signed that the treatment was completed on 09/06, 09/07, 09/09, 09/12 and 09/13. There were no other treatments for Pressure sores. In an interview on 09/14/2016 at 3:00 PM, LVN A stated on 09/09/2016 in the morning hours she provided wound care to Resident #10's left foot second toe. She stated there was one pressure sore when she did the treatment on the morning of 09/09/2016. In an interview on 09/14/2016 at 4:00 PM, RN U, the Hospice Nurse stated on 09/09/16, Resident #10 had two areas on her foot at that time just as she documented. She stated it was change of shift time from day to evening shift on Friday, 09/09/16 at 3:00 PM and she did not talk to either one of the facility charge nurses to inform them of the second pressure sore. RN U further stated CNA J had called her today, Wednesday, 09/14/2016, and told her Resident #10's foot seemed redder and she still has open areas on her foot. RN U stated CNA J did not explain to her Resident #10 had pressure sores between each toe on her left foot and CNA J had not told the charge nurse about the wounds, that Resident #10 had received her shower or that the dressing needed replacing. In an interview on 09/14/2016 at 4:45 PM, CNA J stated she had arrived to the facility at 10:00 AM on Wednesday, 09/14/2016, and bathed Resident #10. She stated she removed the little foam pads from between her toes before bathing her. CNA J stated in August, Resident #10 had one opening on her toes to begin with, then last week she got a second one, and today she had three openings. CNA J stated there were dark spots and dried blood and her foot was redder and had more tenderness than it had on Monday. She stated she did not tell the nurse or the aide at the facility. She stated she didn't feel she had seen anything urgent to tell the nurse about so she had called the Hospice Nurse, RN U. CNA J stated the skin assessment is done on Fridays and that is why she didn't get the nurse to go to the shower on Wednesday 09/14/2016. Review of Resident #10's Physician Order dated 09/14/2016, reflected she was started on an antibiotic with a [DIAGNOSES REDACTED]. Review of the facility compiled pressure Ulcer log dated 08/25/2016 (11 days after Resident #10's first stage 2 was identified) reflected Resident #10 was not on the log. The Pressure Ulcer log dated 09/01/2016, reflected Resident #10 had an onset date of 09/01/2016 for a Deep Tissue injury (it was identified as a stage 2 by ADON) to the left medial 2nd toe (there was no size documented) and the family and MD were notified on 09/01/2016. The Pressure Ulcer log dated 09/08/2016, reflected Resident #10's ulcer was a stage 2 and was increasing in size at 0.7 x 0.8 cm and there was a new treatment for [REDACTED]. In an interview on 09/14/2016 at 5:25 PM, LVN A stated she would have expected RN U to have notified the charge nurse when she found the second opening on Resident #10's foot on 09/09/2016. LVN A also stated she expected CNA J to notify her of any changes in her residents, such as new wounds, and she wanted to be told when she could do her treatment to wounds for the day. In an interview on 09/14/2016 at 5:29 PM, the ADON, stated it was up to the charge nurse to notify the family and MD of new wounds and to get the treatment started. She further stated it was her responsibility to measure the wounds weekly and call the MD if she noticed a decline or the treatment wasn't working. In an interview on 09/16/2016 at 11:25 AM, Resident #10's Primary Physician did not address whether she wanted to be notified of new pressure injuries and worsening pressure injuries before the phone call was lost and there was no further answer to the calls. In an interview on 09/15/2016 at 1:15 PM, the Medical Director stated eschar is deeper and indicates the wound is declining. He stated if eschar occurred or if there were an increase in the number of wounds, the MD would need to be notified, so that the MD can determine what the issue is whether it is pressure from a dressing, circulatory problems or some other issue. It is up to the primary physician to decide what diagnostic procedures are appropriate for each resident. B. Resident #11 was [AGE] years old and admitted to the facility on [DATE] and a readmission on 03//04/16 with [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] reflected Resident #11 was at high risk for pressure sore and had a pressure relieving device for the chair and an overlay mattress for the bed. Review of a Care plan for Resident #11 dated 08/22/14 and updated on 06/22/16 reflected the following: This resident will have intact skin, free from redness, blisters, or discolorations through 09/22/16. The resident's pressure sore will show signs of healing and remain from infection through 09/22/16. Interventions: Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD. Keep Responsible Party informed (RP). {The care plan did not specify the frequency of assess/record/monitor wound healing.} Monitor/document/report as needed any changes in skin status, appearance, color, wound healing, signs and symptoms of infections, wound size (length x width x depth) and stage. Keep RP informed. Review of physician orders for Resident # 11 reflected the following: 08/17/16 Cleanse Stage I to the right heel with normal saline, pat dry apply skin prep and baby powder and insert heel in protector. Change dressing three times a week and as needed. (The National Pressure Ulcer Advisory Panel defines a Stage I as intact skin with a localized area of non-blanchable redness www.NPUAP.org) Review of a facility Wound Assessment Worksheets dated 08/17/16, 08/24/16, and 08/3016 for Resident and completed by ADON reflected the following: Wound Location- Left heel Treatment to be used: Skin prep, baby powder, padded heel. Stage 1, Length 2.0 cm x 1.5 cm, no depth Wound base- Red, Drainage None, No odor, No Eschar (dead tissue), Peri-wound- scaley Review of the facility's weekly Decubitus Log for the following dates, 08/25/16, 09/01/16, and 09/08/16 reflected there was no documentation of Resident #11's pressure sore to her left heel. An observation on 09/14/16 at 4:35 PM of a head to toe skin assessment of Resident #11 conducted by LVN A and assisted by CNA M reflected the following (the ADON joined the skin assessment to confirm the findings of the left heel): Left Heel: Medial Left heel an area of necrotic/eschar (black in color and dead) tissue measuring 4.5 cm x 2.3 cm. with 2 cm x 2 cm area of boggy tissue located below the necrotic/eschar area. (Suspected Deep Tissue Injury - depth unknown. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue www.NPUAP.org) In an interview on 09/14/16 at 5:20 PM, LVN A stated she felt the area of eschar on Resident #11's left heel had been present for approximately a month and there had been no changes in the treatment orders. LVN A stated she didn't say anything about the change in Resident #11's left heel because she thought the ADON was measuring and assessing weekly. In an interview on 09/14/16 at 5:00 PM, the ADON stated she had assumed the responsibilities of the treatment nurse in April when the full-time treatment nurse resigned. The ADON went on to say the new responsibilities were in addition to those of the ADON position, and she also works the floor when charge nurses are unavailable. The ADON added, the charge nurses were responsible for the residents' weekly skin assessments performed on a shower day; and signing off on the CNAs Skin Monitoring records completed for each shower day indicating they had been reviewed for any concerns. In a continued interview on 09/14/16 at 5:00 PM, the ADON confirmed she had not done weekly wound assessments and measurements on Resident #11 since 08/30/16. The ADON stated she must have been working the floor and was unable to perform them due to time constraints. The ADON stated she had not informed the DON she had not completed the weekly wound assessments, but she should have. The ADON stated she thought she had seen the pressure sore on Resident #11's left heel about a week ago, but couldn't be certain and was unaware of the area of eschar. The ADON did not have an explanation for why the pressure sore on Resident #11's left heel was not reviewed in the facility's weekly Skin Conditions meeting, other than she thought because the area on her right heel was resolved and there were no other pressure sore areas. According to the ADON, she participates in the weekly meetings with the DON, MDS nurse and the Medical Director and felt strongly all of the wounds/pressure sores were thoroughly reviewed. The ADON stated she is aware if a new wound develops or doesn't improve or worsens in a two week period, she is to consult with the physician and notify the family. Review of nurses' notes for Resident #11 dated 09/15/16 and completed by the ADON reflected the following: Resident has dark area to left heel. Appears as dark blood under the eschar. Unstageable at this time. Nurse Practitioner removed dry skin from left heel and found soft pink skin under the eschar. New orders to keep socks off resident use [MEDICATION NAME] lotion to moisturize, and use floatation device for heels at all times. In an interview on 09/16/16 at 3:20 PM, the Nurse Practitioner (NP) stated she was requested by the facility to assess Resident #11's feet. The NP stated after seeing the area of eschar on Resident #11's left heel it was mechanically removed and found old blood underneath and fairly healthy tissue; but she didn't address the bogginess of the left heel other than instructions to monitor. The NP added she discontinued the current orders for skin prep and baby powder because the powder was drying out all the skin on her feet and she was concerned the skin may crack open. She further stated the new orders for Resident #11 were to apply [MEDICATION NAME] cream, no socks, and to float her heels at all times. The NP stated to date she had not been informed Resident #11 had not been assessed for new or worsening pressure sores since 08/30/16. The NP added we rely on them (licensed staff) to assess and inform us (physicians and NPs) if skin conditions are worsening or there is no improvement so appropriate measures can be taken. C. Review of a Face Sheet for Resident #12 reflected she was [AGE] years old with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #12 dated 08/24/16 reflected she had severe cognitive impairment for decision making, required of assistance of 1 person for bed mobility, and she was always incontinent of bowel and bladder. Section M of the MDS indicated Resident #12 was at high risk for pressure sores, but there were no preventative measures listed. Review of a care plan for Resident #12 dated 06/29/16 and updated on 08/31/16 reflected the following: Focus- Resident had fragile skin due to alteration in skin integrity. Goal-The resident will maintain clean and intact skin. Interventions-Monitor/document as needed any changes in skin status, appearance, color, wound healing, signs and symptoms of infection, wound size and keep RP informed. Weekly skin review. Notify MD of any concerns. Wound care as ordered and monitor for effectiveness. Review of the Weekly Skin Monitoring assessment log for Resident #12 dated 09/02/16 and 09/09/16 reflected in the section for Blisters- left heel was documented and signed by LVN B. Review of a Treatment Administration Record for Resident #12 for the month of July reflected the following: 07/22/16 Feet in foot pillows while in bed. Apply skin prep and baby powder and heel protector to left lateral heel for Stage I pressure ulcer. Wrap ankle with gauze. Change three times a week on shower days and as needed until resolved. An observation on 09/15/16 at 11:30 AM revealed the ADON performing a head to toe skin assessment for Resident #12. Resident #12 had a pressure injury to her left heel. The ADON measured two areas. One area measured 1.5 cm x 1.5 cm of eschar (black, dead tissue) and a peri- wound of redness measuring 2 cm x 2.5 cm. During the observed skin assessment of Resident #12, the ADON stated she thought this area had healed on 08/24/16. In an interview on 05/1516 at 2:05 PM, LVN B stated she was treating the blistered area on Resident #12's left heel because she did not have an order to discontinue the treatments. LVN B stated she had not notified the physician or RP when she identified the blistered area because she thought it was the ADON's responsibility. Review of the facility ' s weekly Decubitus Logs from 0722/16 through 09/08/16 revealed documentation that Resident #12 had a boggy left heel. There was no documentation in the area on the Decubitus Logs that read 'Date Healed' to support the pressure sore on Resident #12's left heal had healed. In an interview on 09/16/16 at 11:10 AM, the ADON stated she had not reviewed the Weekly Skin Monitoring Sheets for Resident #12 indicating she had a blister on her left heel, but should have. The ADON stated she didn't know she was supposed to get an order to discontinue a treatment when a pressure sore healed. Review of physician orders for Resident #12 dated 09/15/16 reflected the following: Cleanse wound to left heel with normal saline and pat dry. Apply skin prep and cover with heel protectors. Elevate heels on floating devices. Change dressing three times a week and as needed. Apply [MEDICATION NAME] cream to both feet and ankles daily for dry skin. Review of the facility policy not dated, reflected: B5. Discussion with the Wound Care physician and resident/responsible party includes notification of any skin impairment identified on admission. The policy stated the Wound Care Nurse is responsible for program oversight and coordination. Section G; Notification 1. A written protocol is established for: a. Physician notification of pressure ulcer presence and response to treatment. d. Family notification of pressure ulcer presence, treatment plan, response to treatment and changes in treatment due to wound deterioration. e. The Wound Care Committee discusses the presence of a pressure ulcer and /or deterioration in wound status weekly. f. Facility protocols for documentation and notification. The facility did not provide the protocols for notification and documentation. On 09/14/2016 at 8:28 PM, the Administrator was informed an Immediate jeopardy situation had been identified due to facility failure to identify, assess, notify and treat new pressure sores and worsening of known pressure sores. In an interview on 09/14/2016 at 8:30 PM, the Administrator stated he expected the Hospice CNAs and Nurses to tell the charge nurse when there was a new wound or a decline in the identified wounds. The Administrator stated he expected the family and physician to be notified of new wounds timely. Review of the facility policy: Wound Care with no date reflected: Accountability; The wound Management Program includes Medical Director, Administrator, DON, ADON, Wound Care Nurse and other nursing personnel. Wound Care Nurse is responsible for program oversight and coordination. Charge Nurse and CNAs involved in prevention and treatment. The policy further stated the wounds would be assessed weekly or more frequently and Braden Assessment would be completed. C.8. A. stated if the wound is not showing signs of healing, it is to be re-evaluated and documented in the medical record. D. Wound management principles reflected control or elimination of causative factors such as pressure. F. Documentation and Care Planning: Required comprehensive description of pressure ulcer weekly. Weekly meeting with Committee and report from Wound Care Nurse. Risk factors include b. Need for pressure relief such as support surfaces, repositioning, pressure relieving devices g. Orders from MD. G. Notification 1. A. Physician notification of pressure ulcer presence and response to treatment. D. Family notification of pressure ulcer presence, treatment plan, response to treatment, and changes in treatment due to wound deterioration. E. The Committee discusses the presence of a pressure injury and or deterioration in wound status weekly. F. Facility protocols for documentation and notification. The following Plan of Removal was submitted on 09/15/2016 at 1:28 PM. The final Plan of Removal was accepted by the survey team on 09/16/2016 at 4:00 PM. Plan of Removal Facility Will: Identify all residents at risk: 1. Resident #10 - All wounds will be assessed, measured and staged. Resident will be assessed for preventative measures by September 16, 2016 at 5:00 PM. Provide a pressure reduction mattress for her bed on September 16, 2016 at 5:00 PM. The Physician was notified of the four new pressure sores on her left foot on September 14, 2016 at 5:00 PM. Treatment orders were obtained. The wound will measured and staged by a Registered Nurse weekly and each wound will be documented on an individual record. Family was notified of pressure sores on September 15, 2016 at 5:00 PM. 2. Resident #11 - Was assessed for pressure reduction intervention on September 16, 2016 at 9:00 AM. Pressure areas were assessed, measured and staged on September 1;6, 2016 at 9:00 AM. Physician was notified on September 15, 2016 at 5:00 PM for treatment orders. Family was notified of changes in condition on September 15, 2016 at 5:00 PM. Air overlay and foot cradle will remain on the bed along with floating devices. This was all completed on September 16, 2016 at 5:00 PM. 3. All Residents - Every resident in the Facility will have a skin assessment done by Administrative Nurse Staff, by September 16, 2016 at 9:00 AM. Any abnormality identified will be assessed by wound Consultant Nurse, RN A and RN D and identified, measured, staged, and documented. This will be completed on September 16, 2016 at 5:00 PM. The assessment will also determine what caused the skin issue and what preventative measure can be implemented by the facility to prevent future problems; i.e. air mattress, heel floating devices, sheet supports, or chair cushions, heel pressure relief devices. This will be completed by September 16, 2016. The Braden Scale will be utilized on all Residents when admitted , then every week for three weeks and quarterly after that to determine need for pressure reduction intervention. For any issue identified, the Physician will notified for any treatment orders needed, by Friday, September 16, 2016 at 5:00 PM. The family will be notified and the Care Plan updated by 5:00 PM on September 16, 2016. All preventative measures will be in place by September 16, 2016 at 5:00 PM. Staff: 1. DON and ADON - A Nurse consultant will be hired September 16, 2016 to in-service the DON and ADON and Staff RNs on proper techniques for identifying, staging, and measuring pressure areas. The newly hired consultant will observe wound staging and measuring by the DON and the ADON on a weekly basis for period of 30 days or until they determine that our staff is skilled to measure and stage wounds. The Consultant Nurse will review the charts and wound sheet and compare to skin issues observed for each pressure issue for each resident on a weekly basis to determine accuracy of documented assessments. This will begin September 16, 2016 at 5:00 PM. 2. Charge Nurse - The Charge Nurse will do skin assessment each week on all residents in the building during their shower. Any new skin issues noted will be documented on the skin assessment sheets given to the DON or ADON. This will be effective September 16. 2016 at 5:00 PM. The Charge Nurse will do the ordered treatments and dressing changes on any wounds as prescribed by the Physician and follow the Physician orders daily and will notify the family responsible party with changes of condition. All Facility Nurses will be in-serviced on the weekly skin assessments, measuring pressure areas, and documentation on September 16, 2016 at 5:0 PM. ADON or DN will review skin sheets and spot check residents for accuracy to make sure the weekly skin assessments are being done, documented and physician and family notified of changes of condition. Spot checks will be documented on the Skin Policy Review Form. This will be in place September 16, 2016 at 5:00 PM. 3. CNA - The CNA will observe the resident on a daily basis and report to the Charge Nurse any observed new skin issue. Any observed new skin issues will be noted and documented on Skin sheet. Charge Nurse will accompany CNA to observe resident immediately when a change of condition exists. CNA will perform full skin assessments on each resident on shower day and once a week ask charge nurse to come check the resident. Charge Nurse ill spot check the CNA for timely reporting of changes and report any issues to the DON or ADON. The CNAs were in-serviced to follow the above procedures by 5:00 PM on September 16, 2016. Administrative Review 1. The Facility will have a weekly skin meeting to review all skin issues in the building. The meeting will be attended by the Medical Director, Administrator, DON, ADON, MDS Coordinator and Medicare Coordinator. This procedure will effective September 15, 2016 at 5:00 PM. 2. Administrator notified the Medical Director of the IJ concern on Wednesday September 14, 2016 at 8:30 PM. Survey team monitored the current plan of removal as follows: 1. Resident #10's pressure sores were measured and assessed on 09/14/2016 at 3:24 PM. The physician and family were notified by 5:00 PM on 09/15/16. 2. Resident #11 was seen by the NP, the pressure sore was debrided. and new orders were received and implemented. Wound Assessment Worksheets were completed to include assessment, measurements, and staging. Observations revealed her heels were floated. no socks were in place and [MEDICATION NAME] cream was applied. The physician and family were notified on 09/15/16. 3. Resident #12 pressure sore was assessed, new orders for treatment and interventions were implemented. Wound Assessment Worksheets were completed to include assessment, measurements, and staging. The physician and family were notified. 4. Surveyors monitored the staff in-services for CNAs at 2:30 and 3:00 PM on 09/16/2016. 5. Surveyors monitored the LVN/RN in-service at 2:30 PM on 09/16/2016. 6. Interviews conducted on 09/16 and 09/17/2016 with CNAs reflected the CNAs knew how to prevent, monitor and report changes in resident skin 7. Interviews conducted on 09/16/2016 and 09/17/2016 reflected the LVNs and RNs knew how to prevent, monitor and report changes in resident skin. 8. Survey team monitored Residents #10, #11 and #12 and two of eight (8) residents with pressure sores for notification, measurement, staging, and pressure prevention interventions until 09/18/2016. 9. The facility Administrative Nurses presented newly conducted skin audit sheets of every resident in the building on 09/15/2016 which included twelve pressure sores on six (6) residents which were previously staged at a lower level of severity (mis-staged) or were not previously documented on the individual wound assessment form. 10. The facility was monitored for pressure reduction interventions being appropriately placed until 09/18/2016 at 2:50 PM. 11. On 09/18/2016 at 2:33 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The CMS form 2567 reflected the facility had 35 residents identified by the facility as receiving preventive skin care who were at risk for pressure sores. <

Based on observation, interview, and record review the facility failed to be administered in a manner that enabled it to use resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for four (4) of four (4) residents reviewed for pressure injuries (Resident # 11, #10, #12, and #5.). A. The Administrator failed to supervise and identify the DON was not fulfilling her responsibilites when: - pressure sore policies and procedures were not consistently implemented -Weekly Skin Condition meetings were not conducted in an effective manner to identify: those residents who were not receiving weekly assessments of existing pressure sores; failures to follow-up on charge nurses weekly assessments when new suspected pressure sores were noted; worsening of existing wounds. - physicians were not consulted when pressure sores worsened, did not respond to treatments, and/or new areas of pressure sores developed. - the ADON did not receive the necessary training/education and supervision for the treatment nurse responsibilities in order to correctly assess, measure and stage pressure sores. B. The Administrator was unaware of CMS regulations that the DON cannot work as a charge nurse when the facility census averages 60 or greater. Therefore he had the DON work as a charge nurse which contributed to the resulting fragmented management of resident care and staff education. These failures further resulted in an identification of an Immediate Jeopardy (IJ) on 09/14/2016. While the IJ was removed on 09/18/2016, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could effect a facility census of 8 residents with current pressure injuries and 35 residents identified by the facility as requiring preventative skin care by placing them at risk for unidentified pressure injuries, complications of new and/or worsening pressure injuries to include local and systemic infections, pain, need for mechanical debridement, and delayed physician ordered treatments and interventions. The Findings Include: A. 1.) Resident #11 was [AGE] years old and admitted to the facility on [DATE] and a readmission on 03//04/16 with [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] reflected Resident #11 was at high risk for pressure sore and had a pressure relieving device for the chair and an overlay mattress for the bed. Review of a Care plan for Resident #11 dated 08/22/14 and updated on 06/22/16 reflected the following: This resident will have intact skin, free from redness, blisters, or discolorations through 09/22/16. The resident's pressure sore will show signs of healing and remain from infection through 09/22/16. Interventions: Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD. Keep Responsible Party informed (RP). {The care plan did not specify the frequency of assess/record/monitor wound healing.} Monitor/document/report as needed any changes in skin status, appearance, color, wound healing, signs and symptoms of infections, wound size (length x width x depth) and stage. Keep RP informed. Review of physician orders for Resident # 11 reflected the following: 08/17/16 Cleanse Stage I to the right heel with normal saline, pat dry apply skin prep and baby powder and insert heel in protector. Change dressing three times a week and as needed. (The National Pressure Ulcer Advisory Panel defines a Stage I as intact skin with a localized area of non-blanchable redness www.NPUAP.org) Review of a facility Wound Assessment Worksheets dated 08/17/16, 08/24/16, and 08/3016 for Resident and completed by ADON reflected the following: Wound Location- Left heel Treatment to be used: Skin prep, baby powder, padded heel. Stage 1, Length 2.0 cm x 1.5 cm, no depth Wound base- Red, Drainage None, No odor, No Eschar (dead tissue), Peri-wound- scaley Review of the facility's weekly Decubitus Log for the following dates, 08/25/16, 09/01/16, and 09/08/16 reflected there was no documentation of Resident #11's pressure sore to her left heel. An observation on 09/14/16 at 4:35 PM of a head to toe skin assessment of Resident #11 conducted by LVN A and assisted by CNA M reflected the following (the ADON joined the skin assessment to confirm the findings of the left heel ) : Left Heel: Medial Left heel an area of necrotic/eschar (black in color and dead) tissue measuring 4.5 cm x 2.3 cm. with 2 cm x 2 cm area of boggy tissue located below the necrotic/eschar area. In an interview on 09/14/16 at 5:20 PM, LVN A stated she felt the area of eschar on Resident #11's left heel had been present for approximately a month and there had been no changes in the treatment orders. LVN A stated she didn't say anything about the change in Resident #11's left heel because she thought the ADON was measuring and assessing weekly. In an interview on 09/14/16 at 5:00 PM, the ADON stated she had assumed the responsibilities of the treatment nurse in April when the full-time treatment nurse resigned. The ADON went on to say the new responsibilities were in addition to those of the ADON position, and she also works the floor when charge nurses are unavailable. The ADON added, the charge nurses were responsible for the residents' weekly skin assessments performed on a shower day; and signing off on the CNAs Skin Monitoring records completed for each shower day indicating they had been reviewed for any concerns. In a continued interview on 09/14/16 at 5:00 PM, the ADON confirmed she had not done weekly wound assessments and measurements on Resident #11 since 08/30/16. The ADON stated she must have been working the floor and was unable to perform them due to time constraints. The ADON stated she had not informed the DON she had not completed the weekly wound assessments, but she should have. The ADON stated she thought she had seen the pressure sore on Resident #11's left heel about a week ago, but couldn't be certain and was unaware of the area of eschar. The ADON did not have an explanation for why the pressure sore on Resident #11's left heel was not reviewed in the facility's weekly Skin Conditions meeting, other than she thought because the area on her right heel was resolved and there were no other pressure sore areas. According to the ADON, she participates in the weekly meetings with the DON, MDS nurse and the Medical Director and felt strongly all of the wounds/pressure sore were thoroughly reviewed. Review of nurses' notes for Resident #11 dated 09/15/16 and completed by the ADON reflected the following: Resident has dark area to left heel. Appears as dark blood under the eschar. Unstageable at this time. Nurse Practitioner removed dry skin from left heel and found soft pink skin under the eschar. New orders to keep socks off resident use [MEDICATION NAME] lotion to moisturize, and use floatation device for heels at all times. In an interview on 09/16/16 at 3:20 PM, the Nurse Practitioner (NP) stated she was requested by the facility to assess Resident #11's feet. The NP stated after seeing the area of eschar on Resident #11's left heel it was mechanically removed and found old blood underneath and fairly healthy tissue; but she didn't address the bogginess of the left heel other than instructions to monitor. The NP added she discontinued the current orders for skin prep and baby powder because the powder was drying out all the skin on her feet and she was concerned the skin may crack open. She further stated the new orders for Resident #11 were to apply [MEDICATION NAME] cream, no socks, and to float her heels at all times. The NP stated to date she had not been informed Resident #11 had not been assessed for new or worsening pressure sores since 08/30/16. The NP added we rely on them (licensed staff) to assess and inform us (physicians and NPs) if skin conditions are worsening or there is no improvement so appropriate measures can be taken. In a continued interview on 09/14/16 at 5:00 PM, the ADON stated the process of the weekly Skin meetings is she brings her documentation (Wound Assessment Worksheets) to use as a reference and the rest of the team uses the weekly Decubitus Log documentation. The ADON stated the two forms of documentation are not reconciled during the meeting to possibly identify missing wounds or changes in them. The ADON also confirmed she does not bring the weekly skin assessments completed by the charge nurses to review for changes or new areas of suspicious pressure sores. In an interview on 09/16/16 at 11:10 AM, the ADON was asked about the training she received when she assumed the duties of the treatment nurse. The ADON stated prior to April 2016 the facility had a treatment nurse and a wound care physician that cared for the residents; but the wound care nurse resigned and the wound care physician retired. The ADON stated her training consisted of using the National Pressure Ulcer Advisory Panel's poster as a reference for staging; the facility's Wound Care Policy, and in-services she has had attended during her nursing positions in the past. The ADON stated the facility will now have a wound care certified nurse consultant available to her through an outside agency. In an interview on 09/16/16 at 11:45 AM, the DON stated the ADON had not informed her she was unable to do weekly wound assessments on residents. The DON stated there were times when she was told by the ADON that she didn't think she was going to be able to do them; but there wasn't any follow up on her (the DON) part. The DON stated she felt like the ADON was doing a good job with managing wounds in the facility. The DON added she does not review the ADON's documentation during the weekly skin meetings or review the charge nurses weekly skin assessments. The DON also stated she was unaware the ADON was not reviewing them as well. The DON added she is ultimately responsible for ensuring residents receive the care they need, including all aspects of pressure sore management. 2.) Review of Resident #10's Face Sheet reflected a [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Quarterly MDS dated [DATE] reflected Resident #10 was assessed as having short and long term memory problems with severely impaired decision making. Resident #10 was assessed as requiring limited assistance of one person for bed mobility and transferring and she had no episodes of continent voiding. She was assessed as being at risk for developing pressure ulcers, and marked as having a pressure relieving device for her bed and her chair. Review of Resident #10's Care Plan reflected she was to receive assistance of one person with her ADLs including bathing and hygiene. Resident #10 was care planned for pain, weight loss and Hospice. In an observation on 09/14/2016 at 2:20 PM Resident #10 warned the CNAs about to transfer her to bed that she had a sore toe and it was a son of a gun. Resident #10 warned the CNAs before they removed her pink house shoes and during the transfer not to hurt her foot. She stated it really hurt and she must have banged it up. Surveyor requested CNA K remove the socks to see the toes. Upon removal of the left sock it was noted Resident #10 had bloody drainage between every toe and on the bottom of her foot at her toes. There were no foam pads between her toes. Resident #10 was on a vinyl mattress with no pressure reduction surface on the bed or in her wheelchair. In an interview on 09/14/2016 at 2:35 PM CNA L stated CNA J had bathed Resident #10 earlier in the shift and she had not spoken to her about Resident #10 or her toes. Review of Resident #10's CNA Skin Monitoring Form dated August 2016 reflected Hospice CNA J bathed and assessed Resident #10 each time she was bathed. She noted Toe in the rash column next to abrasions on the days of 08/19 Friday, 08/20 Saturday, 08/24 Wednesday, and 08/26/2016 Friday. Review of Resident #10's CNA Skin Monitoring Form dated September 2016 reflected Hospice CNA J assessed Resident #10 on 9/07 Wed., 9/09 Fri., 9/12 Mon, and 9/14/16 Wed. Each assessment had a check mark in the columns labeled bruises, abrasions and scabs. There was not a location described and the picture at the bottom of the form was not marked. Review of Resident #10's Weekly Skin Monitoring performed by the Charge Nurse reflected on 08/16 Tues., 08/23 Tues. and 08/30 Tues. the charge nurse for the day wrote Left 2nd toe on the open [MEDICAL CONDITION] line no on the pressure area line. There was no wound description area on the form. Review of Resident #10's Weekly Skin Monitoring (which was photo-copied on 09/19/2016) performed by the Charge Nurse reflected on Tuesday 09/06/16 there was an entry that stated Left 2nd medial toe. On Tuesday 09/13/2016 there was an entry Left 2nd, 3rd, 4th toe. The entry dates of every Tuesday in September were highlighted. LVN A signed the two entries. In an interview on Wednesday 09/14/2016 at 2:40 PM LVN E Resident #10's charge nurse for the day shift stated it was Resident #10's skin assessment day and she had not done a skin check or a dressing change on Resident #10 because she was waiting on CNA J to come to the facility and give Resident #10 a bath. LVN A stated as far as she knew Resident #10 had one pressure sore on her second toe. LVN A stated CNA J should have already been to the facility, and invited LVN A to come into the shower for Resident #10's skin assessment. LVN A further stated she would have put a dressing on Resident #10's foot if she had known CNA J had already been to the facility and given the shower. LVN A stated she was supposed to give report and go on to the other side of the building and take charge for the evening shift which started at 3:00 PM. Review of Resident #10's Nurse Notes dated 09/12/16 reflected RN T recorded; Treatment completed to toes right foot, tender to touch, no sign of infection noted. 09/13/16 9:15 AM Treatment completed to toes right foot, no change noted, no sign of infection noted, very tender to touch will continue to monitor. The previous Nurse Notes did not mention Resident #10's Pressure Sore or pressure reduction mattress or pads from 09/01/16 until 09/12/16. In an interview on 09/14/2016 at 2:35 PM the ADON stated she was to measure the wounds weekly on Wednesdays and whenever a new wound appeared. She further stated no one had informed her Resident #10's Stage 2 Pressure Injury to her second toe had declined to Unstageable eschar and she did not know there were any other wounds to the foot. She stated the Hospice Nurse RN U did not tell her there was a second area on the foot on 09/09/2016. The ADON further stated Resident #10 appeared to have [MEDICAL CONDITION] in her foot also because the top of the foot was red and puffy. In an observation on 09/14/2016 at 3:24 PM Resident #10 was found to have: 1) the existing stage 2 on the left medial toe had declined to an unstageable eschar area 1.1 cm x 0.7 cm. 2) The lateral second toe was 0.5 cm x 1.0 cm stage 2. 3) Third medial toe 0.5 cm x 0.5 cm stage 2. 4) Fourth medial toe 0.5 cm x 0.8 cm stage 3. 5) Fourth lateral toe 0.6 cm x 1.2 cm stage 3. There were two abrasions to the base of the great toe; 1.3 and 1.0 cm long. The ADON stated Resident #10 should have been on a pressure reduction mattress. Review of Resident #10's September 2016 Treatment Record reflected an entry for a wound dressing; Cleanse Stage 2 to right second medial toe with Normal Saline, pat dry, apply honey and foam insert between each toe. Change on shower days and as needed. Signed 09/06/2016 ADON. The form was signed that the treatment was completed on 09/06, 09/07, 09/09, 09/12 and 09/13/16. The Treatment sheet reflected Resident #10 was previously receiving a dressing every day from 08/24/2016 until 09/06/2016 when the treatment changed and the frequency changed to shower days and as needed. In an interview on 09/14/2016 at 3:00 PM LVN A stated on 09/09/2016 in the morning hours she had placed foam between Resident #10's toes and wrapped all of her toes in gauze and then ran the gauze across the top of the foot, around the back of the ankle, across the top of the foot again and secured the gauze to the foot. She stated she didn't have an order to wrap the foot with gauze and she did it to make sure the foam stayed put. LVN A further stated she didn't realize wrapping around the ankle and toes could have caused decreased circulation and possibly more pressure from the dressing inside the shoe. She stated there was one ulcer when she did it on the morning of 09/09/2016. Review of Resident #10's Hospice Nurse Notes dated 09/09/2016 no time reflected, The right foot with open areas between great/2nd toe and 4th/5th toe. Dressing in place and pedal pulse. No concerns voiced by facility staff. RN U. In an interview on 09/14/2016 at 4:00 PM RN U, the Hospice Nurse stated on 09/09/16 Resident #10 had a gauze dressing wrapped around all of her toes, across the top of her foot around her ankle and back to the toes. RN U stated there was a piece of foam between the first and second toe and not between any other toes. She stated the order stated to put foam between each toe and she would have expected to find foam between each toe. RN U further stated there were two areas at that time just as she documented. RN U further stated she wrapped the foot in the same manner after she assessed it. She stated it was change of shift time from day to evening shift on Friday, 09/09/16 3:00 PM and she did not talk to either one of the facility charge nurses to inform them of the second wound. She stated Resident #10 did not have any pain on 09/09/2016 and did not flinch. RN U stated she did not believe the gauze was tight but stated she thought some of the pressure was the shoe. RN U further stated CNA J had called her today Wednesday, 09/14/2016 and told her Resident #10's foot seemed redder and she still has open areas on her foot. RN U stated CNA J did not explain to her Resident #10 had an ulcer between each toe on her left foot and CNA J had not told the charge nurse about the wounds, that Resident #10 had received her shower or that the dressing needed replacing. In an interview on 09/14/2016 at 4:45 PM CNA J stated she had arrived to the facility at 10:00 AM on 09/14 and bathed Resident #10. She stated she removed the little foam pads from between her toes before bathing her. CNA J stated Resident #10 had one opening on her toes to begin with then last week she got a second one and today she had three openings. CNA J stated there were dark spots and dried blood and her foot was redder and had more tenderness than it had on Monday. She stated she did not tell the nurse or the aide at the facility. She stated she didn't feel she had seen anything urgent to tell the nurse about so she had called the Hospice Nurse, RN C. CNA J stated there was no gauze on her foot Monday. CNA J stated the skin assessment is done on Fridays and that is why she didn't get the nurse to go to the shower on Wednesday 09/14. Review of Resident #10's Physician Order dated 09/14/2016 reflected she was started on an antibiotic with a [DIAGNOSES REDACTED]. Review of Resident #10's Individual Wound Assessment Sheets reflected: 08/14/2016 reflected a newly acquired pressure area stage 2 was found to the medial 2nd toe. It was 0.4 cm x 0.5 cm. 08/24/2016 (10 days later) Stage 2 left medial 2nd toe 0.4 cm x 0.5 cm with pain on touch and granulation 95% (new skin growth). 09/07/2016 (14 days later) Stage 2 left medial 2nd toe 0.7 x 0.8 cm pain meds required prior to assessment, new orders honey and foam insert between toes. Review of the TX Nurse/ADON's handwritten notes dated 08/30/2016 reflected a note: Resident #10; Stage 2 left 2nd toe-improving continue same treatment. Review of the facility compiled pressure ulcer log dated 08/25/2016 (11 days after Resident #10's stage 2 was identified) reflected Resident #10 was not on the log. The Pressure Ulcer log dated 09/01/2016 reflected Resident #10 had an onset date of 09/01/2016 for a Deep Tissue injury (identified as a stage 2 by ADON) to the left medial 2nd toe (there was no size documented) and the family and MD were notified on 09/01/2016. The Pressure Ulcer log dated 09/08/2016 reflected Resident #10's ulcer was a stage 2 and was increasing in size at 0.7 x 0.8 cm and there was a new treatment for [REDACTED]. In an interview on 09/14/2016 at 5:25 PM LVN A stated she would have expected RN U to have notified the charge nurse when she found the second opening on Resident #10's foot on 09/09/2016. LVN A stated it wasn't a problem to be interrupted during report at change of shift and she expected to be informed of new wounds. LVN A also stated expects CNA J to notify her of any changes in her residents such as new wounds and she wanted to be told when she could do her treatment to wounds for the day. In an interview on 09/14/2016 at 5:29 PM the ADON stated it was up to the charge nurse to notify the family and MD of new wounds and to get the treatment started. She further stated it was her responsibility to measure the wounds weekly and call the MD if she noticed a decline or the treatment wasn't working. The ADON stated she gave the weekly measurements to the LVN F who compiled the facility report for the skin meeting. She further stated she doesn't get a report for the meetings; she sits with her individual sheets and does not compare the report to what her individual sheets say. She stated she believed she had measured the wound weekly and didn't know why she didn't have a wound assessment sheet every seven days except that she had worked the floor as a charge nurse and didn't always have time to make them. In an interview on 09/14/2016 at 6:30 PM the Administrator stated he thoroughly believed every wound was being measured every week and he believed the weekly skin meeting document was correct and included every ulcer in the building. In an interview on 09/14/2016 at 8:30 PM the Administrator stated he expected the Hospice CNAs and Nurses to tell the charge nurse when there was a new wound or a decline in the identified wounds. He further stated he expected the treatments to be done as ordered. The Administrator also stated he expected the family and physician to be notified of new wounds and he expected the residents to be on pressure reduction surfaces as appropriate. Observation on 09/15/2016 at 10:00 AM reflected Resident #10 was in the lobby by her nurse station in her wheelchair and stated my leg feels like it is gonna fall off and my tail hurts from sitting in this chair. There was no cushion in Resident #10's chair. The nurse gave her some pain medication. In an interview on 09/19/2016 at 2:35 PM the DON stated the family had provided new shoes for Resident #10. 3.)Review of a Face Sheet for Resident #12 reflected she was [AGE] years old with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #12 dated 08/24/16 reflected she had severe cognitive impairment for decision making, required of assistance of 1 person for bed mobility, and she was always incontinent of bowel and bladder. Section M of the MDS indicated Resident #12 was at high risk for pressure sores, but there were no preventative measures listed. Review of a care plan for Resident #12 dated 06/29/16 and updated on 08/31/16 reflected the following: Focus- Resident had fragile skin due to alteration in skin integrity. Goal-The resident will maintain clean and intact skin. Interventions-Monitor/document as needed any changes in skin status, appearance, color, wound healing, signs and symptoms of infection, wound size and keep RP informed. Weekly skin review. Notify MD of any concerns. Wound care as ordered and monitor for effectiveness. Review of the Weekly Skin Monitoring assessment log for Resident #12 dated 09/02/16 and 09/09/16 reflected in the section for Blisters- left heel was documented and signed by LVN B. Review of a Treatment Administration Record for Resident #12 for the month of July reflected the following: 07/22/16 Feet in foot pillows while in bed. Apply skin prep and baby powder and heel protector to left lateral heel for Stage I pressure ulcer. Wrap ankle with gauze. Change three times a week on shower days and as needed until resolved. An observation on 09/15/16 at 11:30 AM revealed the ADON performing a head to toe skin assessment for Resident #12. Resident #12 had a pressure injury to her left heel. The ADON measured two areas. One area measured 1.5 cm x 1.5 cm of eschar (black, dead tissue) and a peri- wound of redness measuring 2 cm x 2.5 cm. During the observed skin assessment of Resident #12, the ADON stated she thought this area had healed on 08/24/16. In an interview on 05/1516 at 2:05 PM, LVN B stated she was treating the blistered area on Resident #12's left heel because she did not have an order to discontinue the treatments. LVN B stated she had not notified the physician or RP when she identified the blistered area because she thought it was the ADON's responsibility. Review of the facility's weekly Decubitus Logs from 0722/16 through 09/08/16 revealed documentation that Resident #12 had a boggy left heel. There was no documentation in the area on the Decubitus Logs that read 'Date Healed' to support the pressure sore on Resident #12's left heal had healed. In an interview on 09/16/16 at 11:10 AM, the ADON stated she had not reviewed the Weekly Skin Monitoring Sheets for Resident #12 indicating she had a blister on her left heel, but should have. The ADON stated she didn't know she was supposed to get an order to discontinue a treatment when a pressure sore healed. Review of physician orders for Resident #12 dated 09/15/16 reflected the following: Cleanse wound to left heel with normal saline and pat dry. Apply skin prep and cover with heel protectors. Elevate heels on floating devices. Change dressing three times a week and as needed. Apply [MEDICATION NAME] cream to both feet and ankles daily for dry skin. 4.) Review of Resident #5's Face Sheet reflected an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Significant Change MDS dated [DATE] reflected she required total assistance for bed mobility, she was receiving pressure ulcer care and had a pressure reducing device in place on her bed. Review of Resident #5's Care plan dated 08/01/2013 reflected she had pressure ulcers and had interventions such as pressure relieving pad in geri chair and air mattress is in place on her bed. In an observation on 09/15/ at 4:25 PM Resident #5 did not have a pressure reduction surface on her bed and was sleeping on a vinyl mattress. In an interview on 09/15/2016 at 4:30 PM the ADON stated Resident #5 should have been on a pressure reduction mattress. She stated she didn't know of a system or who determines who should be putting on pressure reduction surfaces for the residents that are high risk for pressure ulcers or that have pressure ulcers. In an interview on 09/15/2016 at 4:45 PM the LVN F, the MDS Coordinator, stated she completed the Braden Scale quarterly to determine who was at risk for developing pressure ulcers. She stated she does not notify anyone in maintenance or nursing to provide pressure reduction surfaces to the residents that were high risk. She stated there was no system and there was no person responsible for getting the pressure reduction surfaces in place. In a continued interview on 09/14/16 at 5:00 PM, the ADON stated the process of the weekly Skin meetings is she brings her documentation (Wound Assessment Worksheets) to use as a reference and the rest of the team uses the weekly Decubitus Log documentation. The ADON stated the two forms of documentation are not reconciled during the meeting to possibly identify missing wounds or changes in them. The ADON also confirmed she does not bring the weekly skin assessments completed by the charge nurses to review for changes or new areas of suspicious pressure injuries. The ADON confirmed she had not reviewed the weekly skin assessments for Residents #10 #11 and #12 to address the areas of suspicious pressure injuries documented by the charge nurse's prior to the weekly Skin Conditions meetings. The ADON did not have an explanation for why the pressure injury on Resident #11's left heel was not reviewed in the facility's weekly Skin Conditions meeting, other than she thought because the area on her right heel was resolved and there were no other pressure injury areas. Review of the facility policy: Wound Care with no date reflected: Accountability; The wound Management Program includes Medical Director, Administrator, DON, ADON, Wound Care Nurse and other nursing personnel. Wound Care Nurse is responsible for program oversight and coordination. Charge Nurse and CNAs involved in prevention and treatment. The policy further stated the wounds would be assessed weekly or more frequently and Braden Assessment would be completed. C.8. A. stated if the wound is not showing signs of healing, it is to be re-evaluated and documented in the medical record. D. Wound management principles reflected control or elimination of causative factors such as pressure. F. Documentation and Care Planning: Required comprehensive description of pressure ulcer weekly. Weekly meeting with Committee and report from Wound Care Nurse. Risk factors include b. Need for pressure relief such as support surfaces, repositioning, pressure relieving devices g. Orders from MD. G. Notification 1. A. Physician notification of pressure ulcer presence and response to treatment. D. Family notification of pressure ulcer presence, treatment plan, response to treatment, and changes in treatment due to wound deterioration. E. The Committee discusses the presence of a pressure injury and or deterioration in wound status weekly. F. Facility protocols for documentation and notification. The facility did not provide the protocols for notification and documentation as requested prior to exit on 09/19/116. B. In an interview on 09/13/16 at 10:20 AM during initial tour, the DON asked the surveyor to please excuse her inability to recall current medical conditions and [MEDICAL CONDITION] medications for the residents; because she was tired from working the weekend (09/11/16 and 09/12/16 as a charge nurse. In an observation on 09/14/2016 at 4:00 PM the DON was drawing insulin up in a syringe and had the Nurse cart with her. In an interview on 09/14/2016 at 4:00 PM the DON stated she was working the floor until a nurse relieved her. In an observation on 09/19/2016 at 5:30 PM the DON was observed to be working the floor as a Charge Nurse. In an interview on 09/19/2016 at 5:30 PM the DON stated a nurse had called and quit with no notice and there was no one else to work the floor. In an interview on 09/19/2016 at 5:45 PM the Administrator stated when there is not enough staff or someone calls and quits without notice he will not allow his residents to go without the care they need. He stated everyone in Nursing Management had to take their fair turn on working the floor and filling the ho

Based on observation, interview, and record review the facility failed to provide services by qualified persons in accordance with each resident's written plan of care for two (2) of nine (9) residents (Resident #3 and #8) reviewed for following physician orders [REDACTED]. A) On [DATE] the physician changed Resident # 3's treatment for [REDACTED]. The physician ordered treatment never was initiated and there was no wound treatment at all from [DATE] through [DATE]. On [DATE] Resident # 3's pressure sore was assessed at a Stage IV and on [DATE] the physician began antibiotics to treat an infection in the wound. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice affected Resident #3 and placed an additional 24 resident at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), [DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), pain and death. Non-Immediate Jeopardy B) Resident # 8 had a physician order [REDACTED].# 8 did not receive milk at each meal. This deficient practice placed seven (7) residents who received the Fortified Meal Plan with milk at each meal at risk for weight loss and malnutrition. Findings include: A) Review of Resident #3's Face Sheet reflected an [AGE] year old female readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3's Significant Change MDS assessment dated [DATE] reflected Resident #3's BIMS score was a five (5) (severe cognitive impairment), she required extensive assistance of two persons to turn, she had an indwelling Foley Catheter, and was frequently incontinent of bowel. Resident #3 was coded as having three (3) Stage I (Intact skin with non-blanchable redness of a localized area usually over a boney prominence) pressure sores and no pressure reduction devices in place. Review of Resident #3's Comprehensive Plan of Care revised on [DATE] reflected "The resident has some skin breakdown" with interventions of "has a pressure relieving mattress...and the resident has a Foley Catheter." Observation on [DATE] at 4:25 PM revealed Resident #3 on her right side receiving peri-care during which time the dressing fell off the sacrum revealing a Stage IV (Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling) pressure sore. The pressure sore was approximately 3 cm round and 0.3 cm deep with yellow slough attached to the tendon and muscle in the very center of the wound bed with red wound edges. Periwound edges were reddened, [MEDICAL CONDITION] and not adhered to wound bed thereby indicated tunneling was present. Resident # 3 had a standard green plastic mattress on her bed, a mattress with no pressure reducing qualities. There was no Foley Catheter was in place to prevent contamination of the wound. Observation on [DATE] at 10:50 AM revealed Resident #3 in bed sleeping on her back with a strong odor of urine in her room. No pressure relieving device was on the mattress and no Foley Catheter was in place. Review of the Weekly Skin Monitoring for Resident #3 reflected zero (0) decubitus (pressure sore) on [DATE], [DATE], [DATE], and [DATE]. On [DATE] a Stage II pressure sore (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 blister) to coccyx was documented. Review of the Wound Assessment for Resident #3 by RN A (the nurse in charge of assessing and staging wounds) dated [DATE] reflected: "Coccyx Stage II, 1.75 centimeters long and 1.5 cm wide, two (2) millimeters deep, slough; yes." The definition located on the Wound Assessment reflected a Stage II pressure sore does not have slough and a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore may have slough present but does not obscure the depth of tissue loss. Resident # 3's Stage III Coccyx wound was misstaged at a Stage II. On the same sheet there was an additional wound documented as "#2 wound superficial 0.5 cm wide and 0.5 cm long, .0 deep." Wound edges were described as "macerated" (moisture associated skin damage). Review of Resident #3's Nurses' Notes dated [DATE] reflected the physician was notified of a Stage II on [DATE] and the orders were obtained. No responsible party notification was documented. Review of Resident # 3's Physician order [REDACTED]." Review of the next recorded Wound Assessment for Resident #3 was l4 days later by RN A dated [DATE] and reflected: "Coccyx Stage II 2.0 cm long and 1.75 cm wide, one (1) mm deep with some slough. Scattered areas of white slough to wound bed." Again, the wound with slough was staged at a Stage II instead of a Stage III. Review of Resident # 3's Physician order [REDACTED].) to decubitus (pressure sore) on shower days (3 times weekly) and as needed." Review of Resident #3's [DATE] TAR reflected an order for [REDACTED]." The order written by Resident # 3's physician on [DATE] was not placed on the TAR and there was no indication this treatment had started. The [DATE] TAR reflected there were no nurse signatures for the dates ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], or [DATE] and indicated no treatment was performed for Resident # 3 on those dates. Observation on [DATE] at 4:35 PM revealed Resident # 3 was provided the treatment ordered [DATE] where the wound was cleansed with wound cleanser, the nurse patted dry and applied Wound Be Gone and added a padded dressing. The physician order [REDACTED]. In an interview on [DATE] at 12:30 PM the DON stated, "I knew she (Resident # 3) had the order for Santyl, I just didn't know they weren't carrying it out. It might have helped..." Review of the next recorded Wound Assessment for Resident #3 was 14 days later by RN A dated [DATE] reflected: "Coccyx Stage IV pressure sore 3.0 cm long and 3.0 cm wide, tunneling around wound ranges from 0.5 cm deep to 1.25 cm deep. [DIAGNOSES REDACTED] and purple tissue around edges. Very [DIAGNOSES REDACTED]tous to wound margins. (Tunneling was drawn around one half of the wound). Yellow slough present on wound base in center." Review of the Nurse's Notes from [DATE] through [DATE] reflected no further physician notification was documented until [DATE] when resident was sent to the physician and was prescribed an antibiotic for treatment of [REDACTED]. Review of the Physician order [REDACTED]. Notify if worsens." Review of Resident #3's [DATE] MAR indicated [REDACTED]." In an interview on [DATE] at 11:56 PM the DON stated it looked like no treatment was performed from [DATE] through [DATE] on paper. The DON also stated she would expect that the nurse to sign the treatment sheet when the treatment was performed. Regarding the catheter that was no longer in place, The DON stated she did not think they would "get anywhere" with the healing of the pressure sore unless the Foley catheter was put back in place. The DON stated "we didn't have a [DIAGNOSES REDACTED]." The DON stated she expected the nursing staff to use the Santyl now. In an interview on [DATE] at 12:15 PM RN A, nurse in charge of measuring, staging and documenting pressure sore progress, stated [DATE] was when she was first alerted there was an issue with the coccyx. RN A further stated "she (Resident #3) has had a long standing issue with the coccyx. She will get a little pink then heal up. It's not a Stage I, it's a pre-Stage I." RN A stated Resident #3 was "really at risk for pressure sores since she was admitted because she was so emaciated. Immediately after we discontinued the Foley Catheter it started getting worse." RN A further stated Resident #3 "refused the air mattress on admission and has refused it periodically in the past." She stated she was unable to find any documentation regarding the refusals and stated, "on [DATE], I mentioned to her trying to get her on an air mattress and she just wouldn't answer me." RN A further stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In an interview on [DATE] at 3:45 PM Resident #3 was asked if she would like an air mattress overlay placed on her bed while she was up for supper when she stated "yes, it's worse than it's ever been." In an interview on [DATE] at 9:00 AM Resident #3, who was up in her wheelchair and had slept on the air overlay mattress, stated "I like my bed more and I ate 100% (of her breakfast meal)". Resident #3 appeared more comfortable than previous observations. In an interview on [DATE] at 3:45 PM CNA H stated Resident #3 required incontinent care due to bladder incontinence a minimum of two (2) or three (3) times a shift on the evening shifts that she worked. In a telephone interview on [DATE] at 6:15 PM Resident #3's primary Physician stated a Foley Catheter "possibly" could assist in wound healing and that "it should have been a suggestion." Resident # 3's Physician stated that it would be "reasonable" to believe that an air mattress or pressure relieving mattress would be beneficial. He further stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. Resident # 3's Physician also stated "weekly wound measurements may have helped the wound from getting so bad" and stated the Santyl order "would have possibly helped in wound healing" if the order had been followed. In an interview on [DATE] at 12:40 PM the facility's Medical Director stated "when Santyl wound ointment is used correctly you can at least see a difference in the wound progress. If it's not done, sometimes the progress is not as obvious as it should be. I would expect the nurses to use it like it's ordered." He also stated, "I would expect that a resident should be encouraged to use the air mattress or what is available to prevent or improve the wound. If the resident has dementia (he) expects that the family should be encouraged to assist in those interventions." Regarding improper staging of wounds, he replied, "if the wound is not healing or progressing then there are different principles to follow for wound care." Review of the facility's undated policy for PRESSURE ULCER PREVENTION AND MONITORING reflected: 2. Residents with pressure ulcers will have: a. Treatments as ordered.. Review of the undated facility's Pressure Ulcer Management Sheet reflected: "Promptly inform the physician (and responsible party, as appropriate) of new pressure ulcers. Obtain and initiate treatment orders." In an interview on [DATE] at 4:30 PM the DON stated the skin nurse should let the charge nurse know when she sees worsening of condition of wounds. The DON stated the LVN should realize to notify the family and physician. When asked who was responsible for making sure orders are carried out the DON stated, "the charge nurses are responsible to make sure they are carried out." The DON stated she and the ADON were responsible for making sure staff followed facility policy. The DON stated it was her and the ADON's responsibility to ensure staff knew what the facility policies and procedures were. In an interview on [DATE] at 6:05 PM the facility Administrator stated the DON, ADON and charge nurses are responsible for notifying the physician and family. The ADON was responsible for making sure orders were carried out. The Administrator stated the he and the Nursing Department are responsible for making sure staff followed procedures. The Administrator further stated it was ultimately his responsibility to make sure staff followed procedures. The Administrator stated the DON should definitely know what wounds were in the building. He was aware his policy stated pressure sores were to be measured weekly. Regarding whether he and his staff had neglected the care of the residents he stated, "It was not correct (the care of the residents). I do not appreciate professional people that I trust not doing what I expect." The facility Administrator was notified on [DATE] at 6:20 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was first submitted by the Administrator on [DATE] at 9:04 AM. The final Plan of Removal was accepted by the survey team on [DATE] at 7:30 PM. Cameron Nursing and Rehab Plan of Removal of Immediate Jeopardy In responses Wound Issues, Cameron Nursing and Rehab will do the following: 1. An RN from (Hospice) to in-service nursing staff on the care and treatment of [REDACTED]. DON, ADON, RN, Medicare Coordinator, and MDS Nurse and charge nurses LVN's will attend. In-service will be at 10:00 on Friday [DATE]. 2. Two Staff Registered Nurses will assess and measure all wounds on a weekly basis. All current wounds will be reassessed after training on [DATE]. 3. Facility will identify all "At Risk" residents for Skin Breakdown by using the Braden Scale. After in-service, all At Risk residents will be assessed by a RN and LVN to identify any possible pressure issues [DATE]. 4. All Physician orders [REDACTED]. A pink copy of all telephone order forms will be given to the ADON when completed. The ADON will monitor the order and follow through to make sure all meds are ordered and orders entered on treatment sheet and or MARs. This process was started on [DATE]. 5. DON and ADON will do in-service with all charge nurses regarding proper documentation of resident's change of condition, pressure sores, treatments, Physician Orders, and notifying family members and Physician. This will be complete during the in-service on [DATE]. 6. ADON and DON will report to Administrator any new skin issues and update of treatments in progress on Friday of each week with a copy of the weekly decubitus skin assessment log and non-decubitus log. First meeting will be on [DATE] and then weekly. 7. All pressure wounds will be reviewed and discussed at weekly staff meeting, including DON, ADON, MDS Nurse, Medicaid Coordinator, Registered Nurse on Staff, and Administrator on [DATE]. 8. Medical Director was notified of this at 9:30 am on Thursday [DATE]. Resident #3 Facility will: 1. Ensure air mattress is on Resident #3's bed, [DATE]. 2. Will follow physician orders [REDACTED]. (The new order: "Cleanse wound on coccyx with Normal Saline, pat dry-Apply Normal saline packing to wound bandage BID (twice daily)-Will consult wound care at Scott & White (Temple)-Insert indwelling catheter...-change q (every) month & PRN (as needed)-Record I&O (input and output) q shift-Catheter care q shift".) 3. Registered Nurse will accompany resident to Doctor's appointment on [DATE] to discuss proper treatment and procedure to be used, and request the use of a Catheter, this will be done on [DATE]. ADON or DON will monitor resident treatment with charge nurse for a period of two weeks to assure proper procedure is followed. If there is no improvement or wound worsens, Physician will be notified. 4. Two Registered Nurses will assess and measure wounds on a weekly basis. 5. Have Staff to continue to encourage resident to stay off of her back side and have staff continue to encourage and assist her to turn when in bed. 6. Nursing staff will encourage Resident to take in proper nourishment to help the healing process and have a Care Plan meeting with Son to encourage compliance with treatment plan. Administrator, DON, ADON will meet with son. 7. Have Dietary Consultant review Resident #3's chart and condition and make recommendations for nutrition on her next visit to the facility. Resident #7 1. Make sure resident maintains a pressure relieving mattress on his bed, [DATE]. 2. Nursing staff will encourage resident to try to stay off of his back side as much as possible, offering repositioning and reminded to use overhead bar. 3. Resident #7 request to be up for all three meals each day and remain in his wheelchair. DON, ADON, Administrator will have a care plan meeting will be held with Resident and Responsible Party regarding the benefits of shorter periods of time sitting in the wheelchair. 4. ADON or DON will monitor resident treatment for [REDACTED]. If there is no improvement or wound worsens, Physician will be notified. 5. Confirm with Physician when Heel Protectors should be worn, requested clarification [DATE]. 6. Notify Physician of change of condition [DATE]. 7. Two Registered Nurses will assess and measure resident's wounds on a weekly basis. The survey team monitored the plan of removal as follows: Review was completed of new treatments as per physician order [REDACTED].#3 as shown in the plan of removal. All treatments and interventions were initiated and carried out. Resident #3's Responsible Party was notified. Resident # 7 had a re-assessment of his wounds and physician and responsible party were notified of the decline in the coccyx pressure sore. Observation of the facility in-service on [DATE] at 10:00 AM revealed the in-service was conducted by a RN from a local Hospice agency. The in-service provided information regarding pressure sores, care for pressure sores, assessments including staging and measuring, as well as interventions to prevent pressure sores. The in-service had four (4) RNs and 11 LVNs in attendance. The Medical Director and the Administrator were also present. The facility had over 70% of their licensed nursing staff in-serviced on [DATE]. The Hospice RN gave a competency test after the in-service in which all nursing staff in attendance passed per the Administrator. The facility provided a list of 25 residents who were at risk for pressure sores after completion of a 100% audit using the Braden Scale to identify residents at risk. Observations were made on [DATE] of four (4) of the 25 residents at risk for pressure sores. These Residents were assessed and staged properly and interventions and treatments were in place. The facility notified the Resident's Physicians and Responsible Parties. Observation on [DATE] at 2:40 PM revealed the DON entered a resident room to assess and measure pressure sores. The DON did not bring a cart or any sanitizing agents to the room. She did not prepare a clean surface for her supplies. She placed supplies for wound measurement under the shoes on Resident #14's Geri chair pressure reduction pad of the incontinent resident. She then laid a pair of gloves up against the heels of the shoes and went to the bathroom to wash her hands. She returned from the bathroom and began donning gloves. She approached the resident to explain the process to the resident when the surveyor stopped the DON and instructed her to start over and explained that her articles were contaminated. Later, when the DON began assessing the heel of the resident that had a Deep Tissue Injury (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue) she proceeded to dismiss the area and pronounced it was blanching after she placed pressure on the heel and released it multiple times. The heel was not blanching. Surveyor stepped forward and asked to see the heel turn white and then return to red. The DON applied pressure once again and admitted the heel was not changing color at all and was actually purple. The DON and ADON then tried to decide if the heel sore was a Stage I or not since it wasn't red. The Surveyor handed the DON the in-service Wound Staging Guide as received in the training in-service and asked her to read the description of a Deep Tissue Injury. The DON then correctly identified the heel as having a deep tissue injury. DON then observed the Stage II that was approximately one (1) cm in size with a pinpoint opening on the sacrum. The DON placed the measuring device on the opening and removed it repeatedly. She finally traced the one (1) cm circle and then marked the pinpoint opening. She then placed the device back on the wound and studied it and then asked the ADON to come and see if she had marked her device correctly. The DON then began studying the raised skin edges on the bilateral buttocks and decided that those impaired skin issues needed measuring. After DON applied the graph several times, the Surveyor asked the ADON if she had told the DON that the resident had a rash over her entire perineum. The ADON said she had not informed the DON and then parted the resident's legs so that she could see the raised skin was related to a rash and was not at all pressure sores. When the DON submitted the wound assessment to the surveyor, she had left the entire wound description area of the form blank. The Surveyor returned the form to the DON to complete it. The DON submitted it to the Surveyor the second time. The Surveyor returned the form to the DON and asked her to complete the periwound skin assessment line on the form. In an interview on [DATE] at 2:43 PM the Surveyor asked the DON as she donned gloves if she realized that she had her wound care items under a pair of shoes in the seat of a chair, she stated that she was so nervous that she did not realize what she had done. In a meeting on [DATE] at 3:15 PM the facility Administrator was made aware of the DON's actions during the assessment of Resident # 14's wound. The Administrator stated the DON needed more training and decided to have the two RNs performing skin assessments and not include the DON until she was further trained. Observations were made of a LVN and RN performing a skin assessment and identifying a problem on an at risk resident. Then two RNs returned and performed an assessment on the at risk resident and identified an area of concern on her left great toe. The area was identified as a Suspected Deep Tissue Injury. The two RNs correctly assessed, measured, identified prevention interventions, and notified the Physician and the Responsible Party. The facility provided an attendance signature sheet for the Staff Meeting held on [DATE] after the skin audit was completed with the Administrator, DON, ADON, RN A, MDS Coordinator, and one LVN-Medicaid Coordinator in attendance. On [DATE] at 8:00 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided a list of 25 residents at risk for pressure sores. Non-Immediate Jeopardy B. Review of Resident # 8's Face Sheet reflected an [AGE] year old female who entered the facility on [DATE] and re-admitted on [DATE]. Resident # 8's [DIAGNOSES REDACTED]. Generalized [MEDICAL CONDITION], Nonunion of Fracture, [MEDICAL CONDITION] Disorders, [MEDICAL CONDITIONS] Disease, [MEDICAL CONDITION] Reflex and [MEDICAL CONDITION]. Review of Resident # 8's Quarterly MDS assessment dated [DATE] reflected the Resident had severely cognitive impairment, required limited assistance of one (1) person for eating. The assessment reflected Resident # 8 was on a mechanically altered diet and had not had significant weight loss. Review of Resident # 8's Care Plan Dated [DATE] reflected a plan of care for the Resident "has a potential nutritional problem r/t (due to) Adult Failure to Thrive. Interventions included to ..."provide, serve diet as ordered...and RD (Registered Dietician) to evaluate and make diet change recommendations, PRN (as needed)...." Review of Resident # 8's Physician order [REDACTED]. milk each meal. Observation on [DATE] at 12:05 PM through 1:00 PM revealed Resident # 8 received no milk during her meal. Observation on [DATE] at 12:01 PM through 1:00 PM revealed Resident # 8 did not receive milk during her meal. In an interview on [DATE] at 12:15 PM Hospice Aide (HA) X stated she fed Resident # 8 during lunch and the Resident never received milk at lunch. In an interview on [DATE] at 10:30 AM the Dietary Manager (DM) stated the fortified food is sprinkled on and added to the milk during meals. The DM stated Resident # 8 should have milk provided with each meal. The facility provided a list of seven (7) residents who receive the fortified meal plan and included milk as the fortified food is added to the milk.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect for two (2) of nine (9) residents reviewed for neglect when: A) The facility failed to ensure Resident # 3, a resident with a history of developing pressure sores, had a care planned pressure relieving device on her bed. The facility failed to accurately assess and stage Resident # 3's wound to her coccyx. The facility failed to implement a physician ordered treatment change on [DATE] and failed to provide a wound treatment at all from [DATE] through [DATE]. The facility failed to notify the physician of a decline in the wound and failed to ensure pressure sores were assessed every seven (7) days as stated in their policy. Resident # 3's pressure sore declined to a Stage IV with infection. B) The facility failed to accurately assess and stage Resident #7's wound to his coccyx and failed to notify the physician of a decline in the wound. Resident # 7's wound declined from a Stage II to a Stage III. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practice affected Resident #3 and Resident #7 and placed an additional 23 resident at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), [DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), pain and death. Findings include: A) Review of Resident #3's Face Sheet reflected an [AGE] year old female readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3's Significant Change MDS assessment dated [DATE] reflected Resident #3's BIMS score was a five (5) (severe cognitive impairment), she required extensive assistance of two persons to turn, she had an indwelling Foley Catheter, and was frequently incontinent of bowel. Resident #3 was coded as having three (3) Stage I (Intact skin with non-blanchable redness of a localized area usually over a boney prominence) pressure sores and no pressure reduction devices in place. Review of Resident #3's Comprehensive Plan of Care revised on [DATE] reflected "The resident has some skin breakdown" with interventions of "has a pressure relieving mattress...and the resident has a Foley Catheter." Observation on [DATE] at 4:25 PM revealed Resident #3 on her right side receiving peri-care during which time the dressing fell off the sacrum revealing a Stage IV (Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling) pressure sore. The pressure sore was approximately 3 cm round and 0.3 cm deep with yellow slough attached to the tendon and muscle in the very center of the wound bed with red wound edges. Periwound edges were reddened, [MEDICAL CONDITION] and not adhered to wound bed thereby indicated tunneling was present. Resident # 3 had a standard green plastic mattress on her bed, a mattress with no pressure reducing qualities. There was no Foley Catheter was in place to prevent contamination of the wound. Observation on [DATE] at 10:50 AM revealed Resident #3 in bed sleeping on her back with a strong odor of urine in her room. No pressure relieving device was on the mattress and no Foley Catheter was in place. Review of the Weekly Skin Monitoring for Resident #3 reflected zero (0) decubitus (pressure sore) on [DATE], [DATE], [DATE], and [DATE]. On [DATE] a Stage II pressure sore (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 blister) to coccyx was documented. Review of the Wound Assessment for Resident #3 by RN A (the nurse in charge of assessing and staging wounds) dated [DATE] reflected: "Coccyx Stage II, 1.75 centimeters long and 1.5 cm wide, two (2) millimeters deep, slough; yes." The definition located on the Wound Assessment reflected a Stage II pressure sore does not have slough and a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore may have slough present but does not obscure the depth of tissue loss. Resident # 3's Stage III Coccyx wound was misstaged at a Stage II. On the same sheet there was an additional wound documented as "#2 wound superficial 0.5 cm wide and 0.5 cm long, .0 deep." Wound edges were described as "macerated" (moisture associated skin damage). Review of Resident #3's Nurses' Notes dated [DATE] reflected the physician was notified of a Stage II on [DATE] and the orders were obtained. No responsible party notification was documented. Review of Resident # 3's Physician order [REDACTED]." Review of the next recorded Wound Assessment for Resident #3 was l4 days later by RN A dated [DATE] and reflected: "Coccyx Stage II 2.0 cm long and 1.75 cm wide, one (1) mm deep with some slough. Scattered areas of white slough to wound bed." Again, the wound with slough was staged at a Stage II instead of a Stage III. Review of Resident # 3's Physician order [REDACTED].) to decubitus (pressure sore) on shower days (3 times weekly) and as needed." Review of Resident #3's [DATE] TAR reflected an order for [REDACTED]." The order written by Resident # 3's physician on [DATE] was not placed on the TAR and there was no indication this treatment had started. The [DATE] TAR reflected there were no nurse signatures for the dates ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], or [DATE] and indicated no treatment was performed for Resident # 3 on those dates. Observation on [DATE] at 4:35 PM revealed Resident # 3 was provided the treatment ordered [DATE] where the wound was cleansed with wound cleanser, the nurse patted dry and applied Wound Be Gone and added a padded dressing. The physician order [REDACTED]. In an interview on [DATE] at 12:30 PM the DON stated, "I knew she (Resident # 3) had the order for Santyl, I just didn't know they weren't carrying it out. It might have helped..." Review of the next recorded Wound Assessment for Resident #3 was 14 days later by RN A dated [DATE] reflected: "Coccyx Stage IV pressure sore 3.0 cm long and 3.0 cm wide, tunneling around wound ranges from 0.5 cm deep to 1.25 cm deep. [DIAGNOSES REDACTED] and purple tissue around edges. Very [DIAGNOSES REDACTED]tous to wound margins. (Tunneling was drawn around one half of the wound). Yellow slough present on wound base in center." Review of the Nurse's Notes from [DATE] through [DATE] reflected no further physician notification was documented until [DATE] when resident was sent to the physician and was prescribed an antibiotic for treatment of [REDACTED]. Review of the Physician order [REDACTED]. Notify if worsens." Review of Resident #3's [DATE] MAR indicated [REDACTED]." In an interview on [DATE] at 11:56 PM the DON stated it looked like no treatment was performed from [DATE] through [DATE] on paper. The DON also stated she would expect that the nurse to sign the treatment sheet when the treatment was performed. Regarding the catheter that was no longer in place, The DON stated she did not think they would "get anywhere" with the healing of the pressure sore unless the Foley catheter was put back in place. The DON stated "we didn't have a [DIAGNOSES REDACTED]." The DON stated she expected the nursing staff to use the Santyl now. In an interview on [DATE] at 12:15 PM RN A, nurse in charge of measuring, staging and documenting pressure sore progress, stated [DATE] was when she was first alerted there was an issue with the coccyx. RN A further stated "she (Resident #3) has had a long standing issue with the coccyx. She will get a little pink then heal up. It's not a Stage I, it's a pre-Stage I." RN A stated Resident #3 was "really at risk for pressure sores since she was admitted because she was so emaciated. Immediately after we discontinued the Foley Catheter it started getting worse." RN A further stated Resident #3 "refused the air mattress on admission and has refused it periodically in the past." She stated she was unable to find any documentation regarding the refusals and stated, "on [DATE], I mentioned to her trying to get her on an air mattress and she just wouldn't answer me." RN A further stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In an interview on [DATE] at 3:45 PM Resident #3 was asked if she would like an air mattress overlay placed on her bed while she was up for supper when she stated "yes, it's worse than it's ever been." In an interview on [DATE] at 9:00 AM Resident #3, who was up in her wheelchair and had slept on the air overlay mattress, stated "I like my bed more and I ate 100% (of her breakfast meal)". Resident #3 appeared more comfortable than previous observations. In an interview on [DATE] at 3:45 PM CNA H stated Resident #3 required incontinent care due to bladder incontinence a minimum of two (2) or three (3) times a shift on the evening shifts that she worked. In a telephone interview on [DATE] at 6:15 PM Resident #3's primary Physician stated a Foley Catheter "possibly" could assist in wound healing and that "it should have been a suggestion." Resident # 3's Physician stated that it would be "reasonable" to believe that an air mattress or pressure relieving mattress would be beneficial. He further stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. Resident # 3's Physician also stated "weekly wound measurements may have helped the wound from getting so bad" and stated the Santyl order "would have possibly helped in wound healing" if the order had been followed. In an interview on [DATE] at 12:40 PM the facility's Medical Director stated "when Santyl wound ointment is used correctly you can at least see a difference in the wound progress. If it's not done, sometimes the progress is not as obvious as it should be. I would expect the nurses to use it like it's ordered." He also stated, "I would expect that a resident should be encouraged to use the air mattress or what is available to prevent or improve the wound. If the resident has dementia (he) expects that the family should be encouraged to assist in those interventions." Regarding improper staging of wounds, he replied, "if the wound is not healing or progressing then there are different principles to follow for wound care." B) Review of the face sheet reflected Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Nurses' Notes for [DATE] reflected Resident #7 was admitted with a Stage II pressure sore to the coccyx. Review of the initial MDS assessment dated [DATE] reflected Resident #7 to be moderately impaired in thinking, required two persons and a hydraulic lift to transfer, frequently incontinent of bowel and bladder and had one Stage II pressure sore to coccyx. Additional [DIAGNOSES REDACTED]. Review of the Plan of Care dated [DATE] reflected Resident #7 had "breaks in his skin integrity related to pressure ulcer, moisture associated skin damage and stasis ulcers/blisters." Interventions included: "Assist Resident #7 to reposition frequently, monitor treatments for effectiveness and notify physician of any concerns. Try to encourage ventilation to perineum area as much as is possible. This may be more realistic in bed." Review of the TAR for [DATE] for Resident #7 reflected an order placed on the TAR dated [DATE] for Inflatable foot/heel protectors with all three shifts ,[DATE], ,[DATE], ,[DATE] signing the TAR. Review of the Wound Assessment Sheet for Resident #7 dated [DATE] reflected the pressure sore to the coccyx was 2.5 cm long by .75 cm wide with no slough and staged as Stage II documented and signed by RN A. Observation on [DATE] revealed Resident #7 to be up in the wheelchair from 9 AM until 6 PM with no inflatable foot/heel protectors in place. Observation on [DATE] at 4:53 of Resident #7's wound care and measurement by RN A (nurse in charge of assessing and staging wounds) revealed the pressure ulcer on the coccyx to be 3.5 cm long by 1.25 cm wide. The pressure ulcer was 80% covered in yellow slough and was a Stage III pressure ulcer as defined on the Wound Assessment System document RN A was documenting on. In an interview on [DATE] at 4:53 RN A stated the wound bed was 80% covered with yellow slough. She stated "It is a Stage II because there is no depth. I don't really agree with that slough only being a Stage III." RN A underlined slough in the description of a Stage III ulcer. During the measurement of the wound, RN A assured Resident #7 that his pressure sore was looking and getting much better. Review of the Wound Assessment Sheet dated [DATE] reflected RN A had staged the pressure sore a Stage II. In the narrative she documented "wound continues to improve. Has shallow bed of whitish slough to top of wound with approx. (approximately) 20% clean non-granulating tissue to edges. Will continue treatment as ordered." RN A documented "some slough" and the wound base as pink, yellow and white. Review of Wound Assessment Sheets for Resident #7 reflected his wounds were measured every 14 days. Review of the Nurses' Notes for Resident #7 dated [DATE] reflected there had been no notification to the physician of the increase in size and the worsening of the appearance of the pressure ulcer. In an interview on [DATE] at 4:30 PM when asked who should notify the family and physician of pressure sores and changes for Resident #7 the DON stated, "Charge nurses/ Skin nurse when she sees it, she should let the charge nurse know. The LVN should realize to notify." In an interview on [DATE] at 12:15 PM with RN A she stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In a telephone interview on [DATE] at 6:15 PM Resident #7's primary Physician stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. He also stated "weekly wound measurements may have helped the wound from getting so bad." In an interview on [DATE] at 12:40 PM with the facility's Medical Director, he stated regarding improper staging of wounds, "if the wound is not healing or progressing then there are different principles to follow for wound care." Review of the facility's undated policy for PRESSURE ULCER PREVENTION AND MONITORING reflected: "l. All residents admitted at risk for pressure ulcers will be placed on a pressure ulcer prevention program which includes: b. Pressure reducing devices such as special mattresses as needed...e. Intense skin monitoring. 2. Residents with pressure ulcers will have: a. Treatments as ordered...c. Pressure reducing devices such as special mattresses and or/heel protectors as needed...g. At least weekly written assessments including location, stage, odor, color, size, drainage, response to treatment...h. any resident with a pressure ulcer which fails to improve or worsens, will have the physician notified promptly." Review of the undated facility's Pressure Ulcer Management Sheet reflected: "3. Reassess and measure at least weekly or sooner if deterioration of the ulcer is noted. Always document your findings in detail. 4. Promptly inform the physician (and responsible party, as appropriate) of new pressure ulcers. Obtain and initiate treatment orders." In an interview on [DATE] at 4:30 PM the DON stated the skin nurse should let the charge nurse know when she sees worsening of condition of wounds. The DON stated the LVN should realize to notify the family and physician. When asked who was responsible for making sure orders are carried out the DON stated, "the charge nurses are responsible to make sure they are carried out." The DON stated she and the ADON were responsible for making sure staff followed facility policy. The DON stated it was her and the ADON's responsibility to ensure staff knew what the facility policies and procedures were. In an interview on [DATE] at 6:05 PM the facility Administrator stated the DON, ADON and charge nurses are responsible for notifying the physician and family. The ADON was responsible for making sure orders were carried out. The Administrator stated the he and the Nursing Department are responsible for making sure staff followed procedures. The Administrator further stated it was ultimately his responsibility to make sure staff followed procedures. The Administrator stated the DON should definitely know what wounds were in the building. He was aware his policy stated pressure sores were to be measured weekly. Regarding whether he and his staff had neglected the care of the residents he stated, "It was not correct (the care of the residents). I do not appreciate professional people that I trust not doing what I expect." The facility Administrator was notified on [DATE] at 6:20 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was first submitted by the Administrator on [DATE] at 9:04 AM. The final Plan of Removal was accepted by the survey team on [DATE] at 7:30 PM. Cameron Nursing and Rehab Plan of Removal of Immediate Jeopardy In responses Wound Issues, Cameron Nursing and Rehab will do the following: 1. An RN from (Hospice) to in-service nursing staff on the care and treatment of [REDACTED]. DON, ADON, RN, Medicare Coordinator, and MDS Nurse and charge nurses LVN's will attend. In-service will be at 10:00 on Friday [DATE]. 2. Two Staff Registered Nurses will assess and measure all wounds on a weekly basis. All current wounds will be reassessed after training on [DATE]. 3. Facility will identify all "At Risk" residents for Skin Breakdown by using the Braden Scale. After in-service, all At Risk residents will be assessed by a RN and LVN to identify any possible pressure issues [DATE]. 4. All Physician orders [REDACTED]. A pink copy of all telephone order forms will be given to the ADON when completed. The ADON will monitor the order and follow through to make sure all meds are ordered and orders entered on treatment sheet and or MARs. This process was started on [DATE]. 5. DON and ADON will do in-service with all charge nurses regarding proper documentation of resident's change of condition, pressure sores, treatments, Physician Orders, and notifying family members and Physician. This will be complete during the in-service on [DATE]. 6. ADON and DON will report to Administrator any new skin issues and update of treatments in progress on Friday of each week with a copy of the weekly decubitus skin assessment log and non-decubitus log. First meeting will be on [DATE] and then weekly. 7. All pressure wounds will be reviewed and discussed at weekly staff meeting, including DON, ADON, MDS Nurse, Medicaid Coordinator, Registered Nurse on Staff, and Administrator on [DATE]. 8. Medical Director was notified of this at 9:30 am on Thursday [DATE]. Resident #3 Facility will: 1. Ensure air mattress is on Resident #3's bed, [DATE]. 2. Will follow physician orders [REDACTED]. (The new order: "Cleanse wound on coccyx with Normal Saline, pat dry-Apply Normal saline packing to wound bandage BID (twice daily)-Will consult wound care at Scott & White (Temple)-Insert indwelling catheter...-change q (every) month & PRN (as needed)-Record I&O (input and output) q shift-Catheter care q shift".) 3. Registered Nurse will accompany resident to Doctor's appointment on [DATE] to discuss proper treatment and procedure to be used, and request the use of a Catheter, this will be done on [DATE]. ADON or DON will monitor resident treatment with charge nurse for a period of two weeks to assure proper procedure is followed. If there is no improvement or wound worsens, Physician will be notified. 4. Two Registered Nurses will assess and measure wounds on a weekly basis. 5. Have Staff to continue to encourage resident to stay off of her back side and have staff continue to encourage and assist her to turn when in bed. 6. Nursing staff will encourage Resident to take in proper nourishment to help the healing process and have a Care Plan meeting with Son to encourage compliance with treatment plan. Administrator, DON, ADON will meet with son. 7. Have Dietary Consultant review Resident #3's chart and condition and make recommendations for nutrition on her next visit to the facility. Resident #7 1. Make sure resident maintains a pressure relieving mattress on his bed, [DATE]. 2. Nursing staff will encourage resident to try to stay off of his back side as much as possible, offering repositioning and reminded to use overhead bar. 3. Resident #7 request to be up for all three meals each day and remain in his wheelchair. DON, ADON, Administrator will have a care plan meeting will be held with Resident and Responsible Party regarding the benefits of shorter periods of time sitting in the wheelchair. 4. ADON or DON will monitor resident treatment for [REDACTED]. If there is no improvement or wound worsens, Physician will be notified. 5. Confirm with Physician when Heel Protectors should be worn, requested clarification [DATE]. 6. Notify Physician of change of condition [DATE]. 7. Two Registered Nurses will assess and measure resident's wounds on a weekly basis. The survey team monitored the plan of removal as follows: Review was completed of new treatments as per physician order [REDACTED].#3 as shown in the plan of removal. All treatments and interventions were initiated and carried out. Resident #3's Responsible Party was notified. Resident # 7 had a re-assessment of his wounds and physician and responsible party were notified of the decline in the coccyx pressure sore. Observation of the facility in-service on [DATE] at 10:00 AM revealed the in-service was conducted by a RN from a local Hospice agency. The in-service provided information regarding pressure sores, care for pressure sores, assessments including staging and measuring, as well as interventions to prevent pressure sores. The in-service had four (4) RNs and 11 LVNs in attendance. The Medical Director and the Administrator were also present. The facility had over 70% of their licensed nursing staff in-serviced on [DATE]. The Hospice RN gave a competency test after the in-service in which all nursing staff in attendance passed per the Administrator. The facility provided a list of 25 residents who were at risk for pressure sores. The facility completed a 100% audit using the Braden Scale to identify residents at risk for pressure sores. Twenty-five (25) residents were identified at risk for pressure sores. Observations were made on [DATE] of four (4) of the 25 residents at risk for pressure sores. These Residents were assessed and staged properly and interventions and treatments were in place. The facility notified the Resident's Physicians and Responsible Parties. Observation on [DATE] at 2:40 PM revealed the DON entered a resident room to assess and measure pressure sores. The DON did not bring a cart or any sanitizing agents to the room. She did not prepare a clean surface for her supplies. She placed supplies for wound measurement under the shoes on Resident #14's Geri chair pressure reduction pad of the incontinent resident. She then laid a pair of gloves up against the heels of the shoes and went to the bathroom to wash her hands. She returned from the bathroom and began donning gloves. She approached the resident to explain the process to the resident when the surveyor stopped the DON and instructed her to start over and explained that her articles were contaminated. Later, when the DON began assessing the heel of the resident that had a Deep Tissue Injury (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue) she proceeded to dismiss the area and pronounced it was blanching after she placed pressure on the heel and released it multiple times. The heel was not blanching. Surveyor stepped forward and asked to see the heel turn white and then return to red. The DON applied pressure once again and admitted the heel was not changing color at all and was actually purple. The DON and ADON then tried to decide if the heel sore was a Stage I or not since it wasn't red. The Surveyor handed the DON the in-service Wound Staging Guide as received in the training in-service and asked her to read the description of a Deep Tissue Injury. The DON then correctly identified the heel as having a deep tissue injury. DON then observed the Stage II that was approximately one (1) cm in size with a pinpoint opening on the sacrum. The DON placed the measuring device on the opening and removed it repeatedly. She finally traced the one (1) cm circle and then marked the pinpoint opening. She then placed the device back on the wound and studied it and then asked the ADON to come and see if she had marked her device correctly. The DON then began studying the raised skin edges on the bilateral buttocks and decided that those impaired skin issues needed measuring. After DON applied the graph several times, the Surveyor asked the ADON if she had told the DON that the resident had a rash over her entire perineum. The ADON said she had not informed the DON and then parted the resident's legs so that she could see the raised skin was related to a rash and was not at all pressure sores. When the DON submitted the wound assessment to the surveyor, she had left the entire wound description area of the form blank. The Surveyor returned the form to the DON to complete it. The DON submitted it to the Surveyor the second time. The Surveyor returned the form to the DON and asked her to complete the periwound skin assessment line on the form. In an interview on [DATE] at 2:43 PM the Surveyor asked the DON as she donned gloves if she realized that she had her wound care items under a pair of shoes in the seat of a chair, she stated that she was so nervous that she did not realize what she had done. In a meeting on [DATE] at 3:15 PM the facility Administrator was made aware of the DON's actions during the assessment of Resident # 14's wound. The Administrator stated the DON needed more training and decided to have the two RNs performing skin assessments and not include the DON until she was further trained. Observations were made of a LVN and RN performing a skin assessment and identifying a problem on an at risk resident. Then two RNs returned and performed an assessment on the at risk resident and identified an area of concern on her left great toe. The area was identified as a Suspected Deep Tissue Injury. The two RNs correctly assessed, measured, identified prevention interventions, and notified the Physician and the Responsible Party. The facility provided an attendance signature sheet for the Staff Meeting held on [DATE] after the skin audit was completed with the Administrator, DON, ADON, RN A, MDS Coordinator, and one LVN-Medicaid Coordinator in attendance. On [DATE] at 8:00 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided a list of 25 residents at risk for pressure sores.

Based on observation, interview, and record review the facility failed to meet professional standards of quality for the DON when she did not follow facility policy regarding weekly pressure sore assessments, measuring and staging. The DON failed to assume accountability of the staff for the weekly assessment, measuring and correct staging of pressure sores for two (2) of nine (9) residents (Resident #3 and #7) reviewed for pressure sores. The DON also failed to provide standard infection control practices while measuring a pressure sore, failed to assume accountability of the staff to determine physician orders [REDACTED]. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices affected Resident #3 and Resident #7 and placed an additional 63 residents at risk of not receiving timely medical assessments and services as needed due to facility staff incorrectly assessing, failing to notify the Physician and Family of condition changes, and failing to implement physician orders. Findings include: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses... The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure... Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses...shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (E) Respect the client's right to privacy by protecting confidential information unless required or allowed by law to disclose the information; (F) Promote and participate in education and counseling to a client(s) and, where applicable, the family/significant other(s) based on health needs; (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations; (O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; (R) Be responsible for one's own continuing competence in nursing practice and individual professional growth. Review of the facility's undated policy for PRESSURE ULCER PREVENTION AND MONITORING reflected: "l. All residents admitted at risk for pressure ulcers will be placed on a pressure ulcer prevention program which includes: b. Pressure reducing devices such as special mattresses as needed...e. Intense skin monitoring. 2. Residents with pressure ulcers will have: a. Treatments as ordered...c. Pressure reducing devices such as special mattresses and or/heel protectors as needed...g. At least weekly written assessments including location, stage, odor, color, size, drainage, response to treatment...h. any resident with a pressure ulcer which fails to improve or worsens, will have the physician notified promptly." Review of the undated facility's Pressure Ulcer Management Sheet reflected: "3. Reassess and measure at least weekly or sooner if deterioration of the ulcer is noted. Always document your findings in detail. 4. Promptly inform the physician (and responsible party, as appropriate) of new pressure ulcers. Obtain and initiate treatment orders." A) Review of Resident #3's Face Sheet reflected an [AGE] year old female readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3's Significant Change MDS assessment dated [DATE] reflected Resident #3's BIMS score was a five (5) (severe cognitive impairment), she required extensive assistance of two persons to turn, she had an indwelling Foley Catheter, and was frequently incontinent of bowel. Resident #3 was coded as having three (3) Stage I (Intact skin with non-blanchable redness of a localized area usually over a boney prominence) pressure sores and no pressure reduction devices in place. Review of Resident #3's Comprehensive Plan of Care revised on [DATE] reflected "The resident has some skin breakdown" with interventions of "has a pressure relieving mattress...and the resident has a Foley Catheter." Observation on [DATE] at 4:25 PM revealed Resident #3 on her right side receiving peri-care during which time the dressing fell off the sacrum revealing a Stage IV (Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling) pressure sore. The pressure sore was approximately 3 cm round and 0.3 cm deep with yellow slough attached to the tendon and muscle in the very center of the wound bed with red wound edges. Periwound edges were reddened, [MEDICAL CONDITION] and not adhered to wound bed thereby indicated tunneling was present. Resident # 3 had a standard green plastic mattress on her bed, a mattress with no pressure reducing qualities. There was no Foley Catheter was in place to prevent contamination of the wound. Observation on [DATE] at 10:50 AM revealed Resident #3 in bed sleeping on her back with a strong odor of urine in her room. No pressure relieving device was on the mattress and no Foley Catheter was in place. Review of the Weekly Skin Monitoring for Resident #3 reflected zero (0) decubitus (pressure sore) on [DATE], [DATE], [DATE], and [DATE]. On [DATE] a Stage II pressure sore (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 blister) to coccyx was documented. Review of the Wound Assessment for Resident #3 by RN A (the nurse in charge of assessing and staging wounds) dated [DATE] reflected: "Coccyx Stage II, 1.75 centimeters long and 1.5 cm wide, two (2) millimeters deep, slough; yes." The definition located on the Wound Assessment reflected a Stage II pressure sore does not have slough and a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore may have slough present but does not obscure the depth of tissue loss. Resident # 3's Stage III Coccyx wound was misstaged at a Stage II. On the same sheet there was an additional wound documented as "#2 wound superficial 0.5 cm wide and 0.5 cm long, .0 deep." Wound edges were described as "macerated" (moisture associated skin damage). Review of Resident #3's Nurses' Notes dated [DATE] reflected the physician was notified of a Stage II on [DATE] and the orders were obtained. No responsible party notification was documented. Review of Resident # 3's Physician order [REDACTED]." Review of the next recorded Wound Assessment for Resident #3 was l4 days later by RN A dated [DATE] and reflected: "Coccyx Stage II 2.0 cm long and 1.75 cm wide, one (1) mm deep with some slough. Scattered areas of white slough to wound bed." Again, the wound with slough was staged at a Stage II instead of a Stage III. Review of Resident # 3's Physician order [REDACTED].) to decubitus (pressure sore) on shower days (3 times weekly) and as needed." Review of Resident #3's [DATE] TAR reflected an order for [REDACTED]." The order written by Resident # 3's physician on [DATE] was not placed on the TAR and there was no indication this treatment had started. The [DATE] TAR reflected there were no nurse signatures for the dates ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], or [DATE] and indicated no treatment was performed for Resident # 3 on those dates. Observation on [DATE] at 4:35 PM revealed Resident # 3 was provided the treatment ordered [DATE] where the wound was cleansed with wound cleanser, the nurse patted dry and applied Wound Be Gone and added a padded dressing. The physician order [REDACTED]. In an interview on [DATE] at 12:30 PM the DON stated, "I knew she (Resident # 3) had the order for Santyl, I just didn't know they weren't carrying it out. It might have helped..." Review of the next recorded Wound Assessment for Resident #3 was 14 days later by RN A dated [DATE] reflected: "Coccyx Stage IV pressure sore 3.0 cm long and 3.0 cm wide, tunneling around wound ranges from 0.5 cm deep to 1.25 cm deep. [DIAGNOSES REDACTED] and purple tissue around edges. Very [DIAGNOSES REDACTED]tous to wound margins. (Tunneling was drawn around one half of the wound). Yellow slough present on wound base in center." Review of the Nurse's Notes from [DATE] through [DATE] reflected no further physician notification was documented until [DATE] when resident was sent to the physician and was prescribed an antibiotic for treatment of [REDACTED]. Review of the Physician order [REDACTED]. Notify if worsens." Review of Resident #3's [DATE] MAR indicated [REDACTED]." In an interview on [DATE] at 11:56 PM the DON stated it looked like no treatment was performed from [DATE] through [DATE] on paper. The DON also stated she would expect that the nurse to sign the treatment sheet when the treatment was performed. Regarding the catheter that was no longer in place, The DON stated she did not think they would "get anywhere" with the healing of the pressure sore unless the Foley catheter was put back in place. The DON stated "we didn't have a [DIAGNOSES REDACTED]." The DON stated she expected the nursing staff to use the Santyl now. In an interview on [DATE] at 12:15 PM RN A, nurse in charge of measuring, staging and documenting pressure sore progress, stated [DATE] was when she was first alerted there was an issue with the coccyx. RN A further stated "she (Resident #3) has had a long standing issue with the coccyx. She will get a little pink then heal up. It's not a Stage I, it's a pre-Stage I." RN A stated Resident #3 was "really at risk for pressure sores since she was admitted because she was so emaciated. Immediately after we discontinued the Foley Catheter it started getting worse." RN A further stated Resident #3 "refused the air mattress on admission and has refused it periodically in the past." She stated she was unable to find any documentation regarding the refusals and stated, "on [DATE], I mentioned to her trying to get her on an air mattress and she just wouldn't answer me." RN A further stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In an interview on [DATE] at 3:45 PM Resident #3 was asked if she would like an air mattress overlay placed on her bed while she was up for supper when she stated "yes, it's worse than it's ever been." In an interview on [DATE] at 9:00 AM Resident #3, who was up in her wheelchair and had slept on the air overlay mattress, stated "I like my bed more and I ate 100% (of her breakfast meal)". Resident #3 appeared more comfortable than previous observations. In an interview on [DATE] at 3:45 PM CNA H stated Resident #3 required incontinent care due to bladder incontinence a minimum of two (2) or three (3) times a shift on the evening shifts that she worked. In a telephone interview on [DATE] at 6:15 PM Resident #3's primary Physician stated a Foley Catheter "possibly" could assist in wound healing and that "it should have been a suggestion." Resident # 3's Physician stated that it would be "reasonable" to believe that an air mattress or pressure relieving mattress would be beneficial. He further stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. Resident # 3's Physician also stated "weekly wound measurements may have helped the wound from getting so bad" and stated the Santyl order "would have possibly helped in wound healing" if the order had been followed. In an interview on [DATE] at 12:40 PM the facility's Medical Director stated "when Santyl wound ointment is used correctly you can at least see a difference in the wound progress. If it's not done, sometimes the progress is not as obvious as it should be. I would expect the nurses to use it like it's ordered." He also stated, "I would expect that a resident should be encouraged to use the air mattress or what is available to prevent or improve the wound. If the resident has dementia (he) expects that the family should be encouraged to assist in those interventions." Regarding improper staging of wounds, he replied, "if the wound is not healing or progressing then there are different principles to follow for wound care." B) Review of the face sheet reflected Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Nurses' Notes for [DATE] reflected Resident #7 was admitted with a Stage II pressure sore to the coccyx. Review of the initial MDS assessment dated [DATE] reflected Resident #7 to be moderately impaired in thinking, required two persons and a hydraulic lift to transfer, frequently incontinent of bowel and bladder and had one Stage II pressure sore to coccyx. Additional [DIAGNOSES REDACTED]. Review of the Plan of Care dated [DATE] reflected Resident #7 had "breaks in his skin integrity related to pressure ulcer, moisture associated skin damage and stasis ulcers/blisters." Interventions included: "Assist Resident #7 to reposition frequently, monitor treatments for effectiveness and notify physician of any concerns. Try to encourage ventilation to perineum area as much as is possible. This may be more realistic in bed." Review of the TAR for [DATE] for Resident #7 reflected an order placed on the TAR dated [DATE] for Inflatable foot/heel protectors with all three shifts ,[DATE], ,[DATE], ,[DATE] signing the TAR. Review of the Wound Assessment Sheet for Resident #7 dated [DATE] reflected the pressure sore to the coccyx was 2.5 cm long by .75 cm wide with no slough and staged as Stage II documented and signed by RN A. Observation on [DATE] revealed Resident #7 to be up in the wheelchair from 9 AM until 6 PM with no inflatable foot/heel protectors in place. Observation on [DATE] at 4:53 of Resident #7's wound care and measurement by RN A (nurse in charge of assessing and staging wounds) revealed the pressure ulcer on the coccyx to be 3.5 cm long by 1.25 cm wide. The pressure ulcer was 80% covered in yellow slough and was a Stage III pressure ulcer as defined on the Wound Assessment System document RN A was documenting on. In an interview on [DATE] at 4:53 RN A stated the wound bed was 80% covered with yellow slough. She stated "It is a Stage II because there is no depth. I don't really agree with that slough only being a Stage III." RN A underlined slough in the description of a Stage III ulcer. During the measurement of the wound, RN A assured Resident #7 that his pressure sore was looking and getting much better. Review of the Wound Assessment Sheet dated [DATE] reflected RN A had staged the pressure sore a Stage II. In the narrative she documented "wound continues to improve. Has shallow bed of whitish slough to top of wound with approx. (approximately) 20% clean non-granulating tissue to edges. Will continue treatment as ordered." RN A documented "some slough" and the wound base as pink, yellow and white. Review of Wound Assessment Sheets for Resident #7 reflected his wounds were measured every 14 days. Review of the Nurses' Notes for Resident #7 dated [DATE] reflected there had been no notification to the physician of the increase in size and the worsening of the appearance of the pressure ulcer. In an interview on [DATE] at 12:15 PM with RN A she stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In a telephone interview on [DATE] at 6:15 PM Resident #7's primary Physician stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. He also stated "weekly wound measurements may have helped the wound from getting so bad." In an interview on [DATE] at 12:40 PM with the facility's Medical Director, he stated regarding improper staging of wounds, "if the wound is not healing or progressing then there are different principles to follow for wound care." In an interview on [DATE] at 4:30 PM the DON stated the skin nurse should let the charge nurse know when she sees worsening of condition of wounds. The DON stated the LVN should realize to notify the family and physician. When asked who was responsible for making sure orders are carried out the DON stated, "the charge nurses are responsible to make sure they are carried out." The DON stated she and the ADON were responsible for making sure staff followed facility policy. The DON stated it was her and the ADON's responsibility to ensure staff knew what the facility policies and procedures were. In an interview on [DATE] at 6:05 PM the facility Administrator stated the DON, ADON and charge nurses are responsible for notifying the physician and family. The ADON was responsible for making sure orders were carried out. The Administrator stated the he and the Nursing Department are responsible for making sure staff followed procedures. The Administrator further stated it was ultimately his responsibility to make sure staff followed procedures. The Administrator stated the DON should definitely know what wounds were in the building. He was aware his policy stated pressure sores were to be measured weekly. Regarding whether he and his staff had neglected the care of the residents he stated, "It was not correct (the care of the residents). I do not appreciate professional people that I trust not doing what I expect." The facility Administrator was notified on [DATE] at 6:20 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was first submitted by the Administrator on [DATE] at 9:04 AM. The final Plan of Removal was accepted by the survey team on [DATE] at 7:30 PM. Cameron Nursing and Rehab Plan of Removal of Immediate Jeopardy In responses Wound Issues, Cameron Nursing and Rehab will do the following: 1. An RN from (Hospice) to in-service nursing staff on the care and treatment of [REDACTED]. DON, ADON, RN, Medicare Coordinator, and MDS Nurse and charge nurses LVN's will attend. In-service will be at 10:00 on Friday [DATE]. 2. Two Staff Registered Nurses will assess and measure all wounds on a weekly basis. All current wounds will be reassessed after training on [DATE]. 3. Facility will identify all "At Risk" residents for Skin Breakdown by using the Braden Scale. After in-service, all At Risk residents will be assessed by a RN and LVN to identify any possible pressure issues [DATE]. 4. All Physician orders [REDACTED]. A pink copy of all telephone order forms will be given to the ADON when completed. The ADON will monitor the order and follow through to make sure all meds are ordered and orders entered on treatment sheet and or MARs. This process was started on [DATE]. 5. DON and ADON will do in-service with all charge nurses regarding proper documentation of resident's change of condition, pressure sores, treatments, Physician Orders, and notifying family members and Physician. This will be complete during the in-service on [DATE]. 6. ADON and DON will report to Administrator any new skin issues and update of treatments in progress on Friday of each week with a copy of the weekly decubitus skin assessment log and non-decubitus log. First meeting will be on [DATE] and then weekly. 7. All pressure wounds will be reviewed and discussed at weekly staff meeting, including DON, ADON, MDS Nurse, Medicaid Coordinator, Registered Nurse on Staff, and Administrator on [DATE]. 8. Medical Director was notified of this at 9:30 am on Thursday [DATE]. Resident #3 Facility will: 1. Ensure air mattress is on Resident #3's bed, [DATE]. 2. Will follow physician orders [REDACTED]. (The new order: "Cleanse wound on coccyx with Normal Saline, pat dry-Apply Normal saline packing to wound bandage BID (twice daily)-Will consult wound care at Scott & White (Temple)-Insert indwelling catheter...-change q (every) month & PRN (as needed)-Record I&O (input and output) q shift-Catheter care q shift".) 3. Registered Nurse will accompany resident to Doctor's appointment on [DATE] to discuss proper treatment and procedure to be used, and request the use of a Catheter, this will be done on [DATE]. ADON or DON will monitor resident treatment with charge nurse for a period of two weeks to assure proper procedure is followed. If there is no improvement or wound worsens, Physician will be notified. 4. Two Registered Nurses will assess and measure wounds on a weekly basis. 5. Have Staff to continue to encourage resident to stay off of her back side and have staff continue to encourage and assist her to turn when in bed. 6. Nursing staff will encourage Resident to take in proper nourishment to help the healing process and have a Care Plan meeting with Son to encourage compliance with treatment plan. Administrator, DON, ADON will meet with son. 7. Have Dietary Consultant review Resident #3's chart and condition and make recommendations for nutrition on her next visit to the facility. Resident #7 1. Make sure resident maintains a pressure relieving mattress on his bed, [DATE]. 2. Nursing staff will encourage resident to try to stay off of his back side as much as possible, offering repositioning and reminded to use overhead bar. 3. Resident #7 request to be up for all three meals each day and remain in his wheelchair. DON, ADON, Administrator will have a care plan meeting will be held with Resident and Responsible Party regarding the benefits of shorter periods of time sitting in the wheelchair. 4. ADON or DON will monitor resident treatment for [REDACTED]. If there is no improvement or wound worsens, Physician will be notified. 5. Confirm with Physician when Heel Protectors should be worn, requested clarification [DATE]. 6. Notify Physician of change of condition [DATE]. 7. Two Registered Nurses will assess and measure resident's wounds on a weekly basis. The survey team monitored the plan of removal as follows: Review was completed of new treatments as per physician order [REDACTED].#3 as shown in the plan of removal. All treatments and interventions were initiated and carried out. Resident #3's Responsible Party was notified. Resident # 7 had a re-assessment of his wounds and physician and responsible party were notified of the decline in the coccyx pressure sore. Observation of the facility in-service on [DATE] at 10:00 AM revealed the in-service was conducted by a RN from a local Hospice agency. The in-service provided information regarding pressure sores, care for pressure sores, assessments including staging and measuring, as well as interventions to prevent pressure sores. The in-service had four (4) RNs and 11 LVNs in attendance. The Medical Director and the Administrator were also present. The facility had over 70% of their licensed nursing staff in-serviced on [DATE]. The Hospice RN gave a competency test after the in-service in which all nursing staff in attendance passed per the Administrator. The facility provided a list of 25 residents who were at risk for pressure sores. The facility completed a 100% audit using the Braden Scale to identify residents at risk for pressure sores. Twenty-five (25) residents were identified at risk for pressure sores. Observations were made on [DATE] of four (4) of the 25 residents at risk for pressure sores. These Residents were assessed and staged properly and interventions and treatments were in place. The facility notified the Resident's Physicians and Responsible Parties. Observation on [DATE] at 2:40 PM revealed the DON entered a resident room to assess and measure pressure sores. The DON did not bring a cart or any sanitizing agents to the room. She did not prepare a clean surface for her supplies. She placed supplies for wound measurement under the shoes on Resident #14's Geri chair pressure reduction pad of the incontinent resident. She then laid a pair of gloves up against the heels of the shoes and went to the bathroom to wash her hands. She returned from the bathroom and began donning gloves. She approached the resident to explain the process to the resident when the surveyor stopped the DON and instructed her to start over and explained that her articles were contaminated. Later, when the DON began assessing the heel of the resident that had a Deep Tissue Injury (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue) she proceeded to dismiss the area and pronounced it was blanching after she placed pressure on the heel and released it multiple times. The heel was not blanching. Surveyor stepped forward and asked to see the heel turn white and then return to red. The DON applied pressure once again and admitted the heel was not changing color at all and was actually purple. The DON and ADON then tried to decide if the heel sore was a Stage I or not since it wasn't red. The Surveyor handed the DON the in-service Wound Staging Guide as received in the training in-service and asked her to read the description of a Deep Tissue Injury. The DON then correctly identified the heel as having a deep tissue injury. DON then observed the Stage II that was approximately one (1) cm in size with a pinpoint opening on the sacrum. The DON placed the measuring device on the opening and removed it repeatedly. She finally traced the one (1) cm circle and then marked the pinpoint opening. She then placed the device back on the wound and studied it and then asked the ADON to come and see if she had marked her device correctly. The DON then began studying the raised skin edges on the bilateral buttocks and decided that those impaired skin issues needed measuring. After DON applied the graph several times, the Surveyor asked the ADON if she had told the DON that the resident had a rash over her entire perineum. The ADON said she had not informed the DON and then parted the resident's legs so that she could see the raised skin was related to a rash and was not at all pressure sores. When the DON submitted the wound assessment to the surveyor, she had left the entire wound description area of the form blank. The Surveyor returned the form to the DON to complete it. The DON submitted it to the Surveyor the second time. The Surveyor returned the form to the DON and asked her to complete the periwound skin assessment line on the form. In an interview on [DATE] at 2:43 PM the Surveyor asked the DON as she donned gloves if she realized that she had her wound care items under a pair of shoes in the seat of a chair, she stated that she was so nervous that she did not realize what she had done. In a meeting on [DATE] at 3:15 PM the facility Administrator was made aware of the DON's actions during the assessment of Resident # 14's wound. The Administrator stated the DON needed more training and decided to have the two RNs performing skin assessments and not include the DON until she was further trained. Observations were made of a LVN and RN performing a skin assessment and identifying a problem on an at risk resident. Then two RNs returned and performed an assessment on the at risk resident and identified an area of concern on her left great toe. The area was identified as a Suspected Deep Tissue Injury. The two RNs correctly assessed, measured, identified prevention interventions, and notified the Physician and the Responsible Party. The facility provided an attendance signature sheet for the Staff Meeting held on [DATE] after the skin audit was completed with the Administrator, DON, ADON, RN A, MDS Coordinator, and one LVN-Medicaid Coordinator in attendance. On [DATE] at 8:00 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided a list of 25 residents at risk for pressure sores.

Based on observation, interview and record review the facility Administrator and the DON failed to administer the facility in a manner that enabled them to use their resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of nine (9) residents (Resident #3 and #7) reviewed for pressure sores when: The Administrator failed to supervise staff, consult with the DON and ensure the facility policy was implemented for pressure sores. The DON failed to supervise staff and ensure the facility policy was implemented for pressure sores. The Administrator and DON failure resulted in worsening of pressure sores for Resident # 3 and Resident # 7 when: A) The facility failed to ensure Resident # 3, a resident with a history of developing pressure sores, had a care planned pressure relieving device on her bed. The facility failed to accurately assess and stage Resident # 3's wound to her coccyx. The facility failed to implement a physician ordered treatment change on [DATE] and failed to provide a wound treatment at all from [DATE] through [DATE]. The facility failed to notify the physician of a decline in the wound and failed to ensure pressure sores were assessed every seven (7) days as stated in their policy. Resident # 3's pressure sore declined to a Stage IV with infection. B) The facility failed to accurately assess and stage Resident #7's wound to his coccyx and failed to notify the physician of a decline in the wound. Resident # 7's wound declined from a Stage II to a Stage III. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practice affected Resident #3 and Resident #7 and placed an additional 23 resident at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), [DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), pain and death. Findings include: A) Review of Resident #3's Face Sheet reflected an [AGE] year old female readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3's Significant Change MDS assessment dated [DATE] reflected Resident #3's BIMS score was a five (5) (severe cognitive impairment), she required extensive assistance of two persons to turn, she had an indwelling Foley Catheter, and was frequently incontinent of bowel. Resident #3 was coded as having three (3) Stage I (Intact skin with non-blanchable redness of a localized area usually over a boney prominence) pressure sores and no pressure reduction devices in place. Review of Resident #3's Comprehensive Plan of Care revised on [DATE] reflected "The resident has some skin breakdown" with interventions of "has a pressure relieving mattress...and the resident has a Foley Catheter." Observation on [DATE] at 4:25 PM revealed Resident #3 on her right side receiving peri-care during which time the dressing fell off the sacrum revealing a Stage IV (Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling) pressure sore. The pressure sore was approximately 3 cm round and 0.3 cm deep with yellow slough attached to the tendon and muscle in the very center of the wound bed with red wound edges. Periwound edges were reddened, [MEDICAL CONDITION] and not adhered to wound bed thereby indicated tunneling was present. Resident # 3 had a standard green plastic mattress on her bed, a mattress with no pressure reducing qualities. There was no Foley Catheter was in place to prevent contamination of the wound. Observation on [DATE] at 10:50 AM revealed Resident #3 in bed sleeping on her back with a strong odor of urine in her room. No pressure relieving device was on the mattress and no Foley Catheter was in place. Review of the Weekly Skin Monitoring for Resident #3 reflected zero (0) decubitus (pressure sore) on [DATE], [DATE], [DATE], and [DATE]. On [DATE] a Stage II pressure sore (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 blister) to coccyx was documented. Review of the Wound Assessment for Resident #3 by RN A (the nurse in charge of assessing and staging wounds) dated [DATE] reflected: "Coccyx Stage II, 1.75 centimeters long and 1.5 cm wide, two (2) millimeters deep, slough; yes." The definition located on the Wound Assessment reflected a Stage II pressure sore does not have slough and a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore may have slough present but does not obscure the depth of tissue loss. Resident # 3's Stage III Coccyx wound was misstaged at a Stage II. On the same sheet there was an additional wound documented as "#2 wound superficial 0.5 cm wide and 0.5 cm long, .0 deep." Wound edges were described as "macerated" (moisture associated skin damage). Review of Resident #3's Nurses' Notes dated [DATE] reflected the physician was notified of a Stage II on [DATE] and the orders were obtained. No responsible party notification was documented. Review of Resident # 3's Physician order [REDACTED]." Review of the next recorded Wound Assessment for Resident #3 was l4 days later by RN A dated [DATE] and reflected: "Coccyx Stage II 2.0 cm long and 1.75 cm wide, one (1) mm deep with some slough. Scattered areas of white slough to wound bed." Again, the wound with slough was staged at a Stage II instead of a Stage III. Review of Resident # 3's Physician order [REDACTED].) to decubitus (pressure sore) on shower days (3 times weekly) and as needed." Review of Resident #3's [DATE] TAR reflected an order for [REDACTED]." The order written by Resident # 3's physician on [DATE] was not placed on the TAR and there was no indication this treatment had started. The [DATE] TAR reflected there were no nurse signatures for the dates ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], or [DATE] and indicated no treatment was performed for Resident # 3 on those dates. Observation on [DATE] at 4:35 PM revealed Resident # 3 was provided the treatment ordered [DATE] where the wound was cleansed with wound cleanser, the nurse patted dry and applied Wound Be Gone and added a padded dressing. The physician order [REDACTED]. In an interview on [DATE] at 12:30 PM the DON stated, "I knew she (Resident # 3) had the order for Santyl, I just didn't know they weren't carrying it out. It might have helped..." Review of the next recorded Wound Assessment for Resident #3 was 14 days later by RN A dated [DATE] reflected: "Coccyx Stage IV pressure sore 3.0 cm long and 3.0 cm wide, tunneling around wound ranges from 0.5 cm deep to 1.25 cm deep. [DIAGNOSES REDACTED] and purple tissue around edges. Very [DIAGNOSES REDACTED]tous to wound margins. (Tunneling was drawn around one half of the wound). Yellow slough present on wound base in center." Review of the Nurse's Notes from [DATE] through [DATE] reflected no further physician notification was documented until [DATE] when resident was sent to the physician and was prescribed an antibiotic for treatment of [REDACTED]. Review of the Physician order [REDACTED]. Notify if worsens." Review of Resident #3's [DATE] MAR indicated [REDACTED]." In an interview on [DATE] at 11:56 PM the DON stated it looked like no treatment was performed from [DATE] through [DATE] on paper. The DON also stated she would expect that the nurse to sign the treatment sheet when the treatment was performed. Regarding the catheter that was no longer in place, The DON stated she did not think they would "get anywhere" with the healing of the pressure sore unless the Foley catheter was put back in place. The DON stated "we didn't have a [DIAGNOSES REDACTED]." The DON stated she expected the nursing staff to use the Santyl now. In an interview on [DATE] at 12:15 PM RN A, nurse in charge of measuring, staging and documenting pressure sore progress, stated [DATE] was when she was first alerted there was an issue with the coccyx. RN A further stated "she (Resident #3) has had a long standing issue with the coccyx. She will get a little pink then heal up. It's not a Stage I, it's a pre-Stage I." RN A stated Resident #3 was "really at risk for pressure sores since she was admitted because she was so emaciated. Immediately after we discontinued the Foley Catheter it started getting worse." RN A further stated Resident #3 "refused the air mattress on admission and has refused it periodically in the past." She stated she was unable to find any documentation regarding the refusals and stated, "on [DATE], I mentioned to her trying to get her on an air mattress and she just wouldn't answer me." RN A further stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In an interview on [DATE] at 3:45 PM Resident #3 was asked if she would like an air mattress overlay placed on her bed while she was up for supper when she stated "yes, it's worse than it's ever been." In an interview on [DATE] at 9:00 AM Resident #3, who was up in her wheelchair and had slept on the air overlay mattress, stated "I like my bed more and I ate 100% (of her breakfast meal)". Resident #3 appeared more comfortable than previous observations. In an interview on [DATE] at 3:45 PM CNA H stated Resident #3 required incontinent care due to bladder incontinence a minimum of two (2) or three (3) times a shift on the evening shifts that she worked. In a telephone interview on [DATE] at 6:15 PM Resident #3's primary Physician stated a Foley Catheter "possibly" could assist in wound healing and that "it should have been a suggestion." Resident # 3's Physician stated that it would be "reasonable" to believe that an air mattress or pressure relieving mattress would be beneficial. He further stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. Resident # 3's Physician also stated "weekly wound measurements may have helped the wound from getting so bad" and stated the Santyl order "would have possibly helped in wound healing" if the order had been followed. In an interview on [DATE] at 12:40 PM the facility's Medical Director stated "when Santyl wound ointment is used correctly you can at least see a difference in the wound progress. If it's not done, sometimes the progress is not as obvious as it should be. I would expect the nurses to use it like it's ordered." He also stated, "I would expect that a resident should be encouraged to use the air mattress or what is available to prevent or improve the wound. If the resident has dementia (he) expects that the family should be encouraged to assist in those interventions." Regarding improper staging of wounds, he replied, "if the wound is not healing or progressing then there are different principles to follow for wound care." B) Review of the face sheet reflected Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Nurses' Notes for [DATE] reflected Resident #7 was admitted with a Stage II pressure sore to the coccyx. Review of the initial MDS assessment dated [DATE] reflected Resident #7 to be moderately impaired in thinking, required two persons and a hydraulic lift to transfer, frequently incontinent of bowel and bladder and had one Stage II pressure sore to coccyx. Additional [DIAGNOSES REDACTED]. Review of the Plan of Care dated [DATE] reflected Resident #7 had "breaks in his skin integrity related to pressure ulcer, moisture associated skin damage and stasis ulcers/blisters." Interventions included: "Assist Resident #7 to reposition frequently, monitor treatments for effectiveness and notify physician of any concerns. Try to encourage ventilation to perineum area as much as is possible. This may be more realistic in bed." Review of the TAR for [DATE] for Resident #7 reflected an order placed on the TAR dated [DATE] for Inflatable foot/heel protectors with all three shifts ,[DATE], ,[DATE], ,[DATE] signing the TAR. Review of the Wound Assessment Sheet for Resident #7 dated [DATE] reflected the pressure sore to the coccyx was 2.5 cm long by .75 cm wide with no slough and staged as Stage II documented and signed by RN A. Observation on [DATE] revealed Resident #7 to be up in the wheelchair from 9 AM until 6 PM with no inflatable foot/heel protectors in place. Observation on [DATE] at 4:53 of Resident #7's wound care and measurement by RN A (nurse in charge of assessing and staging wounds) revealed the pressure ulcer on the coccyx to be 3.5 cm long by 1.25 cm wide. The pressure ulcer was 80% covered in yellow slough and was a Stage III pressure ulcer as defined on the Wound Assessment System document RN A was documenting on. In an interview on [DATE] at 4:53 RN A stated the wound bed was 80% covered with yellow slough. She stated "It is a Stage II because there is no depth. I don't really agree with that slough only being a Stage III." RN A underlined slough in the description of a Stage III ulcer. During the measurement of the wound, RN A assured Resident #7 that his pressure sore was looking and getting much better. Review of the Wound Assessment Sheet dated [DATE] reflected RN A had staged the pressure sore a Stage II. In the narrative she documented "wound continues to improve. Has shallow bed of whitish slough to top of wound with approx. (approximately) 20% clean non-granulating tissue to edges. Will continue treatment as ordered." RN A documented "some slough" and the wound base as pink, yellow and white. Review of Wound Assessment Sheets for Resident #7 reflected his wounds were measured every 14 days. Review of the Nurses' Notes for Resident #7 dated [DATE] reflected there had been no notification to the physician of the increase in size and the worsening of the appearance of the pressure ulcer. In an interview on [DATE] at 4:30 PM when asked who should notify the family and physician of pressure sores and changes for Resident #7 the DON stated, "Charge nurses/ Skin nurse when she sees it, she should let the charge nurse know. The LVN should realize to notify." In an interview on [DATE] at 12:15 PM with RN A she stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In a telephone interview on [DATE] at 6:15 PM Resident #7's primary Physician stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. He also stated "weekly wound measurements may have helped the wound from getting so bad." In an interview on [DATE] at 12:40 PM with the facility's Medical Director, he stated regarding improper staging of wounds, "if the wound is not healing or progressing then there are different principles to follow for wound care." Review of the facility's undated policy for PRESSURE ULCER PREVENTION AND MONITORING reflected: "l. All residents admitted at risk for pressure ulcers will be placed on a pressure ulcer prevention program which includes: b. Pressure reducing devices such as special mattresses as needed...e. Intense skin monitoring. 2. Residents with pressure ulcers will have: a. Treatments as ordered...c. Pressure reducing devices such as special mattresses and or/heel protectors as needed...g. At least weekly written assessments including location, stage, odor, color, size, drainage, response to treatment...h. any resident with a pressure ulcer which fails to improve or worsens, will have the physician notified promptly." Review of the undated facility's Pressure Ulcer Management Sheet reflected: "3. Reassess and measure at least weekly or sooner if deterioration of the ulcer is noted. Always document your findings in detail. 4. Promptly inform the physician (and responsible party, as appropriate) of new pressure ulcers. Obtain and initiate treatment orders." In an interview on [DATE] at 4:30 PM the DON stated the skin nurse should let the charge nurse know when she sees worsening of condition of wounds. The DON stated the LVN should realize to notify the family and physician. When asked who was responsible for making sure orders are carried out the DON stated, "the charge nurses are responsible to make sure they are carried out." The DON stated she and the ADON were responsible for making sure staff followed facility policy. The DON stated it was her and the ADON's responsibility to ensure staff knew what the facility policies and procedures were. In an interview on [DATE] at 6:05 PM the facility Administrator stated the DON, ADON and charge nurses are responsible for notifying the physician and family. The ADON was responsible for making sure orders were carried out. The Administrator stated the he and the Nursing Department are responsible for making sure staff followed procedures. The Administrator further stated it was ultimately his responsibility to make sure staff followed procedures. The Administrator stated the DON should definitely know what wounds were in the building. He was aware his policy stated pressure sores were to be measured weekly. Regarding whether he and his staff had neglected the care of the residents he stated, "It was not correct (the care of the residents). I do not appreciate professional people that I trust not doing what I expect." The facility Administrator was notified on [DATE] at 6:20 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was first submitted by the Administrator on [DATE] at 9:04 AM. The final Plan of Removal was accepted by the survey team on [DATE] at 7:30 PM. Cameron Nursing and Rehab Plan of Removal of Immediate Jeopardy In responses Wound Issues, Cameron Nursing and Rehab will do the following: 1. An RN from (Hospice) to in-service nursing staff on the care and treatment of [REDACTED]. DON, ADON, RN, Medicare Coordinator, and MDS Nurse and charge nurses LVN's will attend. In-service will be at 10:00 on Friday [DATE]. 2. Two Staff Registered Nurses will assess and measure all wounds on a weekly basis. All current wounds will be reassessed after training on [DATE]. 3. Facility will identify all "At Risk" residents for Skin Breakdown by using the Braden Scale. After in-service, all At Risk residents will be assessed by a RN and LVN to identify any possible pressure issues [DATE]. 4. All Physician orders [REDACTED]. A pink copy of all telephone order forms will be given to the ADON when completed. The ADON will monitor the order and follow through to make sure all meds are ordered and orders entered on treatment sheet and or MARs. This process was started on [DATE]. 5. DON and ADON will do in-service with all charge nurses regarding proper documentation of resident's change of condition, pressure sores, treatments, Physician Orders, and notifying family members and Physician. This will be complete during the in-service on [DATE]. 6. ADON and DON will report to Administrator any new skin issues and update of treatments in progress on Friday of each week with a copy of the weekly decubitus skin assessment log and non-decubitus log. First meeting will be on [DATE] and then weekly. 7. All pressure wounds will be reviewed and discussed at weekly staff meeting, including DON, ADON, MDS Nurse, Medicaid Coordinator, Registered Nurse on Staff, and Administrator on [DATE]. 8. Medical Director was notified of this at 9:30 am on Thursday [DATE]. Resident #3 Facility will: 1. Ensure air mattress is on Resident #3's bed, [DATE]. 2. Will follow physician orders [REDACTED]. (The new order: "Cleanse wound on coccyx with Normal Saline, pat dry-Apply Normal saline packing to wound bandage BID (twice daily)-Will consult wound care at Scott & White (Temple)-Insert indwelling catheter...-change q (every) month & PRN (as needed)-Record I&O (input and output) q shift-Catheter care q shift".) 3. Registered Nurse will accompany resident to Doctor's appointment on [DATE] to discuss proper treatment and procedure to be used, and request the use of a Catheter, this will be done on [DATE]. ADON or DON will monitor resident treatment with charge nurse for a period of two weeks to assure proper procedure is followed. If there is no improvement or wound worsens, Physician will be notified. 4. Two Registered Nurses will assess and measure wounds on a weekly basis. 5. Have Staff to continue to encourage resident to stay off of her back side and have staff continue to encourage and assist her to turn when in bed. 6. Nursing staff will encourage Resident to take in proper nourishment to help the healing process and have a Care Plan meeting with Son to encourage compliance with treatment plan. Administrator, DON, ADON will meet with son. 7. Have Dietary Consultant review Resident #3's chart and condition and make recommendations for nutrition on her next visit to the facility. Resident #7 1. Make sure resident maintains a pressure relieving mattress on his bed, [DATE]. 2. Nursing staff will encourage resident to try to stay off of his back side as much as possible, offering repositioning and reminded to use overhead bar. 3. Resident #7 request to be up for all three meals each day and remain in his wheelchair. DON, ADON, Administrator will have a care plan meeting will be held with Resident and Responsible Party regarding the benefits of shorter periods of time sitting in the wheelchair. 4. ADON or DON will monitor resident treatment for [REDACTED]. If there is no improvement or wound worsens, Physician will be notified. 5. Confirm with Physician when Heel Protectors should be worn, requested clarification [DATE]. 6. Notify Physician of change of condition [DATE]. 7. Two Registered Nurses will assess and measure resident's wounds on a weekly basis. The survey team monitored the plan of removal as follows: Reviewed was completed of new treatments as per physician order [REDACTED].#3 as shown in the plan of removal. All treatments and interventions were initiated and carried out. Resident #3's Responsible Party was notified. Resident # 7 had a re-assessment of his wounds and physician and responsible party were notified of the decline in the coccyx pressure sore. Observation of the facility in-service on [DATE] at 10:00 AM revealed the in-service was conducted by a RN from a local Hospice agency. The in-service provided information regarding pressure sores, care for pressure sores, assessments including staging and measuring, as well as interventions to prevent pressure sores. The in-service had four (4) RNs and 11 LVNs in attendance. The Medical Director and the Administrator were also present. The facility had over 70% of their licensed nursing staff in-serviced on [DATE]. The Hospice RN gave a competency test after the in-service in which all nursing staff in attendance passed per the Administrator. The facility provided a list of 25 residents who were at risk for pressure sores. The facility completed a 100% audit using the Braden Scale to identify residents at risk for pressure sores. Twenty-five (25) residents were identified at risk for pressure sores. Observations were made on [DATE] of four (4) of the 25 residents at risk for pressure sores. These Residents were assessed and staged properly and interventions and treatments were in place. The facility notified the Resident's Physicians and Responsible Parties. Observation on [DATE] at 2:40 PM revealed the DON entered a resident room to assess and measure pressure sores. The DON did not bring a cart or any sanitizing agents to the room. She did not prepare a clean surface for her supplies. She placed supplies for wound measurement under the shoes on Resident #14's Geri chair pressure reduction pad of the incontinent resident. She then laid a pair of gloves up against the heels of the shoes and went to the bathroom to wash her hands. She returned from the bathroom and began donning gloves. She approached the resident to explain the process to the resident when the surveyor stopped the DON and instructed her to start over and explained that her articles were contaminated. Later, when the DON began assessing the heel of the resident that had a Deep Tissue Injury (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue) she proceeded to dismiss the area and pronounced it was blanching after she placed pressure on the heel and released it multiple times. The heel was not blanching. Surveyor stepped forward and asked to see the heel turn white and then return to red. The DON applied pressure once again and admitted the heel was not changing color at all and was actually purple. The DON and ADON then tried to decide if the heel sore was a Stage I or not since it wasn't red. The Surveyor handed the DON the in-service Wound Staging Guide as received in the training in-service and asked her to read the description of a Deep Tissue Injury. The DON then correctly identified the heel as having a deep tissue injury. DON then observed the Stage II that was approximately one (1) cm in size with a pinpoint opening on the sacrum. The DON placed the measuring device on the opening and removed it repeatedly. She finally traced the one (1) cm circle and then marked the pinpoint opening. She then placed the device back on the wound and studied it and then asked the ADON to come and see if she had marked her device correctly. The DON then began studying the raised skin edges on the bilateral buttocks and decided that those impaired skin issues needed measuring. After DON applied the graph several times, the Surveyor asked the ADON if she had told the DON that the resident had a rash over her entire perineum. The ADON said she had not informed the DON and then parted the resident's legs so that she could see the raised skin was related to a rash and was not at all pressure sores. When the DON submitted the wound assessment to the surveyor, she had left the entire wound description area of the form blank. The Surveyor returned the form to the DON to complete it. The DON submitted it to the Surveyor the second time. The Surveyor returned the form to the DON and asked her to complete the periwound skin assessment line on the form. In an interview on [DATE] at 2:43 PM the Surveyor asked the DON as she donned gloves if she realized that she had her wound care items under a pair of shoes in the seat of a chair, she stated that she was so nervous that she did not realize what she had done. In a meeting on [DATE] at 3:15 PM the facility Administrator was made aware of the DON's actions during the assessment of Resident # 14's wound. The Administrator stated the DON needed more training and decided to have the two RNs performing skin assessments and not include the DON until she was further trained. Observations were made of a LVN and RN performing a skin assessment and identifying a problem on an at risk resident. Then two RNs returned and performed an assessment on the at risk resident and identified an area of concern on her left great toe. The area was identified as a Suspected Deep Tissue Injury. The two RNs correctly assessed, measured, identified prevention interventions, and notified the Physician and the Responsible Party. The facility provided an attendance signature sheet for the Staff Meeting held on [DATE] after the skin audit was completed with the Administrator, DON, ADON, RN A, MDS Coordinator, and one LVN-Medicaid Coordinator in attendance. On [DATE] at 8:00 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided a list of 25 residents at risk for pressure sores.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit neglect for two (2) of nine (9) residents (Resident #3 and #7) reviewed for neglect when: A) The facility failed to ensure Resident # 3, a resident with a history of developing pressure sores, had a care planned pressure relieving device on her bed. The facility failed to accurately assess and stage Resident # 3's wound to her coccyx. The facility failed to implement a physician ordered treatment change on [DATE] and failed to provide a wound treatment at all from [DATE] through [DATE]. The facility failed to notify the physician of a decline in the wound and failed to ensure pressure sores were assessed every seven (7) days as stated in their policy. Resident # 3's pressure sore declined to a Stage IV with infection. B) The facility failed to accurately assess and stage Resident #7's wound to his coccyx and failed to notify the physician of a decline in the wound. Resident # 7's wound declined from a Stage II to a Stage III. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practice affected Resident #3 and Resident #7 and placed an additional 23 resident at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), [DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), pain and death. Findings include: Review of the facility's policy revised ,[DATE] entitled Recognizing Signs and Symptoms of Abuse/Neglect reflected under statement "Our facility will not condone any form of resident neglect." The Policy also reflected "Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness." Under "Signs of Actual Physical Neglect: ...(6) Inadequate provision of care; (7) Caregiver indifference to resident's personal care and needs..." Review of the facility's undated policy for PRESSURE ULCER PREVENTION AND MONITORING reflected: "l. All residents admitted at risk for pressure ulcers will be placed on a pressure ulcer prevention program which includes: b. Pressure reducing devices such as special mattresses as needed...e. Intense skin monitoring. 2. Residents with pressure ulcers will have: a. Treatments as ordered...c. Pressure reducing devices such as special mattresses and or/heel protectors as needed...g. At least weekly written assessments including location, stage, odor, color, size, drainage, response to treatment...h. any resident with a pressure ulcer which fails to improve or worsens, will have the physician notified promptly." Review of the undated facility's Pressure Ulcer Management Sheet reflected: "3. Reassess and measure at least weekly or sooner if deterioration of the ulcer is noted. Always document your findings in detail. 4. Promptly inform the physician (and responsible party, as appropriate) of new pressure ulcers. Obtain and initiate treatment orders." A) Review of Resident #3's Face Sheet reflected an [AGE] year old female readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3's Significant Change MDS assessment dated [DATE] reflected Resident #3's BIMS score was a five (5) (severe cognitive impairment), she required extensive assistance of two persons to turn, she had an indwelling Foley Catheter, and was frequently incontinent of bowel. Resident #3 was coded as having three (3) Stage I (Intact skin with non-blanchable redness of a localized area usually over a boney prominence) pressure sores and no pressure reduction devices in place. Review of Resident #3's Comprehensive Plan of Care revised on [DATE] reflected "The resident has some skin breakdown" with interventions of "has a pressure relieving mattress...and the resident has a Foley Catheter." Observation on [DATE] at 4:25 PM revealed Resident #3 on her right side receiving peri-care during which time the dressing fell off the sacrum revealing a Stage IV (Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling) pressure sore. The pressure sore was approximately 3 cm round and 0.3 cm deep with yellow slough attached to the tendon and muscle in the very center of the wound bed with red wound edges. Periwound edges were reddened, [MEDICAL CONDITION] and not adhered to wound bed thereby indicated tunneling was present. Resident # 3 had a standard green plastic mattress on her bed, a mattress with no pressure reducing qualities. There was no Foley Catheter was in place to prevent contamination of the wound. Observation on [DATE] at 10:50 AM revealed Resident #3 in bed sleeping on her back with a strong odor of urine in her room. No pressure relieving device was on the mattress and no Foley Catheter was in place. Review of the Weekly Skin Monitoring for Resident #3 reflected zero (0) decubitus (pressure sore) on [DATE], [DATE], [DATE], and [DATE]. On [DATE] a Stage II pressure sore (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 blister) to coccyx was documented. Review of the Wound Assessment for Resident #3 by RN A (the nurse in charge of assessing and staging wounds) dated [DATE] reflected: "Coccyx Stage II, 1.75 centimeters long and 1.5 cm wide, two (2) millimeters deep, slough; yes." The definition located on the Wound Assessment reflected a Stage II pressure sore does not have slough and a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore may have slough present but does not obscure the depth of tissue loss. Resident # 3's Stage III Coccyx wound was misstaged at a Stage II. On the same sheet there was an additional wound documented as "#2 wound superficial 0.5 cm wide and 0.5 cm long, .0 deep." Wound edges were described as "macerated" (moisture associated skin damage). Review of Resident #3's Nurses' Notes dated [DATE] reflected the physician was notified of a Stage II on [DATE] and the orders were obtained. No responsible party notification was documented. Review of Resident # 3's Physician order [REDACTED]." Review of the next recorded Wound Assessment for Resident #3 was l4 days later by RN A dated [DATE] and reflected: "Coccyx Stage II 2.0 cm long and 1.75 cm wide, one (1) mm deep with some slough. Scattered areas of white slough to wound bed." Again, the wound with slough was staged at a Stage II instead of a Stage III. Review of Resident # 3's Physician order [REDACTED].) to decubitus (pressure sore) on shower days (3 times weekly) and as needed." Review of Resident #3's [DATE] TAR reflected an order for [REDACTED]." The order written by Resident # 3's physician on [DATE] was not placed on the TAR and there was no indication this treatment had started. The [DATE] TAR reflected there were no nurse signatures for the dates ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], or [DATE] and indicated no treatment was performed for Resident # 3 on those dates. Observation on [DATE] at 4:35 PM revealed Resident # 3 was provided the treatment ordered [DATE] where the wound was cleansed with wound cleanser, the nurse patted dry and applied Wound Be Gone and added a padded dressing. The physician order [REDACTED]. In an interview on [DATE] at 12:30 PM the DON stated, "I knew she (Resident # 3) had the order for Santyl, I just didn't know they weren't carrying it out. It might have helped..." Review of the next recorded Wound Assessment for Resident #3 was 14 days later by RN A dated [DATE] reflected: "Coccyx Stage IV pressure sore 3.0 cm long and 3.0 cm wide, tunneling around wound ranges from 0.5 cm deep to 1.25 cm deep. [DIAGNOSES REDACTED] and purple tissue around edges. Very [DIAGNOSES REDACTED]tous to wound margins. (Tunneling was drawn around one half of the wound). Yellow slough present on wound base in center." Review of the Nurse's Notes from [DATE] through [DATE] reflected no further physician notification was documented until [DATE] when resident was sent to the physician and was prescribed an antibiotic for treatment of [REDACTED]. Review of the Physician order [REDACTED]. Notify if worsens." Review of Resident #3's [DATE] MAR indicated [REDACTED]." In an interview on [DATE] at 11:56 PM the DON stated it looked like no treatment was performed from [DATE] through [DATE] on paper. The DON also stated she would expect that the nurse to sign the treatment sheet when the treatment was performed. Regarding the catheter that was no longer in place, The DON stated she did not think they would "get anywhere" with the healing of the pressure sore unless the Foley catheter was put back in place. The DON stated "we didn't have a [DIAGNOSES REDACTED]." The DON stated she expected the nursing staff to use the Santyl now. In an interview on [DATE] at 12:15 PM RN A, nurse in charge of measuring, staging and documenting pressure sore progress, stated [DATE] was when she was first alerted there was an issue with the coccyx. RN A further stated "she (Resident #3) has had a long standing issue with the coccyx. She will get a little pink then heal up. It's not a Stage I, it's a pre-Stage I." RN A stated Resident #3 was "really at risk for pressure sores since she was admitted because she was so emaciated. Immediately after we discontinued the Foley Catheter it started getting worse." RN A further stated Resident #3 "refused the air mattress on admission and has refused it periodically in the past." She stated she was unable to find any documentation regarding the refusals and stated, "on [DATE], I mentioned to her trying to get her on an air mattress and she just wouldn't answer me." RN A further stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In an interview on [DATE] at 3:45 PM Resident #3 was asked if she would like an air mattress overlay placed on her bed while she was up for supper when she stated "yes, it's worse than it's ever been." In an interview on [DATE] at 9:00 AM Resident #3, who was up in her wheelchair and had slept on the air overlay mattress, stated "I like my bed more and I ate 100% (of her breakfast meal)". Resident #3 appeared more comfortable than previous observations. In an interview on [DATE] at 3:45 PM CNA H stated Resident #3 required incontinent care due to bladder incontinence a minimum of two (2) or three (3) times a shift on the evening shifts that she worked. In a telephone interview on [DATE] at 6:15 PM Resident #3's primary Physician stated a Foley Catheter "possibly" could assist in wound healing and that "it should have been a suggestion." Resident # 3's Physician stated that it would be "reasonable" to believe that an air mattress or pressure relieving mattress would be beneficial. He further stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. Resident # 3's Physician also stated "weekly wound measurements may have helped the wound from getting so bad" and stated the Santyl order "would have possibly helped in wound healing" if the order had been followed. In an interview on [DATE] at 12:40 PM the facility's Medical Director stated "when Santyl wound ointment is used correctly you can at least see a difference in the wound progress. If it's not done, sometimes the progress is not as obvious as it should be. I would expect the nurses to use it like it's ordered." He also stated, "I would expect that a resident should be encouraged to use the air mattress or what is available to prevent or improve the wound. If the resident has dementia (he) expects that the family should be encouraged to assist in those interventions." Regarding improper staging of wounds, he replied, "if the wound is not healing or progressing then there are different principles to follow for wound care." B) Review of the face sheet reflected Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Nurses' Notes for [DATE] reflected Resident #7 was admitted with a Stage II pressure sore to the coccyx. Review of the initial MDS assessment dated [DATE] reflected Resident #7 to be moderately impaired in thinking, required two persons and a hydraulic lift to transfer, frequently incontinent of bowel and bladder and had one Stage II pressure sore to coccyx. Additional [DIAGNOSES REDACTED]. Review of the Plan of Care dated [DATE] reflected Resident #7 had "breaks in his skin integrity related to pressure ulcer, moisture associated skin damage and stasis ulcers/blisters." Interventions included: "Assist Resident #7 to reposition frequently, monitor treatments for effectiveness and notify physician of any concerns. Try to encourage ventilation to perineum area as much as is possible. This may be more realistic in bed." Review of the TAR for [DATE] for Resident #7 reflected an order placed on the TAR dated [DATE] for Inflatable foot/heel protectors with all three shifts ,[DATE], ,[DATE], ,[DATE] signing the TAR. Review of the Wound Assessment Sheet for Resident #7 dated [DATE] reflected the pressure sore to the coccyx was 2.5 cm long by .75 cm wide with no slough and staged as Stage II documented and signed by RN A. Observation on [DATE] revealed Resident #7 to be up in the wheelchair from 9 AM until 6 PM with no inflatable foot/heel protectors in place. Observation on [DATE] at 4:53 of Resident #7's wound care and measurement by RN A (nurse in charge of assessing and staging wounds) revealed the pressure ulcer on the coccyx to be 3.5 cm long by 1.25 cm wide. The pressure ulcer was 80% covered in yellow slough and was a Stage III pressure ulcer as defined on the Wound Assessment System document RN A was documenting on. In an interview on [DATE] at 4:53 RN A stated the wound bed was 80% covered with yellow slough. She stated "It is a Stage II because there is no depth. I don't really agree with that slough only being a Stage III." RN A underlined slough in the description of a Stage III ulcer. During the measurement of the wound, RN A assured Resident #7 that his pressure sore was looking and getting much better. Review of the Wound Assessment Sheet dated [DATE] reflected RN A had staged the pressure sore a Stage II. In the narrative she documented "wound continues to improve. Has shallow bed of whitish slough to top of wound with approx. (approximately) 20% clean non-granulating tissue to edges. Will continue treatment as ordered." RN A documented "some slough" and the wound base as pink, yellow and white. Review of Wound Assessment Sheets for Resident #7 reflected his wounds were measured every 14 days. Review of the Nurses' Notes for Resident #7 dated [DATE] reflected there had been no notification to the physician of the increase in size and the worsening of the appearance of the pressure ulcer. In an interview on [DATE] at 12:15 PM with RN A she stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In a telephone interview on [DATE] at 6:15 PM Resident #7's primary Physician stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. He also stated "weekly wound measurements may have helped the wound from getting so bad." In an interview on [DATE] at 12:40 PM with the facility's Medical Director, he stated regarding improper staging of wounds, "if the wound is not healing or progressing then there are different principles to follow for wound care." In an interview on [DATE] at 4:30 PM the DON stated the skin nurse should let the charge nurse know when she sees worsening of condition of wounds. The DON stated the LVN should realize to notify the family and physician. When asked who was responsible for making sure orders are carried out the DON stated, "the charge nurses are responsible to make sure they are carried out." The DON stated she and the ADON were responsible for making sure staff followed facility policy. The DON stated it was her and the ADON's responsibility to ensure staff knew what the facility policies and procedures were. In an interview on [DATE] at 6:05 PM the facility Administrator stated the DON, ADON and charge nurses are responsible for notifying the physician and family. The ADON was responsible for making sure orders were carried out. The Administrator stated the he and the Nursing Department are responsible for making sure staff followed procedures. The Administrator further stated it was ultimately his responsibility to make sure staff followed procedures. The Administrator stated the DON should definitely know what wounds were in the building. He was aware his policy stated pressure sores were to be measured weekly. Regarding whether he and his staff had neglected the care of the residents he stated, "It was not correct (the care of the residents). I do not appreciate professional people that I trust not doing what I expect." The facility Administrator was notified on [DATE] at 6:20 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was first submitted by the Administrator on [DATE] at 9:04 AM. The final Plan of Removal was accepted by the survey team on [DATE] at 7:30 PM. Cameron Nursing and Rehab Plan of Removal of Immediate Jeopardy In responses Wound Issues, Cameron Nursing and Rehab will do the following: 1. An RN from (Hospice) to in-service nursing staff on the care and treatment of [REDACTED]. DON, ADON, RN, Medicare Coordinator, and MDS Nurse and charge nurses LVN's will attend. In-service will be at 10:00 on Friday [DATE]. 2. Two Staff Registered Nurses will assess and measure all wounds on a weekly basis. All current wounds will be reassessed after training on [DATE]. 3. Facility will identify all "At Risk" residents for Skin Breakdown by using the Braden Scale. After in-service, all At Risk residents will be assessed by a RN and LVN to identify any possible pressure issues [DATE]. 4. All Physician orders [REDACTED]. A pink copy of all telephone order forms will be given to the ADON when completed. The ADON will monitor the order and follow through to make sure all meds are ordered and orders entered on treatment sheet and or MARs. This process was started on [DATE]. 5. DON and ADON will do in-service with all charge nurses regarding proper documentation of resident's change of condition, pressure sores, treatments, Physician Orders, and notifying family members and Physician. This will be complete during the in-service on [DATE]. 6. ADON and DON will report to Administrator any new skin issues and update of treatments in progress on Friday of each week with a copy of the weekly decubitus skin assessment log and non-decubitus log. First meeting will be on [DATE] and then weekly. 7. All pressure wounds will be reviewed and discussed at weekly staff meeting, including DON, ADON, MDS Nurse, Medicaid Coordinator, Registered Nurse on Staff, and Administrator on [DATE]. 8. Medical Director was notified of this at 9:30 am on Thursday [DATE]. Resident #3 Facility will: 1. Ensure air mattress is on Resident #3's bed, [DATE]. 2. Will follow physician orders [REDACTED]. (The new order: "Cleanse wound on coccyx with Normal Saline, pat dry-Apply Normal saline packing to wound bandage BID (twice daily)-Will consult wound care at Scott & White (Temple)-Insert indwelling catheter...-change q (every) month & PRN (as needed)-Record I&O (input and output) q shift-Catheter care q shift".) 3. Registered Nurse will accompany resident to Doctor's appointment on [DATE] to discuss proper treatment and procedure to be used, and request the use of a Catheter, this will be done on [DATE]. ADON or DON will monitor resident treatment with charge nurse for a period of two weeks to assure proper procedure is followed. If there is no improvement or wound worsens, Physician will be notified. 4. Two Registered Nurses will assess and measure wounds on a weekly basis. 5. Have Staff to continue to encourage resident to stay off of her back side and have staff continue to encourage and assist her to turn when in bed. 6. Nursing staff will encourage Resident to take in proper nourishment to help the healing process and have a Care Plan meeting with Son to encourage compliance with treatment plan. Administrator, DON, ADON will meet with son. 7. Have Dietary Consultant review Resident #3's chart and condition and make recommendations for nutrition on her next visit to the facility. Resident #7 1. Make sure resident maintains a pressure relieving mattress on his bed, [DATE]. 2. Nursing staff will encourage resident to try to stay off of his back side as much as possible, offering repositioning and reminded to use overhead bar. 3. Resident #7 request to be up for all three meals each day and remain in his wheelchair. DON, ADON, Administrator will have a care plan meeting will be held with Resident and Responsible Party regarding the benefits of shorter periods of time sitting in the wheelchair. 4. ADON or DON will monitor resident treatment for [REDACTED]. If there is no improvement or wound worsens, Physician will be notified. 5. Confirm with Physician when Heel Protectors should be worn, requested clarification [DATE]. 6. Notify Physician of change of condition [DATE]. 7. Two Registered Nurses will assess and measure resident's wounds on a weekly basis. The survey team monitored the plan of removal as follows: Review was completed of new treatments as per physician order [REDACTED].#3 as shown in the plan of removal. All treatments and interventions were initiated and carried out. Resident #3's Responsible Party was notified. Resident # 7 had a re-assessment of his wounds and physician and responsible party were notified of the decline in the coccyx pressure sore. Observation of the facility in-service on [DATE] at 10:00 AM revealed the in-service was conducted by a RN from a local Hospice agency. The in-service provided information regarding pressure sores, care for pressure sores, assessments including staging and measuring, as well as interventions to prevent pressure sores. The in-service had four (4) RNs and 11 LVNs in attendance. The Medical Director and the Administrator were also present. The facility had over 70% of their licensed nursing staff in-serviced on [DATE]. The Hospice RN gave a competency test after the in-service in which all nursing staff in attendance passed per the Administrator. The facility provided a list of 25 residents who were at risk for pressure sores. The facility completed a 100% audit using the Braden Scale to identify residents at risk for pressure sores. Twenty-five (25) residents were identified at risk for pressure sores. Observations were made on [DATE] of four (4) of the 25 residents at risk for pressure sores. These Residents were assessed and staged properly and interventions and treatments were in place. The facility notified the Resident's Physicians and Responsible Parties. Observation on [DATE] at 2:40 PM revealed the DON entered a resident room to assess and measure pressure sores. The DON did not bring a cart or any sanitizing agents to the room. She did not prepare a clean surface for her supplies. She placed supplies for wound measurement under the shoes on Resident #14's Geri chair pressure reduction pad of the incontinent resident. She then laid a pair of gloves up against the heels of the shoes and went to the bathroom to wash her hands. She returned from the bathroom and began donning gloves. She approached the resident to explain the process to the resident when the surveyor stopped the DON and instructed her to start over and explained that her articles were contaminated. Later, when the DON began assessing the heel of the resident that had a Deep Tissue Injury (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue) she proceeded to dismiss the area and pronounced it was blanching after she placed pressure on the heel and released it multiple times. The heel was not blanching. Surveyor stepped forward and asked to see the heel turn white and then return to red. The DON applied pressure once again and admitted the heel was not changing color at all and was actually purple. The DON and ADON then tried to decide if the heel sore was a Stage I or not since it wasn't red. The Surveyor handed the DON the in-service Wound Staging Guide as received in the training in-service and asked her to read the description of a Deep Tissue Injury. The DON then correctly identified the heel as having a deep tissue injury. DON then observed the Stage II that was approximately one (1) cm in size with a pinpoint opening on the sacrum. The DON placed the measuring device on the opening and removed it repeatedly. She finally traced the one (1) cm circle and then marked the pinpoint opening. She then placed the device back on the wound and studied it and then asked the ADON to come and see if she had marked her device correctly. The DON then began studying the raised skin edges on the bilateral buttocks and decided that those impaired skin issues needed measuring. After DON applied the graph several times, the Surveyor asked the ADON if she had told the DON that the resident had a rash over her entire perineum. The ADON said she had not informed the DON and then parted the resident's legs so that she could see the raised skin was related to a rash and was not at all pressure sores. When the DON submitted the wound assessment to the surveyor, she had left the entire wound description area of the form blank. The Surveyor returned the form to the DON to complete it. The DON submitted it to the Surveyor the second time. The Surveyor returned the form to the DON and asked her to complete the periwound skin assessment line on the form. In an interview on [DATE] at 2:43 PM the Surveyor asked the DON as she donned gloves if she realized that she had her wound care items under a pair of shoes in the seat of a chair, she stated that she was so nervous that she did not realize what she had done. In a meeting on [DATE] at 3:15 PM the facility Administrator was made aware of the DON's actions during the assessment of Resident # 14's wound. The Administrator stated the DON needed more training and decided to have the two RNs performing skin assessments and not include the DON until she was further trained. Observations were made of a LVN and RN performing a skin assessment and identifying a problem on an at risk resident. Then two RNs returned and performed an assessment on the at risk resident and identified an area of concern on her left great toe. The area was identified as a Suspected Deep Tissue Injury. The two RNs correctly assessed, measured, identified prevention interventions, and notified the Physician and the Responsible Party. The facility provided an attendance signature sheet for the Staff Meeting held on [DATE] after the skin audit was completed with the Administrator, DON, ADON, RN A, MDS Coordinator, and one LVN-Medicaid Coordinator in attendance. On [DATE] at 8:00 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided a list of 25 residents at risk for pressure sores.

Based on observation, interview, and record review the facility failed to immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when a need to alter treatment significantly for three (3) of nine (9) residents (Residents #3, #7, and #2) reviewed for notifying the physician and/or interested family member when: A) The facility failed to notify Resident # 3's Physician or Responsible Party of a decline in condition which resulted in the pressure sore declining to a Stage IV with infection. B) The facility failed to notify Resident # 7's Physician or Responsible Party of a decline in his pressure sore. Resident # 7's pressure sore declined from a Stage II to a Stage III. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Non-Immediate Jeopardy C) Resident #2 experienced pain during wound care treatment and the physician was not immediately notified. These deficient practices affected three (3) residents and could affect 65 residents by placing them at risk for delay in appropriate medical treatment, the development of new or worsening medical conditions, and diminished quality of life for any resident who may have a new clinical condition. Findings include: A) Review of Resident #3's Face Sheet reflected an [AGE] year old female readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3's Significant Change MDS assessment dated [DATE] reflected Resident #3's BIMS score was a five (5) (severe cognitive impairment), she required extensive assistance of two persons to turn, she had an indwelling Foley Catheter, and was frequently incontinent of bowel. Resident #3 was coded as having three (3) Stage I (Intact skin with non-blanchable redness of a localized area usually over a boney prominence) pressure sores and no pressure reduction devices in place. Review of Resident #3's Comprehensive Plan of Care revised on [DATE] reflected "The resident has some skin breakdown" with interventions of "has a pressure relieving mattress...and the resident has a Foley Catheter." Observation on [DATE] at 4:25 PM revealed Resident #3 on her right side receiving peri-care during which time the dressing fell off the sacrum revealing a Stage IV (Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling) pressure sore. The pressure sore was approximately 3 cm round and 0.3 cm deep with yellow slough attached to the tendon and muscle in the very center of the wound bed with red wound edges. Periwound edges were reddened, [MEDICAL CONDITION] and not adhered to wound bed thereby indicated tunneling was present. Resident # 3 had a standard green plastic mattress on her bed, a mattress with no pressure reducing qualities. There was no Foley Catheter was in place to prevent contamination of the wound. Observation on [DATE] at 10:50 AM revealed Resident #3 in bed sleeping on her back with a strong odor of urine in her room. No pressure relieving device was on the mattress and no Foley Catheter was in place. Review of the Weekly Skin Monitoring for Resident #3 reflected zero (0) decubitus (pressure sore) on [DATE], [DATE], [DATE], and [DATE]. On [DATE] a Stage II pressure sore (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 blister) to coccyx was documented. Review of the Wound Assessment for Resident #3 by RN A (nurse in charge of assessing and staging wounds) dated [DATE] reflected: "Coccyx Stage II, 1.75 centimeters long and 1.5 cm wide, two (2) millimeters deep, slough; yes." The definition located on the Wound Assessment reflected a Stage II pressure sore does not have slough and a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore may have slough present but does not obscure the depth of tissue loss. Resident # 3's Stage III Coccyx wound was misstaged at a Stage II. On the same sheet there was an additional wound documented as "#2 wound superficial 0.5 cm wide and 0.5 cm long, .0 deep." Wound edges were described as "macerated" (moisture associated skin damage). Review of Resident #3's Nurses' Notes dated [DATE] reflected the physician was notified of a Stage II on [DATE] and the orders were obtained. No responsible party notification was documented. Review of Resident # 3's Physician order [REDACTED]." Review of the next recorded Wound Assessment for Resident #3 was l4 days later by RN A dated [DATE] and reflected: "Coccyx Stage II 2.0 cm long and 1.75 cm wide, one (1) mm deep with some slough. Scattered areas of white slough to wound bed." Again, the wound with slough was staged at a Stage II instead of a Stage III. Review of Resident # 3's Physician order [REDACTED].) to decubitus (pressure sore) on shower days (3 times weekly) and as needed." Review of the Nurse's Notes dated [DATE] reflected no responsible party notification was made. Review of Resident #3's [DATE] TAR reflected an order for [REDACTED]." The order written by Resident # 3's physician on [DATE] was not placed on the TAR and there was no indication this treatment had started. The [DATE] TAR reflected there were no nurse signatures for the dates ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], or [DATE] and indicated no treatment was performed for Resident # 3 on those dates. Observation on [DATE] at 4:35 PM revealed Resident # 3 was provided the treatment ordered [DATE] where the wound was cleansed with wound cleanser, the nurse patted dry and applied Wound Be Gone and added a padded dressing. The physician order [REDACTED]. In an interview on [DATE] at 12:30 PM the DON stated, "I knew she (Resident # 3) had the order for Santyl, I just didn't know they weren't carrying it out. It might have helped..." Review of the next recorded Wound Assessment for Resident #3 was 14 days later by RN A dated [DATE] reflected: "Coccyx Stage IV pressure sore 3.0 cm long and 3.0 cm wide, tunneling around wound ranges from 0.5 cm deep to 1.25 cm deep. [DIAGNOSES REDACTED] and purple tissue around edges. Very [DIAGNOSES REDACTED]tous to wound margins. (Tunneling was drawn around one half of the wound). Yellow slough present on wound base in center." Review of the Nurse's Notes from [DATE] through [DATE] reflected no further physician notification was documented until [DATE] when resident was sent to the physician and was prescribed an antibiotic for treatment of [REDACTED]. Review of the Physician order [REDACTED]. Notify if worsens." Review of Resident #3's [DATE] MAR indicated [REDACTED]." In an interview on [DATE] at 11:56 PM the DON stated it looked like no treatment was performed from [DATE] through [DATE] on paper. The DON also stated she would expect that the nurse to sign the treatment sheet when the treatment was performed. Regarding the catheter that was no longer in place, The DON stated she did not think they would "get anywhere" with the healing of the pressure sore unless the Foley catheter was put back in place. The DON stated "we didn't have a [DIAGNOSES REDACTED]." The DON stated she expected the nursing staff to use the Santyl now. In an interview on [DATE] at 12:15 PM RN A, nurse in charge of measuring, staging and documenting pressure sore progress, stated [DATE] was when she was first alerted there was an issue with the coccyx. RN A further stated "she (Resident #3) has had a long standing issue with the coccyx. She will get a little pink then heal up. It's not a Stage I, it's a pre-Stage I." RN A stated Resident #3 was "really at risk for pressure sores since she was admitted because she was so emaciated. Immediately after we discontinued the Foley Catheter it started getting worse." RN A further stated Resident #3 "refused the air mattress on admission and has refused it periodically in the past." She stated she was unable to find any documentation regarding the refusals and stated, "on [DATE], I mentioned to her trying to get her on an air mattress and she just wouldn't answer me." RN A further stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In an interview on [DATE] at 3:45 PM Resident #3 was asked if she would like an air mattress overlay placed on her bed while she was up for supper when she stated "yes, it's worse than it's ever been." In an interview on [DATE] at 9:00 AM Resident #3, who was up in her wheelchair and had slept on the air overlay mattress, stated "I like my bed more and I ate 100% (of her breakfast meal)." Resident #3 appeared more comfortable than previous observations. In an interview on [DATE] at 3:45 PM CNA H stated Resident #3 required incontinent care due to bladder incontinence a minimum of two (2) or three (3) times a shift on the evening shifts that she worked. In a telephone interview on [DATE] at 6:15 PM Resident #3's primary Physician stated a Foley Catheter "possibly" could assist in wound healing and that "it should have been a suggestion." Resident # 3's Physician stated that it would be "reasonable" to believe that an air mattress or pressure relieving mattress would be beneficial. He further stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. Resident # 3's Physician also stated "weekly wound measurements may have helped the wound from getting so bad" and stated the Santyl order "would have possibly helped in wound healing" if the order had been followed. In an interview on [DATE] at 12:40 PM the facility's Medical Director stated "when Santyl wound ointment is used correctly you can at least see a difference in the wound progress. If it's not done, sometimes the progress is not as obvious as it should be. I would expect the nurses to use it like it's ordered." He also stated, "I would expect that a resident should be encouraged to use the air mattress or what is available to prevent or improve the wound. If the resident has dementia (he) expects that the family should be encouraged to assist in those interventions." Regarding improper staging of wounds, he replied, "if the wound is not healing or progressing then there are different principles to follow for wound care." B) Review of the face sheet reflected Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Nurses' Notes for [DATE] reflected Resident #7 was admitted with a Stage II pressure sore to the coccyx. Review of the initial MDS assessment dated [DATE] reflected Resident #7 to be moderately impaired in thinking, required two persons and a hydraulic lift to transfer, frequently incontinent of bowel and bladder and had one Stage II pressure sore to coccyx. Additional [DIAGNOSES REDACTED]. Review of the Plan of Care dated [DATE] reflected Resident #7 had "breaks in his skin integrity related to pressure ulcer, moisture associated skin damage and stasis ulcers/blisters." Interventions included: "monitor treatments for effectiveness and notify physician of any concerns...Report improvements and declines to the MD." Review of the Wound Assessment Sheet for Resident #7 dated [DATE] reflected the pressure sore to the coccyx was 2.5 cm long by .75 cm wide with no slough and staged as Stage II documented and signed by RN A. Observation on [DATE] at 4:53 of Resident #7's wound care and measurement by RN A (nurse in charge of assessing and staging wounds) revealed the pressure ulcer on the coccyx to be 3.5 cm long by 1.25 cm wide. The pressure ulcer was 80% covered in yellow slough and was a Stage III pressure ulcer as defined on the Wound Assessment System document RN A was documenting on. In an interview on [DATE] at 4:53 RN A stated the wound bed was 80% covered with yellow slough. She stated "It is a Stage II because there is no depth. I don't really agree with that slough only being a Stage III." RN A underlined slough in the description of a Stage III ulcer. During the measurement of the wound, RN A assured Resident #7 that his pressure sore was looking and getting much better. Review of the Wound Assessment Sheet dated [DATE] reflected RN A had staged the pressure sore a Stage II. In the narrative she documented "wound continues to improve. Has shallow bed of whitish slough to top of wound with approx. (approximately) 20% clean non-granulating tissue to edges. Will continue treatment as ordered." RN A documented "some slough" and the wound base as pink, yellow and white. Review of the Nurses' Notes for Resident #7 dated [DATE] reflected there had been no notification to the family or the physician of the increase in size and the worsening of the appearance of the pressure ulcer. In an interview on [DATE] at 4:30 PM when asked who should notify the family and physician of pressure sores and changes for Resident #7 the DON stated, "Charge nurses. Skin nurse when she sees it, she should let the charge nurse know. The LVN should realize to notify." In an interview on [DATE] at 12:15 PM with RN A she stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In a telephone interview on [DATE] at 6:15 PM Resident #7's primary Physician stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. He also stated "weekly wound measurements may have helped the wound from getting so bad." Review of the facility's undated policy for PRESSURE ULCER PREVENTION AND MONITORING reflected: "...h. any resident with a pressure ulcer which fails to improve or worsens, will have the physician notified promptly." Review of the undated facility's Pressure Ulcer Management Sheet reflected: "4. Promptly inform the physician (and responsible party, as appropriate) of new pressure ulcers." In an interview on [DATE] at 4:30 PM the DON stated the skin nurse should let the charge nurse know when she sees a wo0rsening of condition of wounds. The DON stated the LVN should realize to notify the family and physician. The DON stated she and the ADON were responsible for making sure staff followed facility policy. The DON stated it was her and the ADON's responsibility to ensure staff knew what the facility policies and procedures were. In an interview on [DATE] at 6:05 PM the facility Administrator stated the DON, ADON and charge nurses are responsible for notifying the physician and family. The Administrator stated the he and the Nursing Department are responsible for making sure staff followed procedures. The Administrator further stated it was ultimately his responsibility to make sure staff followed procedures. The Administrator stated the DON should definitely know what wounds were in the building. He was aware his policy stated pressure sores were to be measured weekly. The facility Administrator was notified on [DATE] at 6:20 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was first submitted by the Administrator on [DATE] at 9:04 AM. The final Plan of Removal was accepted by the survey team on [DATE] at 7:30 PM. Cameron Nursing and Rehab Plan of Removal of Immediate Jeopardy In responses Wound Issues, Cameron Nursing and Rehab will do the following: 1. An RN from (Hospice) to in-service nursing staff on the care and treatment of [REDACTED]. DON, ADON, RN, Medicare Coordinator, and MDS Nurse and charge nurses LVN's will attend. In-service will be at 10:00 on Friday [DATE]. 2. Two Staff Registered Nurses will assess and measure all wounds on a weekly basis. All current wounds will be reassessed after training on [DATE]. 3. Facility will identify all "At Risk" residents for Skin Breakdown by using the Braden Scale. After in-service, all At Risk residents will be assessed by a RN and LVN to identify any possible pressure issues [DATE]. 4. All Physician orders [REDACTED]. A pink copy of all telephone order forms will be given to the ADON when completed. The ADON will monitor the order and follow through to make sure all meds are ordered and orders entered on treatment sheet and or MARs. This process was started on [DATE]. 5. DON and ADON will do in-service with all charge nurses regarding proper documentation of resident's change of condition, pressure sores, treatments, Physician Orders, and notifying family members and Physician. This will be complete during the in-service on [DATE]. 6. ADON and DON will report to Administrator any new skin issues and update of treatments in progress on Friday of each week with a copy of the weekly decubitus skin assessment log and non-decubitus log. First meeting will be on [DATE] and then weekly. 7. All pressure wounds will be reviewed and discussed at weekly staff meeting, including DON, ADON, MDS Nurse, Medicaid Coordinator, Registered Nurse on Staff, and Administrator on [DATE]. 8. Medical Director was notified of this at 9:30 am on Thursday [DATE]. Resident #3 Facility will: 1. Ensure air mattress is on Resident #3's bed, [DATE]. 2. Will follow physician orders [REDACTED]. (The new order: "Cleanse wound on coccyx with Normal Saline, pat dry-Apply Normal saline packing to wound bandage BID (twice daily)-Will consult wound care at Scott & White (Temple)-Insert indwelling catheter...-change q (every) month & PRN (as needed)-Record I&O (input and output) q shift-Catheter care q shift".) 3. Registered Nurse will accompany resident to Doctor's appointment on [DATE] to discuss proper treatment and procedure to be used, and request the use of a Catheter, this will be done on [DATE]. ADON or DON will monitor resident treatment with charge nurse for a period of two weeks to assure proper procedure is followed. If there is no improvement or wound worsens, Physician will be notified. 4. Two Registered Nurses will assess and measure wounds on a weekly basis. 5. Have Staff to continue to encourage resident to stay off of her back side and have staff continue to encourage and assist her to turn when in bed. 6. Nursing staff will encourage Resident to take in proper nourishment to help the healing process and have a Care Plan meeting with Son to encourage compliance with treatment plan. Administrator, DON, ADON will meet with son. 7. Have Dietary Consultant review Resident #3's chart and condition and make recommendations for nutrition on her next visit to the facility. Resident #7 1. Make sure resident maintains a pressure relieving mattress on his bed, [DATE]. 2. Nursing staff will encourage resident to try to stay off of his back side as much as possible, offering repositioning and reminded to use overhead bar. 3. Resident #7 request to be up for all three meals each day and remain in his wheelchair. DON, ADON, Administrator will have a care plan meeting will be held with Resident and Responsible Party regarding the benefits of shorter periods of time sitting in the wheelchair. 4. ADON or DON will monitor resident treatment for [REDACTED]. If there is no improvement or wound worsens, Physician will be notified. 5. Confirm with Physician when Heel Protectors should be worn, requested clarification [DATE]. 6. Notify Physician of change of condition [DATE]. 7. Two Registered Nurses will assess and measure resident's wounds on a weekly basis. The survey team monitored the plan of removal as follows: Reviewed was completed of new treatments as per physician order [REDACTED].#3 as shown in the plan of removal. All treatments and interventions were initiated and carried out. Resident #3's Responsible Party was notified. Resident # 7 had a re-assessment of his wounds and physician and responsible party were notified of the decline in the coccyx pressure sore. Observation of the facility in-service on [DATE] at 10:00 AM revealed the in-service was conducted by a RN from a local Hospice agency. The in-service provided information regarding pressure sores, care for pressure sores, assessments including staging and measuring, as well as interventions to prevent pressure sores. The in-service had four (4) RNs and 11 LVNs in attendance. The Medical Director and the Administrator were also present. The facility had over 70% of their licensed nursing staff in-serviced on [DATE]. The Hospice RN gave a competency test after the in-service in which all nursing staff in attendance passed per the Administrator. The facility provided a list of 25 residents who were at risk for pressure sores after completion of a 100% audit using the Braden Scale to identify residents at risk. Observations were made on [DATE] of four (4) of the 25 residents at risk for pressure sores. These Residents were assessed and staged properly and interventions and treatments were in place. The facility notified the Resident's Physicians and Responsible Parties. Observation on [DATE] at 2:40 PM revealed the DON entered a resident room to assess and measure pressure sores. The DON did not bring a cart or any sanitizing agents to the room. She did not prepare a clean surface for her supplies. She placed supplies for wound measurement under the shoes on Resident #14's gerichair pressure reduction pad of the incontinent resident. She then laid a pair of gloves up against the heels of the shoes and went to the bathroom to wash her hands. She returned from the bathroom and began donning gloves. She approached the resident to explain the process to the resident when the surveyor stopped the DON and instructed her to start over and explained that her articles were contaminated. Later, when the DON began assessing the heel of the resident that had a Deep Tissue Injury (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceeded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue) she proceeded to dismiss the area and pronounced it was blanching after she placed pressure on the heel and released it multiple times. The heel was not blanching. Surveyor stepped forward and asked to see the heel turn white and then return to red. The DON applied pressure once again and admitted the heel was not changing color at all and was actually purple. The DON and ADON then tried to decide if the heel sore was a Stage I or not since it wasn't red. The Surveyor handed the DON the inservice Wound Staging Guide as received in the training inservice and asked her to read the description of a Deep Tissue Injury. The DON then correctly identified the heel as having a deep tissue injury. DON then observed the Stage II that was approx. one (1) cm in size with a pinpoint opening on the sacrum. The DON placed the measuring device on the opening and removed it repeatedly. She finally traced the one (1) cm circle and then marked the pinpoint opening. She then placed the device back on the wound and studied it and then asked the ADON to come and see if she had marked her device correctly. The DON then began studying the raised skin edges on the bilateral buttocks and decided that those impaired skin issues needed measuring. After DON applied the graph several times, the Surveyor asked the ADON if she had told the DON that the resident had a rash over her entire perineum? The ADON said she had not informed the DON and then parted the patients legs so that she could see the raised skin was related to a rash and was not at all pressure sores. When the DON submitted the wound assessment to the surveyor, she had left the entire wound description area of the form blank. The Surveyor returned the form to the DON to complete it. The DON submitted it to the Surveyor the second time. The Surveyor returned the form to the DON and asked her to complete the periwound skin assessment line on the form. In an interview on [DATE] at 2:43 PM the Surveyor asked the DON as she donned gloves if she realized that she had her wound care items under a pair of shoes in the seat of a chair, she stated that she was so nervous that she did not realize what she had done. In a meeting on [DATE] at 3:15 PM the facility Administrator was made aware of the DON's actions during the assessment of Resident # 14's wound. The Administrator stated the DON needed more training and decided to have the two RNs performing skin assessments and not include the DON until she was further trained. Observations were made of a LVN and RN performing a skin assessment and identifying a problem on an at risk resident. Then two RNs returned and performed an assessment on the at risk resident and identified an area of concern on her left great toe. The area was identified as a Suspected Deep Tissue Injury. The two RNs correctly assessed, measured, identified prevention interventions, and notified the physician and the responsible party. The facility provided an attendance signature sheet for the Staff Meeting held on [DATE] after the skin audit was completed with the Administrator, DON, ADON, RN A, MDS Coordinator, and one LVN-Medicaid Coordinator in attendance. On [DATE] at 8:00 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided a list of 25 residents who were at risk for pressure sores. Non-Immediate Jeopardy C) Review of the Consolidated Physician order [REDACTED].#2 reflected an [AGE] year old male who was admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #2 did not have an order for [REDACTED]. Observation on [DATE] at 3:00 PM revealed LVN B provided wound care treatment on the coccyx area of Resident #2. Resident #2 was in bed on his left side, LVN B cleaned the area and Resident #2 flinched, grimaced, yell out and complained of pain. In an interview on [DATE] at 5:50 PM LVN C stated "Yes, all the time" to the question does Resident #2 complain of pain during the wound care. LVN C also stated "sometimes up to two to three times a day when we have to change his dressing if it's soiled." In a subsequent interview on [DATE] at 6:00 PM LVN B (who had changed Resident #2's dressing earlier) stated when asked if Resident #2 ever complained of pain before or during wound care "Oh yes". LVN B also stated "I probably should call the physician and get something for pain prior to Resident #2's wound care." In an interview on [DATE] at 3:40 PM LVN E stated she performed wound care on Resident #2 on Sunday [DATE] and remembered Resident #2 flinching and grimacing during wound care and that he was on hospice and they would take care of his pain. In an interview on [DATE] at 3:15 PM Resident #2's attending physician stated his expectations when a resident experienced pain at levels higher than normal or during wound care that was painful, especially if happening two (2) or more times a day, he expected to be notified by phone or facsimile, so he could give an order for [REDACTED]. In an interview on [DATE] at 3:50 PM the physician's office nurse stated the office did not receive a fax on the date of [DATE]-when Resident #2 experienced pain during treatment. The physician's nurse stated the facility requested pain medicine on [DATE] at 6:00 AM via facsimile. In an interview on [DATE] at 9:30 AM Resident #2 stated he still had not received pain medicine prior to or during dressing changes to his "bottom area". Review of the current telephone orders available dated [DATE] reflected no new phone orders for pain medication prior to wound care. Review of the current 24 hour report documentation dated [DATE] and [DATE] did not reflect a physician notification for or of pain during the provision of wound care . Review of the most current Nurses' Notes dated [DATE] and [DATE] did not reflect physician notification requesting new orders for pain medication prior to wound care. Review of the facility's undated Pain Policy reflected a "pain evaluation" will be completed with each OBRA (Omnibus Budget Reconciliation Act) assessment. (Last OBRA assessment dated [DATE].) The facility provided a CMS Form 672 that reflected 34 residents were on pain management.

Based on observation, interview, and record review the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores and ensure residents having pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for two (2) of nine (9) residents (Resident #3 and #7) reviewed for pressure sores when: A) The facility failed to ensure Resident # 3, a resident with a history of developing pressure sores, had a care planned pressure relieving device on her bed. The facility failed to accurately assess and stage Resident # 3's wound to her coccyx. The facility failed to implement a physician ordered treatment change on [DATE] and failed to provide a wound treatment at all from [DATE] through [DATE]. The facility failed to notify the physician of a decline in the wound and failed to ensure pressure sores were assessed every seven (7) days as stated in their policy. Resident # 3's pressure sore declined to a Stage IV with infection. B) The facility failed to accurately assess and stage Resident #7's wound to his coccyx and failed to notify the physician of a decline in the wound. Resident # 7's wound declined from a Stage II to a Stage III. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practice affected Resident #3 and Resident #7 and placed an additional 23 resident at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), [DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), pain and death. Findings include: A) Review of Resident #3's Face Sheet reflected an [AGE] year old female readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3's Significant Change MDS assessment dated [DATE] reflected Resident #3's BIMS score was a five (5) (severe cognitive impairment), she required extensive assistance of two persons to turn, she had an indwelling Foley Catheter, and was frequently incontinent of bowel. Resident #3 was coded as having three (3) Stage I (Intact skin with non-blanchable redness of a localized area usually over a boney prominence) pressure sores and no pressure reduction devices in place. Review of Resident #3's Comprehensive Plan of Care revised on [DATE] reflected "The resident has some skin breakdown" with interventions of "has a pressure relieving mattress...and the resident has a Foley Catheter." Observation on [DATE] at 4:25 PM revealed Resident #3 on her right side receiving peri-care during which time the dressing fell off the sacrum revealing a Stage IV (Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling) pressure sore. The pressure sore was approximately 3 cm round and 0.3 cm deep with yellow slough attached to the tendon and muscle in the very center of the wound bed with red wound edges. Periwound edges were reddened, [MEDICAL CONDITION] and not adhered to wound bed thereby indicated tunneling was present. Resident # 3 had a standard green plastic mattress on her bed, a mattress with no pressure reducing qualities. There was no Foley Catheter was in place to prevent contamination of the wound. Observation on [DATE] at 10:50 AM revealed Resident #3 in bed sleeping on her back with a strong odor of urine in her room. No pressure relieving device was on the mattress and no Foley Catheter was in place. Review of the Weekly Skin Monitoring for Resident #3 reflected zero (0) decubitus (pressure sore) on [DATE], [DATE], [DATE], and [DATE]. On [DATE] a Stage II pressure sore (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 blister) to coccyx was documented. Review of the Wound Assessment for Resident #3 by RN A (the nurse in charge of assessing and staging wounds) dated [DATE] reflected: "Coccyx Stage II, 1.75 centimeters long and 1.5 cm wide, two (2) millimeters deep, slough; yes." The definition located on the Wound Assessment reflected a Stage II pressure sore does not have slough and a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore may have slough present but does not obscure the depth of tissue loss. Resident # 3's Stage III Coccyx wound was misstaged at a Stage II. On the same sheet there was an additional wound documented as "#2 wound superficial 0.5 cm wide and 0.5 cm long, .0 deep." Wound edges were described as "macerated" (moisture associated skin damage). Review of Resident #3's Nurses' Notes dated [DATE] reflected the physician was notified of a Stage II on [DATE] and the orders were obtained. No responsible party notification was documented. Review of Resident # 3's Physician order [REDACTED]." Review of the next recorded Wound Assessment for Resident #3 was l4 days later by RN A dated [DATE] and reflected: "Coccyx Stage II 2.0 cm long and 1.75 cm wide, one (1) mm deep with some slough. Scattered areas of white slough to wound bed." Again, the wound with slough was staged at a Stage II instead of a Stage III. Review of Resident # 3's Physician order [REDACTED].) to decubitus (pressure sore) on shower days (3 times weekly) and as needed." Review of Resident #3's [DATE] TAR reflected an order for [REDACTED]." The order written by Resident # 3's physician on [DATE] was not placed on the TAR and there was no indication this treatment had started. The [DATE] TAR reflected there were no nurse signatures for the dates ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], or [DATE] and indicated no treatment was performed for Resident # 3 on those dates. Observation on [DATE] at 4:35 PM revealed Resident # 3 was provided the treatment ordered [DATE] where the wound was cleansed with wound cleanser, the nurse patted dry and applied Wound Be Gone and added a padded dressing. The physician order [REDACTED]. In an interview on [DATE] at 12:30 PM the DON stated, "I knew she (Resident # 3) had the order for Santyl, I just didn't know they weren't carrying it out. It might have helped..." Review of the next recorded Wound Assessment for Resident #3 was 14 days later by RN A dated [DATE] reflected: "Coccyx Stage IV pressure sore 3.0 cm long and 3.0 cm wide, tunneling around wound ranges from 0.5 cm deep to 1.25 cm deep. [DIAGNOSES REDACTED] and purple tissue around edges. Very [DIAGNOSES REDACTED]tous to wound margins. (Tunneling was drawn around one half of the wound). Yellow slough present on wound base in center." Review of the Nurse's Notes from [DATE] through [DATE] reflected no further physician notification was documented until [DATE] when resident was sent to the physician and was prescribed an antibiotic for treatment of [REDACTED]. Review of the Physician order [REDACTED]. Notify if worsens." Review of Resident #3's [DATE] MAR indicated [REDACTED]." In an interview on [DATE] at 11:56 PM the DON stated it looked like no treatment was performed from [DATE] through [DATE] on paper. The DON also stated she would expect that the nurse to sign the treatment sheet when the treatment was performed. Regarding the catheter that was no longer in place, The DON stated she did not think they would "get anywhere" with the healing of the pressure sore unless the Foley catheter was put back in place. The DON stated "we didn't have a [DIAGNOSES REDACTED]." The DON stated she expected the nursing staff to use the Santyl now. In an interview on [DATE] at 12:15 PM RN A, nurse in charge of measuring, staging and documenting pressure sore progress, stated [DATE] was when she was first alerted there was an issue with the coccyx. RN A further stated "she (Resident #3) has had a long standing issue with the coccyx. She will get a little pink then heal up. It's not a Stage I, it's a pre-Stage I." RN A stated Resident #3 was "really at risk for pressure sores since she was admitted because she was so emaciated. Immediately after we discontinued the Foley Catheter it started getting worse." RN A further stated Resident #3 "refused the air mattress on admission and has refused it periodically in the past." She stated she was unable to find any documentation regarding the refusals and stated, "on [DATE], I mentioned to her trying to get her on an air mattress and she just wouldn't answer me." RN A further stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In an interview on [DATE] at 3:45 PM Resident #3 was asked if she would like an air mattress overlay placed on her bed while she was up for supper when she stated "yes, it's worse than it's ever been." In an interview on [DATE] at 9:00 AM Resident #3, who was up in her wheelchair and had slept on the air overlay mattress, stated "I like my bed more and I ate 100% (of her breakfast meal)". Resident #3 appeared more comfortable than previous observations. In an interview on [DATE] at 3:45 PM CNA H stated Resident #3 required incontinent care due to bladder incontinence a minimum of two (2) or three (3) times a shift on the evening shifts that she worked. In a telephone interview on [DATE] at 6:15 PM Resident #3's primary Physician stated a Foley Catheter "possibly" could assist in wound healing and that "it should have been a suggestion." Resident # 3's Physician stated that it would be "reasonable" to believe that an air mattress or pressure relieving mattress would be beneficial. He further stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. Resident # 3's Physician also stated "weekly wound measurements may have helped the wound from getting so bad" and stated the Santyl order "would have possibly helped in wound healing" if the order had been followed. In an interview on [DATE] at 12:40 PM the facility's Medical Director stated "when Santyl wound ointment is used correctly you can at least see a difference in the wound progress. If it's not done, sometimes the progress is not as obvious as it should be. I would expect the nurses to use it like it's ordered." He also stated, "I would expect that a resident should be encouraged to use the air mattress or what is available to prevent or improve the wound. If the resident has dementia (he) expects that the family should be encouraged to assist in those interventions." Regarding improper staging of wounds, he replied, "if the wound is not healing or progressing then there are different principles to follow for wound care." B) Review of the face sheet reflected Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Nurses' Notes for [DATE] reflected Resident #7 was admitted with a Stage II pressure sore to the coccyx. Review of the initial MDS assessment dated [DATE] reflected Resident #7 to be moderately impaired in thinking, required two persons and a hydraulic lift to transfer, frequently incontinent of bowel and bladder and had one Stage II pressure sore to coccyx. Additional [DIAGNOSES REDACTED]. Review of the Plan of Care dated [DATE] reflected Resident #7 had "breaks in his skin integrity related to pressure ulcer, moisture associated skin damage and stasis ulcers/blisters." Interventions included: "Assist Resident #7 to reposition frequently, monitor treatments for effectiveness and notify physician of any concerns. Try to encourage ventilation to perineum area as much as is possible. This may be more realistic in bed." Review of the TAR for [DATE] for Resident #7 reflected an order placed on the TAR dated [DATE] for Inflatable foot/heel protectors with all three shifts ,[DATE], ,[DATE], ,[DATE] signing the TAR. Review of the Wound Assessment Sheet for Resident #7 dated [DATE] reflected the pressure sore to the coccyx was 2.5 cm long by .75 cm wide with no slough and staged as Stage II documented and signed by RN A. Observation on [DATE] revealed Resident #7 to be up in the wheelchair from 9 AM until 6 PM with no inflatable foot/heel protectors in place. Observation on [DATE] at 4:53 of Resident #7's wound care and measurement by RN A (nurse in charge of assessing and staging wounds) revealed the pressure ulcer on the coccyx to be 3.5 cm long by 1.25 cm wide. The pressure ulcer was 80% covered in yellow slough and was a Stage III pressure ulcer as defined on the Wound Assessment System document RN A was documenting on. In an interview on [DATE] at 4:53 RN A stated the wound bed was 80% covered with yellow slough. She stated "It is a Stage II because there is no depth. I don't really agree with that slough only being a Stage III." RN A underlined slough in the description of a Stage III ulcer. During the measurement of the wound, RN A assured Resident #7 that his pressure sore was looking and getting much better. Review of the Wound Assessment Sheet dated [DATE] reflected RN A had staged the pressure sore a Stage II. In the narrative she documented "wound continues to improve. Has shallow bed of whitish slough to top of wound with approx. (approximately) 20% clean non-granulating tissue to edges. Will continue treatment as ordered." RN A documented "some slough" and the wound base as pink, yellow and white. Review of Wound Assessment Sheets for Resident #7 reflected his wounds were measured every 14 days. Review of the Nurses' Notes for Resident #7 dated [DATE] reflected there had been no notification to the physician of the increase in size and the worsening of the appearance of the pressure ulcer. In an interview on [DATE] at 4:30 PM when asked who should notify the family and physician of pressure sores and changes for Resident #7 the DON stated, "Charge nurses/ Skin nurse when she sees it, she should let the charge nurse know. The LVN should realize to notify." In an interview on [DATE] at 12:15 PM with RN A she stated, "As far as documenting or measuring changes in wounds, I don't know what the policy says honestly. I don't know. The nurses can notify the doctor, I am not the only one that can measure." In a telephone interview on [DATE] at 6:15 PM Resident #7's primary Physician stated he would want to know "right away" if there was a significant change in a wound such as signs of infection and that he would want it to be measured. He also stated "weekly wound measurements may have helped the wound from getting so bad." In an interview on [DATE] at 12:40 PM with the facility's Medical Director, he stated regarding improper staging of wounds, "if the wound is not healing or progressing then there are different principles to follow for wound care." Review of the facility's undated policy for PRESSURE ULCER PREVENTION AND MONITORING reflected: "l. All residents admitted at risk for pressure ulcers will be placed on a pressure ulcer prevention program which includes: b. Pressure reducing devices such as special mattresses as needed...e. Intense skin monitoring. 2. Residents with pressure ulcers will have: a. Treatments as ordered...c. Pressure reducing devices such as special mattresses and or/heel protectors as needed...g. At least weekly written assessments including location, stage, odor, color, size, drainage, response to treatment...h. any resident with a pressure ulcer which fails to improve or worsens, will have the physician notified promptly." Review of the undated facility's Pressure Ulcer Management Sheet reflected: "3. Reassess and measure at least weekly or sooner if deterioration of the ulcer is noted. Always document your findings in detail. 4. Promptly inform the physician (and responsible party, as appropriate) of new pressure ulcers. Obtain and initiate treatment orders." In an interview on [DATE] at 4:30 PM the DON stated the skin nurse should let the charge nurse know when she sees worsening of condition of wounds. The DON stated the LVN should realize to notify the family and physician. When asked who was responsible for making sure orders are carried out the DON stated, "the charge nurses are responsible to make sure they are carried out." The DON stated she and the ADON were responsible for making sure staff followed facility policy. The DON stated it was her and the ADON's responsibility to ensure staff knew what the facility policies and procedures were. In an interview on [DATE] at 6:05 PM the facility Administrator stated the DON, ADON and charge nurses are responsible for notifying the physician and family. The ADON was responsible for making sure orders were carried out. The Administrator stated the he and the Nursing Department are responsible for making sure staff followed procedures. The Administrator further stated it was ultimately his responsibility to make sure staff followed procedures. The Administrator stated the DON should definitely know what wounds were in the building. He was aware his policy stated pressure sores were to be measured weekly. Regarding whether he and his staff had neglected the care of the residents he stated, "It was not correct (the care of the residents). I do not appreciate professional people that I trust not doing what I expect." The facility Administrator was notified on [DATE] at 6:20 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was first submitted by the Administrator on [DATE] at 9:04 AM. The final Plan of Removal was accepted by the survey team on [DATE] at 7:30 PM. Cameron Nursing and Rehab Plan of Removal of Immediate Jeopardy In responses Wound Issues, Cameron Nursing and Rehab will do the following: 1. An RN from (Hospice) to in-service nursing staff on the care and treatment of [REDACTED]. DON, ADON, RN, Medicare Coordinator, and MDS Nurse and charge nurses LVN's will attend. In-service will be at 10:00 on Friday [DATE]. 2. Two Staff Registered Nurses will assess and measure all wounds on a weekly basis. All current wounds will be reassessed after training on [DATE]. 3. Facility will identify all "At Risk" residents for Skin Breakdown by using the Braden Scale. After in-service, all At Risk residents will be assessed by a RN and LVN to identify any possible pressure issues [DATE]. 4. All Physician orders [REDACTED]. A pink copy of all telephone order forms will be given to the ADON when completed. The ADON will monitor the order and follow through to make sure all meds are ordered and orders entered on treatment sheet and or MARs. This process was started on [DATE]. 5. DON and ADON will do in-service with all charge nurses regarding proper documentation of resident's change of condition, pressure sores, treatments, Physician Orders, and notifying family members and Physician. This will be complete during the in-service on [DATE]. 6. ADON and DON will report to Administrator any new skin issues and update of treatments in progress on Friday of each week with a copy of the weekly decubitus skin assessment log and non-decubitus log. First meeting will be on [DATE] and then weekly. 7. All pressure wounds will be reviewed and discussed at weekly staff meeting, including DON, ADON, MDS Nurse, Medicaid Coordinator, Registered Nurse on Staff, and Administrator on [DATE]. 8. Medical Director was notified of this at 9:30 am on Thursday [DATE]. Resident #3 Facility will: 1. Ensure air mattress is on Resident #3's bed, [DATE]. 2. Will follow physician orders [REDACTED]. (The new order: "Cleanse wound on coccyx with Normal Saline, pat dry-Apply Normal saline packing to wound bandage BID (twice daily)-Will consult wound care at Scott & White (Temple)-Insert indwelling catheter...-change q (every) month & PRN (as needed)-Record I&O (input and output) q shift-Catheter care q shift".) 3. Registered Nurse will accompany resident to Doctor's appointment on [DATE] to discuss proper treatment and procedure to be used, and request the use of a Catheter, this will be done on [DATE]. ADON or DON will monitor resident treatment with charge nurse for a period of two weeks to assure proper procedure is followed. If there is no improvement or wound worsens, Physician will be notified. 4. Two Registered Nurses will assess and measure wounds on a weekly basis. 5. Have Staff to continue to encourage resident to stay off of her back side and have staff continue to encourage and assist her to turn when in bed. 6. Nursing staff will encourage Resident to take in proper nourishment to help the healing process and have a Care Plan meeting with Son to encourage compliance with treatment plan. Administrator, DON, ADON will meet with son. 7. Have Dietary Consultant review Resident #3's chart and condition and make recommendations for nutrition on her next visit to the facility. Resident #7 1. Make sure resident maintains a pressure relieving mattress on his bed, [DATE]. 2. Nursing staff will encourage resident to try to stay off of his back side as much as possible, offering repositioning and reminded to use overhead bar. 3. Resident #7 request to be up for all three meals each day and remain in his wheelchair. DON, ADON, Administrator will have a care plan meeting will be held with Resident and Responsible Party regarding the benefits of shorter periods of time sitting in the wheelchair. 4. ADON or DON will monitor resident treatment for [REDACTED]. If there is no improvement or wound worsens, Physician will be notified. 5. Confirm with Physician when Heel Protectors should be worn, requested clarification [DATE]. 6. Notify Physician of change of condition [DATE]. 7. Two Registered Nurses will assess and measure resident's wounds on a weekly basis. The survey team monitored the plan of removal as follows: Reviewed was completed of new treatments as per physician order [REDACTED].#3 as shown in the plan of removal. All treatments and interventions were initiated and carried out. Resident #3's Responsible Party was notified. Resident # 7 had a re-assessment of his wounds and physician and responsible party were notified of the decline in the coccyx pressure sore. Observation of the facility in-service on [DATE] at 10:00 AM revealed the in-service was conducted by a RN from a local Hospice agency. The in-service provided information regarding pressure sores, care for pressure sores, assessments including staging and measuring, as well as interventions to prevent pressure sores. The in-service had four (4) RNs and 11 LVNs in attendance. The Medical Director and the Administrator were also present. The facility had over 70% of their licensed nursing staff in-serviced on [DATE]. The Hospice RN gave a competency test after the in-service in which all nursing staff in attendance passed per the Administrator. The facility provided a list of 25 residents who were at risk for pressure sores. The facility completed a 100% audit using the Braden Scale to identify residents at risk for pressure sores. Twenty-five (25) residents were identified at risk for pressure sores. Observations were made on [DATE] of four (4) of the 25 residents at risk for pressure sores. These Residents were assessed and staged properly and interventions and treatments were in place. The facility notified the Resident's Physicians and Responsible Parties. Observation on [DATE] at 2:40 PM revealed the DON entered a resident room to assess and measure pressure sores. The DON did not bring a cart or any sanitizing agents to the room. She did not prepare a clean surface for her supplies. She placed supplies for wound measurement under the shoes on Resident #14's Geri chair pressure reduction pad of the incontinent resident. She then laid a pair of gloves up against the heels of the shoes and went to the bathroom to wash her hands. She returned from the bathroom and began donning gloves. She approached the resident to explain the process to the resident when the surveyor stopped the DON and instructed her to start over and explained that her articles were contaminated. Later, when the DON began assessing the heel of the resident that had a Deep Tissue Injury (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue) she proceeded to dismiss the area and pronounced it was blanching after she placed pressure on the heel and released it multiple times. The heel was not blanching. Surveyor stepped forward and asked to see the heel turn white and then return to red. The DON applied pressure once again and admitted the heel was not changing color at all and was actually purple. The DON and ADON then tried to decide if the heel sore was a Stage I or not since it wasn't red. The Surveyor handed the DON the in-service Wound Staging Guide as received in the training in-service and asked her to read the description of a Deep Tissue Injury. The DON then correctly identified the heel as having a deep tissue injury. DON then observed the Stage II that was approximately one (1) cm in size with a pinpoint opening on the sacrum. The DON placed the measuring device on the opening and removed it repeatedly. She finally traced the one (1) cm circle and then marked the pinpoint opening. She then placed the device back on the wound and studied it and then asked the ADON to come and see if she had marked her device correctly. The DON then began studying the raised skin edges on the bilateral buttocks and decided that those impaired skin issues needed measuring. After DON applied the graph several times, the Surveyor asked the ADON if she had told the DON that the resident had a rash over her entire perineum. The ADON said she had not informed the DON and then parted the resident's legs so that she could see the raised skin was related to a rash and was not at all pressure sores. When the DON submitted the wound assessment to the surveyor, she had left the entire wound description area of the form blank. The Surveyor returned the form to the DON to complete it. The DON submitted it to the Surveyor the second time. The Surveyor returned the form to the DON and asked her to complete the periwound skin assessment line on the form. In an interview on [DATE] at 2:43 PM the Surveyor asked the DON as she donned gloves if she realized that she had her wound care items under a pair of shoes in the seat of a chair, she stated that she was so nervous that she did not realize what she had done. In a meeting on [DATE] at 3:15 PM the facility Administrator was made aware of the DON's actions during the assessment of Resident # 14's wound. The Administrator stated the DON needed more training and decided to have the two RNs performing skin assessments and not include the DON until she was further trained. Observations were made of a LVN and RN performing a skin assessment and identifying a problem on an at risk resident. Then two RNs returned and performed an assessment on the at risk resident and identified an area of concern on her left great toe. The area was identified as a Suspected Deep Tissue Injury. The two RNs correctly assessed, measured, identified prevention interventions, and notified the Physician and the Responsible Party. The facility provided an attendance signature sheet for the Staff Meeting held on [DATE] after the skin audit was completed with the Administrator, DON, ADON, RN A, MDS Coordinator, and one LVN-Medicaid Coordinator in attendance. On [DATE] at 8:00 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided a list of 25 residents at risk for pressure sores.

Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two (2) of nine (9) residents (Resident #2 and #3) reviewed for pain when: A) The facility failed to evaluate and assess interventions to ensure pain management and control when Resident # 2 experienced pain during wound care. B) During the month of June, 2014, Resident #3 experienced pain at levels of eight (8) to ten (10) on a scale of ten (10) (where 10 is excruciating pain) almost on a daily basis after readmission following a [MEDICAL CONDITION] and repair. The facility failed to assess, evaluate and revise pain relief interventions to ensure consistent pain management and control. These deficient practices placed 34 residents on scheduled pain management at risk for unrelieved or increased pain and poor quality of life that could lead to decreased oral intake, weight loss, dehydration, mood and behavior problems. Findings include: A) Review of the Consolidated Physician order [REDACTED].#2 reflected an [AGE] year old male who was admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #2 did not have an order for [REDACTED]. Review of the Significant Change (SC) MDS assessment dated [DATE] reflected Resident #2 required extensive assistance with bed mobility and total assistance for transfers. Resident #2 did not interfere with care, and was able to make himself understood. Resident #2's BIMS score was a seven (7) which indicated he was severely cognitively impaired. Resident #2 received scheduled pain medication but indicated he did not have pain for the past five days. The SC MDS reflected Resident #2 had one Stage 2 with an onset date of 12/22/2013. The Stage 2 had [MEDICATION NAME] tissue (new skin growing in superficial ulcer). The SC MDS reflected Resident #2 had a pressure reducing divide for the chair, care, and application of ointment/medications under Skin Conditions. Review of the Care Plan dated 01/17/2014 reflected Resident #2 had the following interventions for generalized pain: administer [MEDICATION NAME] as ordered by physician, assess and chart pain, factors that aggravate pain and pain control regimen. Review of the Care Plan dated 06/26/2014 for Resident #2 reflected "..pressure ulcer or potential for pressure ulcer development r/t (related to)...Hx of ulcers..." The Care Plan reflected under Interventions "...Administer medications as ordered. Monitor/document for side effects and effectiveness..." The Care Plan did not address for staff to assess for pain. Review of the Pain Evaluation for Resident #2 dated 05/03/2013 reflected the following [DIAGNOSES REDACTED]. The Evaluation reflected no complaint of pain, but to "continue to assess for complaints of pain." Observation on 06/25/2014 at 3:00 PM revealed LVN B provided wound care treatment to Resident #2's coccyx area. Resident #2 was on his left side in bed; he flinched, yelled out, and complained of pain. In an interview on 06/25/2014 at 4:40 PM Resident #2 stated "Yes" when asked if he had pain during the wound care treatment and he responded "yes" again when asked if he would like pain medication prior to the wound care. Review of the Nurses' Notes for Resident #2 reflected the following documentation: *06/22/2014 at 12:45 PM "dressing to coccyx changed, resident tolerated well." *06/25/2014 at 3:00 PM no documented evidence that Resident #2 experienced pain during wound care. Review of the Hospice Nurse Notes dated 06/23/2014 reflected Breakthrough Pain Medication available and the notes dated 06/25/2014 reflected no medication administered for pain before or after wound care. Review of the June 2014 MAR reflected the following information: *04/27/2014(initial order date)-an order for [REDACTED]. There was no evidence of pain medicine prior to wound care. Review of the physician's orders [REDACTED]. Review of the 24 Hour Report dated 06/25/2014 reflected "dressing was done 7-3 (shift)- c/d/I (clean, dry and intact)." There was no indication the resident experienced pain during the wound care or a facsimile to the physician for pain medication intervention. Review of the Quarterly Nursing Pain Evaluation dated 05/03/2013 reflected no complaint of pain, but continue to assess for complaints of pain. In an interview on 06/25/2014 at 5:50 PM when asked if Resident # 2 complained of pain during wound care, LVN C stated "Yes, all the time." LVN C also stated "sometimes up to two (2) to three (3) times a day when we have to change his dressing if it's soiled." In an interview on 06/25/2014 at 6:00 PM LVN B, who had changed Resident #2's dressing earlier, when asked if Resident #2 ever complained of pain before or during wound care stated "Oh yes, I probably should call the physician and get something for pain prior to Resident #2's wound care." In an interview on 06/27/2014 at 3:40 PM LVN E stated she performed wound care on Resident #2 on Sunday 06/22/2014 and remembered Resident #2 flinching and grimacing during wound care and that he was on hospice and they would take care of his pain. In an interview on 06/27/2014 at 3:15 PM Resident #2's Attending Physician stated he expected to be notified by phone or fax when a resident experienced pain at levels higher than eight(8)-nine(9) or during wound care that was painful, especially if it was happening two (2) or more times a day. Resident # 2's Attending Physician stated he could give an order for [REDACTED]. In an interview on 06/27/2014 at 3:50 PM Resident #2's Physician's Office Nurse stated the office did not receive a facsimile on the date of 06/25/2014 (when Resident #2 experienced pain during the treatment) to request pain medicine. The Physician's Office Nurse stated they received a facsimile on 06/27/2014 at 6:00 AM. In an interview on 06/27/2014 at 9:30 AM Resident #2 stated he still had not received pain medicine prior to or during dressing changes to his "bottom area". B) Review of Resident #3's Face Sheet reflected an [AGE] year old female readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3's Significant Change MDS assessment dated [DATE] reflected Resident #3 had severe cognitive impairment. Resident # 3 was assessed as having pain frequently making it hard to sleep at night and limiting her day to day activities. Review of Resident #3's Care Plan dated 05/21/2014 reflected a care plan for pain due to her recent [MEDICAL CONDITION] with a goal of "resident will voice a level of comfort to her desired level through the review date." Interventions included: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review of Resident #3's May 2014 MAR reflected orders for [MEDICATION NAME] and [MEDICATION NAME] tablets (narcotic pain pills) 5-325 mg one (1) or two (2) tablets by mouth every six (6) hours as needed beginning 05/10/2014, aspirin 81 mg once daily, and [MEDICATION NAME] 325 mg two tablets by mouth every six (6) hours as needed. Review of Resident #3's May 2014 MAR reflected she received 27 PRN (as needed) doses of [MEDICATION NAME] and [MEDICATION NAME] tablets 5/325 one or two tablets within a 20 day time 05/11/2014 to 05/31/2014. Resident Behaviors documented on the MAR are: "crying" seven (7) times, "grimacing" four (4) times and "pain all over" four (4) times. Documentation of effectiveness of intervention reveals the pain was relieved down to a four (4) or below after administration of prn pain medication. Record review of Resident # 3's Daily Pain Assessments from 05/09/2014 through 05/31/2014 reflected: *05/11/2014 9:00 AM pain rating eight (8) behavior: grimacing, [MEDICATION NAME] 5/325 mg one tablet given. Pain after intervention seven (7) still complaining. *05/11/2014 3:00 PM pain rating eight (8) behavior: grimacing, [MEDICATION NAME] 5/325 mg two (2) tablets given. Pain after intervention: blank. *05/12/2014 9:00 pain rating ten (10) behavior: crying, [MEDICATION NAME] 5/325 mg two (2) tablets given. Pain after intervention four (4). *05/13/2014 9:30 pain rating ten (10) behavior: crying, [MEDICATION NAME] 5/325 mg two (2) tablets given. Pain after intervention: four (4). *05/14/2014 9:30 pain rating ten (10) behavior: crying, [MEDICATION NAME] 5/325 mg two (2) tablets given. Pain after intervention: four (4). *05/14/2014 at an unspecified time pain rating eight (8) behavior verbal, grimacing, [MEDICATION NAME] 5/325 mg two (2) tablets given. Pain rating after intervention: not indicated, resting in bed. *05/15/2014 1:20 AM pain rating nine (9) behavior: grimacing complains of pain, [MEDICATION NAME] 5/325 mg two (2) tablets given. Pain after intervention: zero, asleep. *05/15/2014 9:00 pain rating ten (10) behavior: crying, [MEDICATION NAME] 5/325 mg two (2) tablets given. Pain after intervention: four (4). *05/16/2014 2:30 pain rating not legible, [MEDICATION NAME] 5/325 mg for pain all over. Pain after intervention: not recorded. ... (No pain pill interventions recorded for 05/17/2014 thru 05/18/2014). *05/19/2014 9:30 pain rating nine (9) behavior grimacing, [MEDICATION NAME] 5/325 mg one (1) given. Pain after intervention: two (2) resting. *05/20/2014 9:30 pain rating nine (9) behavior: crying, [MEDICATION NAME] 5/325 mg unknown number given. Pain after intervention two (2) resting.....almost daily pain medication dosage given until 05/28/2014 10:00 pain rating eight (8) behavior: verbal complaint [MEDICATION NAME] 5/325 mg unknown amount tablets given. Pain after intervention: two (2). *05/29/2014 7:35 PM pain rating eight (8) behavior verbal complaint, [MEDICATION NAME] 5/325 mg one (1) tablet given. Pain after intervention: two (2) resting in bed. *05/30/2014 9:00 pain rating eight (8) behavior: verbal consent, [MEDICATION NAME] 5/325 mg unknown amount given. Pain after intervention: none, resting in bed. *05/31/2014 11:20 PM pain rating eight (8) behavior: complains of pain/refused repositioning, [MEDICATION NAME] 5/325 mg two (2) tablets given. Pain after intervention: none, asleep (effective). Review of the Nurses Notes from 05/11/2014 through 06/23/2014 reflected Resident # 3's Physician was not notified of significant frequent pain and a request for a routine order of pain medication was not initiated. In an interview on 06/25/2014 at 3:45 PM Resident #3 was asked if she would like an air mattress overlay placed on her bed while she was up for supper when she stated "yes, it's worse than it's ever been" referring to her pain. Resident # 3 stated she had just received pain medication. In an interview on 06/27/2014 at 3:15 PM Resident #3's Attending Physician stated he expected to be notified by phone or fax when a resident experienced pain at levels higher than eight (8)-nine (9), especially if was happening two (2) or more times a day. Review of the facility's undated Pain Policy reflected a "pain evaluation" will be completed with each OBRA (Omnibus Budget Reconciliation Act) assessment. (Last OBRA assessment was dated 05/08/2014.) The facility provided a CMS Form 672 with 34 residents who were on a pain management program.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent accidents for 1 of 15 residents reviewed for accidents. (Resident #44) Resident #44 had a history of [REDACTED]. Between 09/17/12 and 03/12/13, Resident #44 had 5 falls. Following each of the falls, no revisions to the plan of care were implemented to prevent further falls. On 03/31/13, Resident #44 fell and sustained a right hip fracture requiring surgery. This failure contributed to Resident #44's right hip fracture. This failure could place 34 residents identified as being high fall risk at risk for injury or death. Findings included: A facility admission face sheet dated 07/10/12 indicated Resident #44 was admitted on [DATE]. Physician orders [REDACTED]. A nursing note for Resident #44 dated 09/20/12 indicated "resident unsteady this morning, off balance, will place fall alarm..." Fall risk assessments for Resident #44 dated 01/10/13 and 03/23/13 indicated she was high risk for falls. An annual MDS dated [DATE] for Resident #44 indicated therapy as follows: * occupational therapy from 08/30/12 - 09/28/12 * physical therapy from 08/03/12 - 08/27/12 The most recent MDS dated [DATE] for Resident #44 indicated: * severely impaired vision, * cognitive impairment, * independent in walking, * assistance needed with activities of daily living, * continent of bowel and bladder, * one fall without injury * received occupational therapy 08/30/12 - 09/28/12, * received physical therapy 12/13/12 - 01/10/13, A fall risk care plan initiated 02/03/10 and updated 03/31/13 included interventions of: *fall risk assessment quarterly and as needed, *keep call light within reach and encourage her to use it, *has very poor vision - assist her to activities, *remind her to use grooming products (like powder) carefully; they could make the floor slippery. Offer to assist her with these products. *offer toileting/peri-care frequently including on the night shift, *if confusion/changes/falls are noted, suspect a urinary tract infection. Notify physician and collect a urinalysis. *remind resident to use her walker, *ensure resident has sturdy shoes. A March 2013 CNA flow record indicated Resident #44 was checked every two hours. An incident report for Resident #44 dated 09/17/12 noted, "Resident called out 'help' - when staff checked on resident, found resident in bathroom on left side on floor. Resident had ambulated to bathroom by self and fell between commode and lavatory... two reddened areas were on the left side of back." The follow-up noted physical therapy was notified, offer assistance often and toilet every two hours. The report also noted resident was non-compliant, had very poor safety awareness, and had a long, marked history of falls prior to admission to the facility. An acute care plan for falls for Resident #44 dated 09/17/12 included interventions of: *sit resident by nursing station, *cue resident constantly to stay seated, *check on resident frequently, *try to divert attention in another direction. Incident reports for Resident #44 indicated the following: *10/29/12 - "resident found on floor of restroom. She stated I bent over to pick up something to put in the trash. I couldn't come all the way up so I just sat down and pulled the call light. No injuries noted." The follow-up noted physical therapy was informed, "keep call light close (may or may not use it)," and remind her often to call for assistance. The report further noted she had ongoing non-compliance, very poor safety awareness, and resident was unable to retain information. *12/08/12 - "This nurse and CNA heard resident yelling out for help. Resident found sitting on floor near recliner. Resident stated she was transferring from wheelchair to recliner and when resident got up, wheelchair rolled causing her to fall near recliner." There were no injuries noted. The follow-up noted physical therapy was notified and " continue to remind her to call for assistance (usually to no avail)." *12/19/12 - "This nurse heard resident yelling out for help. Resident found sitting on floor with back against recliner. Resident stated "I was trying to get into my chair and fell ." There were no injuries noted. Follow-up noted physical therapy was informed, "remind her to call for assistance-to no avail", and use fall alarm if she will allow. The report further noted non-compliance continued. There were no acute fall care plans initiated and there was no update to the fall risk care plan following the falls on 10/29/12, 12/08/12, and 12/19/12. Nursing notes dated 09/17/12-03/12/13 for Resident #44 indicated there was no documentation of staff reminding her to use her walker, of the type of shoes she wore, the use of any products which made the floor slippery, or of a urinalysis being obtained following falls per the approaches in her fall risk care plan dated 02/03/10. There was no documentation of staff sitting the resident by the nursing station, cueing resident constantly to stay seated, or trying to divert her attention in another direction per the approaches of the acute fall care plan dated 09/17/12. An incident report dated 03/12/13 for Resident #44 indicated "heard a clang and bump noise at nursing station, on investigation found resident sitting on floor in her bathroom. Resident stated she tripped on trash can and fell to (her) bottom." There were no injuries noted. Follow-up noted physical therapy was informed and will use fall alarm. The report also noted severe dementia, chronic poor decisions related to personal safety, and "years of trying to decrease falls have been to no avail." A fall risk care plan dated 03/18/13 for Resident #44 noted interventions were identical to her fall risk care plan initiated 02/03/10, except for the addition of keeping pathways clear of obstacles due to her poor vision. An incident report dated 03/31/13 for Resident #44 indicated, "Resident found in bathroom on floor with head in the bookcase, broke shelf, feet next to commode, complained of right hip hurting, tender to touch with right foot rotating outward. Swelling noted at hip joints. Resident confused, did not ask for help." The follow-up noted the resident was sent to hospital, continue to use fall alarm, remind her to ask for help, keep call light close to her, and enlist responsible party for assistance. The report also noted ongoing noncompliance and "fracture to right hip - surgical repair". There were no fall risk assessments documented following Resident #44's falls on 09/17/13, 10/29/12, 12/08/12, 12/19/12, and 03/12/13. There were no physical therapy screens documented following Resident #44's falls on 09/17/13, 10/29/13, and 03/12/13. Physical therapy notes indicated Resident #44 received physical therapy following the fall on 12/08/12, beginning 12/13/12. She was still on physical therapy when she fell on [DATE]. The notes indicated Resident #44 was discharged from physical therapy 01/10/13. The next documentation indicated physical therapy was initiated 04/04/13 following surgery for [REDACTED]. During an observation on 04/09/13 at 8:51 a.m., Resident #44 was lying in her bed sleeping. She did not have a fall alarm in place. During an observation on 04/09/13 at 10:50 a.m., Resident #44 was sitting in her wheelchair without a fall alarm in place. During an observation and interview on 04/09/13 at 11:14 a.m., Resident #44 was sitting in her wheelchair without a fall alarm in place. CNA A said she could not find the fall alarm. She said Resident #44 should have the fall alarm on. During an interview on 04/09/13 at 10:00 a.m., the DON said Resident #44 would remove her fall alarm. She said the fall alarm was addressed in her care plan. She said Resident #44 did not use her call light and would remove her fall alarm. During an interview on 04/09/13 at 10:21 a.m., RN E said when she responded to Resident #44's fall on 03/31/13, the resident was lying on the floor. She said Resident #44 said her leg was hurting. She said the resident was very confused. RN E said they had not tried a cushion fall alarm for Resident #44 when she slept in her recliner. She said they monitored to assure her fall alarm was in place, but it was not documented. During an interview on 04/09/13 at 10:32 a.m., CNA A said on 03/31/13, she heard someone yelling, but did not hear a fall alarm sounding. She said when Resident #44 fell , the alarm was not on her. She said they used a fall alarm for Resident #44 which clipped to her shirt. She said the resident knew how to take it off and put it back on. She said Resident #44 would remove the alarm once it sounded, but she did not take it off prior to the alarm sounding. She said the resident was confused. She said the resident did not have a bed and chose to sleep in her recliner prior to her hip fracture. She said they never tried a cushion fall alarm on resident. They only used the clip-type fall alarm. She said they did not document it when they monitored for alarm placement. She said Resident #44 was confused and unable to consistently remember to use her call light. During an interview on 04/09/13 at 10:40 a.m., RN F said they had tried the clip fall alarm, redirecting, and involving Resident #44's responsible party to prevent her falls. She said they monitored her frequently. She said Resident #44 had a history of [REDACTED]. She was not aware of the resident using a cushion fall alarm. During an interview on 04/09/13 at 1:55 p.m., the DON said they normally obtain a physician order [REDACTED]. She said Resident #44 had a history of [REDACTED]. She was not sure if they tried the cushion fall alarm for Resident #44 for her recliner in the past. She said Resident #44 did not retain information well. She thought the fall alarm placement was in Resident #44's care plan. She also thought Resident #44 removing the fall alarm was care planned. She said there was no set time to check to assure the alarm was in place. She said they conducted rounds at a minimum of every two hours. She did not think there was any documentation for staff to sign to show they checked the alarm placement. She said the care plans should be revised after a fall. She said they continued the same interventions for Resident #44 because they "had done all they could do." She said they spoke with Resident #44's responsible party about moving her closer to the nursing station (resident resides at the last room on the hall), but he did not want to move her. She said it was not necessary to re-assess Resident #44 after each fall because she had always been and remained a high risk for falls. She said they conduct fall risk assessments quarterly and annually. She said the assessments were "just paper" and "re-assessing her would not have changed anything." During an interview on 04/09/13 at 2:44 p.m., Resident #44's responsible party said he visited often and did not always see her fall alarm on her. He was not aware of her taking off her fall alarm. He said staff talked to him after she fell on [DATE] about moving her closer to the nursing station. He said he was in agreement and thought it was in the process. During an interview on 04/09/13 at 3:25 p.m., the administrator said Resident #44's responsible party wanted her to have a private room and they did not have a private room for her closer to the nursing station. When asked if they considered increased monitoring or any other interventions for Resident #44 since they could not move her closer to the nursing station, neither the administrator, DON, nor ADON responded. During an interview on 04/10/13 at 9:28 a.m., CNA B said Resident #44 used to be able to go to the bathroom on her own before she fell and fractured her hip. Now they place a brief on her since she can no longer get up to the bath room. He said she asked them if she was just supposed to "pee" on herself. He said they told her to go in her brief, and they would check her every hour. He said they checked on her hourly prior to her hip fracture. He said she required a lot more assistance since she fractured her hip. During an interview on 04/10/13 at 9:35 a.m., CNA C said before Resident #44's hip fracture, she was able to stand, walk with her walker, sleep in her recliner, and only required one person assistance. She said the resident now had to sleep in bed; they had to perform peri-care on her, and were two people assistance. She continued to say Resident #44 was not as mobile as she was before. She said her vision had always been poor. She said the nurses had a sheet to monitor checking the fall alarm batteries, but the nurse aides did not have a sheet to sign they checked for alarm placement or conducted more frequent checks of the resident. She said she thought residents who were at risk for falls should be kept near the nursing station so they could be watched closer. During an interview on 04/10/13 at 11:18 a.m., MDS Coordinator D said she had a significant change MDS for Resident #44 due on 04/10/13. She said the significant change was due to her having hip surgery which led to a change in her ADL abilities. She said Resident #44 was total assistance with transfers. Prior to the hip fracture, she required only supervision or limited assistance with transfers. An undated falls policy and procedure indicated: "Falls can be very dangerous for our residents and we should try to prevent them if at all possible. Dangerous complications can result in injuries from falls." "Follow the acute care plan for falls." "A fall risk assessment is performed every quarter on every resident." "For all of these high risk residents, use the following interventions: identify factors that increase the resident's potential for falls/injuries. Eliminate as many of those factors as possible. Encourage the resident to request assistance. Assess/evaluate any falls that do occur as to patterns and the cause of the fall. Anticipate and intervene to prevent future recurrence. Monitor high risk residents frequently. Anticipate and meet resident's needs. Be sure the call light is within reach and encourage the resident to use it. Coordinate with appropriate staff to ensure a safe environment with: floors free from spills or clutter, adequate light, bed in low position at night, handrails on walls and personal items within reach." "Provide education, including safety reminders, of what to do if a fall occurs. Physical therapy as the physician orders." "A 'rise' (clip on or cushion) alarm may be ordered by the physician to notify staff when a resident who is at risk for falls begins to rise from their chair or bed. Respond promptly to this alarm to intervene in any unsafe behaviors. If the alarm does not seem to be working correctly, notify the charge nurse." An undated alarm system for chair/bed policy and procedure indicated: "Residents who get up without help often benefit from a chair/bed alarm system. The device is clipped to the back of a chair or the side of the bed. If the resident gets up, the cord is pulled away from the magnet where it is connected and an alarm sounds. This way the staff can know the resident has gotten up without calling for help. It is a way to prevent falls." "The alarm is placed by physician order..." "The system should be documented on the activities of daily living flow sheet." A list provided by the DON on 04/10/13 at 3:45 p.m. indicated 34 residents were high risk for falls.