Every finding on record at Life Care Center Of Merrimack Valley

Based on records reviewed and interviews for one of three sampled residents (Resident #2), who started to lose his/her balance during care, was lowered to the floor by a staff member, the Facility failed to ensure nursing notified the Provider and the Health Care Agent of the incident, a few days later Resident #2 was noted to have a decline in functional status and was experiencing pain with mobility. Findings include:Review of the Facility's policy titled, Changes in Resident's Condition or Status, revised August 2025 indicated:- The nurse will notify the residents' attending physician or physician on call and resident representative of changes in resident's condition or status and must notify the physician immediately of:An Accident involving the resident which has the potential for requiring physician intervention.Resident #2 was admitted to the Facility in October 2023, diagnoses included dementia, osteoporosis (bone density decreases, making bone weak, brittle and highly prone to fractures), hypertension, chronic kidney disease and a history of falls.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 04/10/26, indicated that Resident #2 had a staff assisted fall in his/her bathroom when he/she began to slip and was lowered to the floor by a nursing staff member (later identified as Certified Nurse Aide (CNA) #1).The Report indicated that Resident #2 initially denied pain but later complained of left hip pain while being repositioned in bed and an x-ray was ordered by the physician. The Report indicated that Resident #2 was diagnosed with a left acute femoral intertrochanteric (hip) fracture with mild osteoporosis.Review of Resident #2's medical record indicated there was no documentation to support nursing notified the provider or health care agent on 4/05/26 of his/her staff assisted fall.Review of CNA #1's witness statement dated 4/07/26, indicated she was providing care to Resident #2 who was in a standing position in his/her bathroom, he/she lost his/her balance and was lowered to the floor.During an interview on 4/23/26 at 1:30 P.M., Nurse #1 said that on 4/05/26 around 12:00 P.M., CNA #1 reported to her that Resident #2 became weak while in the bathroom, that she had to lower him/her to the floor and she needed assistance to get him/her back up. Nurse #1 said before they moved Resident #2, she assessed him/her in the bathroom, his/her vital signs were stable and he/she denied pain, then she and CNA #1 assisted him/her back to bed.Nurse #1 said she did not notify Resident #2's Provider, or his/her Health Care Agent of the staff assisted fall but said she should have.During an interview on 4/23/26 at 2:50 P.M., Certified Nurse's Aide (CNA) #2 said Resident #2 had not been feeling well on 4/06/26 and wasn't his/her usual self, and she reported her concerns to the Nurse, and the decision was made to keep him/her in bed. CNA #2 said she was not made aware that Resident #2 had a fall on 4/05/26. During an interview on 4/23/26 at 2:12 P.M., the Unit Manager said Resident #2 complained of left hip pain on 4/07/26 and that is when she was made aware that he/she had been lowered to the floor in a staff assisted fall on 4/05/26. The Unit Manager said she notified the Provider and received orders for a left hip x-ray, and the results showed a left hip fracture. The Unit Manager said she notified Resident #2's Health Care Agent and the decision was made not to send him/her to the hospital. The Unit Manager said she reeducated staff that an assisted fall is a fall and it should have been reported to the Provider and Health Care Agent immediately. During an interview on 4/23/26 at 2:42 P.M., the Director of Nursing (DON) said there was no documentation in Resident #2's medical record to support that Nurse #1 called the Provider or Health Care Agent to notify them that Resident #2 had a fall. The DON said that it is the facility's expectation that nursing staff notify the resident's provider and health care agent, document it in the medical record, but however in this case it was not done.

Based on observation, interviews, and record review, the facility failed to ensure two Residents (#85 and #113) were free from significant medication errors, out of a total sample of 26 residents. Specifically,1. For Resident #85, the facility failed to ensure Nurse #3 administered the correct dose of furosemide on twelve occasions.2. For Resident #113, the facility failed to ensure nursing transcribed the correct dose of lisinopril from his/her hospital discharge medication list resulting in Resident #113 receiving the incorrect dose of lisinopril on four occasions. Findings include: 1. Review of the facility policy titled, Administration of Medications, dated 9/9/25, indicated the facility will ensure medications are administered safety and appropriately per physician's order to address residents' diagnosis and signs and symptoms.2. Staff who are responsible for medication administration will adhere to the 10 rights of medication administration. c. Right Dose. Check the Medication Administration Record (MAR) and the physician's order before medicating. Resident #85 was admitted to the facility in October 2023 with diagnoses including chronic kidney disease stage three and congestive heart failure (CHF). Review of the most recent Minimum Data Set (MDS) assessment, dated 9/17/25, indicated that Resident #85 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #85 received a diuretic medication. Review of Resident #85's physician's order, dated 11/5/25, indicated: -Lasix Oral Tablet (Furosemide, diuretic medication), give 30 milligrams (mg) by mouth in the morning for CHF. On 12/9/25 at 8:38 A.M., during the medication administration task, the surveyor observed Nurse #3 prepare medications for Resident #85. Nurse #3 obtained a medication card of furosemide 20 milligrams (mg) cut in half to equal 10 mgs. The medication card indicated to give one half tablet (10mg) with one whole tablet (20 mg) for a total dose 30 mg in the morning. Nurse #3 only removed one half tablet from the medication card. On 12/9/25 at 9:01 A.M., Nurse #3 had committed to administering only the one-half tablet of furosemide to Resident #85. Nurse #3 said that he only placed one half tab tablet in the medication cup, and he re-reviewed the order with the surveyor. Nurse #3 showed the surveyor another card of furosemide 20 mg tablets and then Nurse #3 said he had only been administering this one-half tablet since the order changed about a month ago. Nurse #3 administered Resident #85 only 10 mg of furosemide despite the order for 30 mg and he returned to the medication cart with the surveyor. Nurse #3 was unable to comprehend his error. The surveyor immediately reported the medication error to Unit Manager #1. During an interview on 12/9/25 at 9:11 A.M., Unit Manager #1 said that Nurse #3 should administer the correct dose of furosemide. During a follow-up interview on 12/9/25 at 9:35 A.M., Unit Manager #1 said that the order for the furosemide was unclear in the electronic health record, and she clarified the order. Unit Manager #1 said that she reviewed the order with Nurse #3, and she said that he now understood his mistake. During a follow-up interview on 12/9/25 at 9:38 A.M., Nurse #3 said that he did not realize the error he had made with the furosemide and he said that he has been working the medication cart for over a month and he has been administering incorrect dose of furosemide. Review of Resident #85's Medication Administration Record, between 11/17/25 through 12/9/25, indicated Nurse #3 administered the furosemide twelve times. During an interview on 12/10/25 at 10:50 A.M., the Director of Nursing said that nursing should administer the correct dose of furosemide to prevent medication errors. During an interview on 12/10/25 at 11:52 A.M., the Physician said that Resident #85 is prescribed furosemide for heart failure and the medication is used to keep the fluid off the heart. The Physician said that nursing should administer the correct dose of furosemide to prevent errors. 2. Review of the facility policy titled, Medication Reconciliation across the Continuum of Care, dated as revised 9/9/25, indicated medications will be reconciled by the licensed nurse. Clinically significant medication issues identified will be communicated to the physician, acted upon, and documented in the medical record. 3. The home medication listing (if available), the physician admitting orders, and the hospital transfer form (if coming from a hospital) are received by a licensed nurse who reconciles the medication lists, phones the physician if necessary for clarification, obtains physician's orders and then updates the electronic health record. Resident #113 admitted to the facility in December 2025 with diagnoses including osteoarthritis of the hip, hypertension, and spinal stenosis. Review of Resident #113's NRSG: Admission/readmission Collection Tool - V 6 assessment, dated 12/5/25, indicated Resident #113 was alert and oriented to person, place, time, and situation. Review of Resident #113's NRSG: Medication Reconciliation Form assessment, dated 12/6/25, indicated: 1. Type of Reconciliation, coded as Admission. 2. Were there any clinically significant medication issues identified during reconciliation, coded as no. Review of Resident #113's hospital Discharge summary, dated [DATE], indicated:- lisinopril 20 milligrams (mg), take 10 mg by mouth in the morning. Review of Resident #113's, physician's order, dated 12/5/25, indicated:- lisinopril 20 mg, give 1 tablet by mouth one time a day for hypertension. During an interview on 12/9/25 11:11 A.M., Resident #113 said his/her home dose of lisinopril is 10 mg. Resident #113 showed the surveyor his/her home medication list from his/her pharmacy that indicated Resident #113 was prescribed lisinopril 10mg by mouth daily. During an interview on 12/9/25 at 12:10 P.M., Nurse #1 said that she obtained the physician's orders for Resident #113 based on the hospital discharge summary. Nurse #1 said she contacted the on-call and reviewed the hospital discharge summary with the on-call provider. Nurse #1 said that there were no changes made in the medication list, and she transcribed the orders as written from the hospital discharge summary. Nurse #1 said she did not complete the medication reconciliation with the Resident. Nurse #1 reviewed the order for the lisinopril, and she said she should have transcribed the order as lisinopril 10mg by mouth in the morning. During an interview on 12/9/25 at 2:17 P.M., Nurse #4 said that she completed Resident #113's Medication Reconciliation Form and she said that she misread the order for the lisinopril in the hospital discharge summary, and she thought that Nurse #1 had transcribed the order correctly and she should have noticed that the order was for lisinopril 10mg by mouth daily. Nurse #4 said that had she caught the error on the transcribed medication she would have contacted the physician for a new order. Nurse #4 said that administering a higher dose of lisinopril could cause the Resident to bottom out (hypotensive episode, low blood pressure). During an interview on 12/9/25 at 1:32 P.M., Unit Manager #1 said that medications are to be transcribed according to the hospital discharge summary. Unit Manager #1 said that new orders are supposed to be checked by the night nurse and there is also a medication reconciliation form used to catch errors. Unit Manager #1 reviewed Resident #113's hospital discharge summary and she said the order was not transcribed correctly. Unit Manager #1 said that too much lisinopril can result in low blood pressure. During an interview on 12/9/25 at 1:39 P.M., the Director of Nursing (DON) said that new admission orders should be transcribed based on the hospital discharge summary. The DON said that orders placed in the electronic health record and should be reviewed by the overnight nurse and corrections should be made. The DON said that medication reconciliation should be completed accurately on all new admissions. During an interview on 12/10/25 at 11:49 A.M., the Physician said that Resident #113 is prescribed lisinopril for blood pressure and heart failure. The Physician said that nursing should have obtained and transcribed orders based on Resident's hospital discharge summary.

Based on record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#14) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 25 residents. Specifically, for Resident #14 the facility failed to ensure nursing scheduled his/her phosphate binder (medication that is essential for managing elevated phosphate levels in the blood, a condition known as hyperphosphatemia. This condition often occurs in residents with chronic kidney disease because their kidneys are less able to excrete phosphate. High phosphate levels can lead to various health issues, including weakened bones and cardiovascular problems) to be administered with meals and snacks as recommended by the dialysis center. Findings include: Review of the facility policy titled, Hemodialysis Offsite Policy, dated as revised 9/16/25, indicated the facility assures that each resident receives care and services for the provision of offsite hemodialysis dialysis consistent with professional standards of practice. This includes: 3. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. - Procedure3. The facility and dialysis facility dietitians should coordinate the nutritional care including monitoring, documenting, and deciding how and when to address weight changes and nutrition issues.- Communication Between the Dialysis Center 3.The communication process should include how the communication will occur, who is responsible for communicating, and where the communication and responses will be documented in the medical record, including but not limited to: a. Timely medication administration (initiated, administered, held or discontinued) by the nursing home and/or dialysis facility; andb. Physician/treatment orders, laboratory values, and vital signs. Resident #14 was admitted to the facility in April 2025 with diagnosis including diabetes, heart failure, chronic kidney disease and dependence on renal dialysis. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/22/25, indicated that Resident #14 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #14 required dialysis. Review of Resident #14's plan of care related to therapeutic diet needs, dated 10/23/25, indicated:- Registered Dietitian (RD) to evaluate and make diet change recommendations as needed (PRN). Diet education as needed per collaboration of needs with dialysis (renal) RD. - Administer medications as ordered.- Lab/diagnostic work as ordered. Report results to physician and follow-up as indicated.-Receives dialysis. Send to dialysis on Tuesday /Thursday / Saturday bag lunch. Collaborate care with hemodialysis. Review of Resident #14's physician's order, dated 8/5/25, indicated: -Dialysis Resident: Receives dialysis. Send to dialysis on Tues/Thurs/Sat pick up at 10:00 A.M. Review of Resident #14's physicians order, dated 10/28/25, indicated:- GIVE CALCIUM ACETATE 667 milligrams (mg) WITH MEALS OR SNACK, three times a day for kidney health. Scheduled three times daily at 8:00 A.M., 2:00 P.M., and 8:00 P.M. Review of the facility's meal truck delivery time form, dated as current, indicated the following meal truck delivery times for the C-Unit: -Breakfast: 7:40 A.M., -Lunch: 12:00 P.M., and -Dinner: 5:00 P.M. Review of Resident #14's most recent NUTRITION: Quarterly Nutrition Data Collection. - V 2 assessment, dated 10/23/25, indicated:-phosphorus level is high.Summary: October 2025 monthly dialysis labs indicate corrected calcium 8.3 (Low), phosphorus 7.7 (High), same as September, dietary interventions implemented after September level of 7.7 milligrams/deciliter (mg/dL). Communications with hemodialysis dietitian, indicate next step to address phosphorus with a binder - calcium acetate suggested due to his/her low corrected calcium. Review of Resident #14's hemodialysis form titled Nutrition and Blood Test Reports, dated 12/4/25, indicated:Phosphorus: Goal of 3.0 to 5.5 mg/dLDraw Date: 11/4/25 6.4 mg/dLDraw Date: 12/2/25 6.6 mg/dLNotes and comments: Reach the goal for health bones and heart. Take phosphorus binder as prescribed. Review of Resident #14's form titled Pre/Post Dialysis Communication from the Dialysis Dietitian, dated 12/4/25, indicted:- Lab result phosphorus 6.6, remains high, continue to provide phosphorus binders with oral intakes with meals and snacks. During an interview on 12/9/25 at 10:00 A.M., Resident #14 said that he/she was waiting to go dialysis. Resident #14 said that he/she takes a bag lunch with him/her to dialysis and he/she does not take any medications. Resident #14 said that he/she is back at the facility for dinner. During an interview on 12/10/25 at 8:40 A.M., Nurse #3 said that he obtained the recommendation for Resident #14's phosphorus binder, and he said the order should be scheduled with meals and snacks. During an interview on 12/10/25 at 8:43 A.M., Nurse #6 said that Resident #14 receives a phosphorus binder, and she said the medication should be given with meals and with snacks. Nurse #6 said that she was not sure why the order was in the computer to be given at 2:00 P.M, because that is after his/her lunch. Nurse #6 said that she does not work the evening shift and she reviewed the order, and she said that dinner time medications are to be scheduled at 5:00 P.M. During an interview on 12/10/25 at 8:59 A.M., Nurse #1 said Resident #14 is on a phosphorus binder and the medication should be taken with meals and snacks according to pill bottle. The surveyor and Nurse #1 reviewed Resident #14's medication bottle that indicated:- Calcium Acetate 667 mg capsule, take one capsule three times daily and with snacks. Take with meals. During an interview on 12/10/25 at 10:02 A.M., Unit Manager #1 said that phosphorus binders should be scheduled to administered with meals, and she said that Resident #14's were not scheduled correctly. Unit Manager #1 said that the phosphorus binder should be scheduled at 8:00 A.M, 12:00 P.M., and 5:00 P.M. During an interview on 12/10/25 at 10:50 A.M., the Director of Nursing said that nursing should have transcribed the phosphorus binder to be administered during mealtimes as recommended by the dialysis center. The DON said that the phosphorus binder should be scheduled at 8:00 A.M, 12:00 P.M., and 5:00 P.M., and there should be an order as needed for staff to administer the medication with snack. During an interview on 12/10/25 at 11:51 A.M., the Physician said that Resident #14 is prescribed a phosphorus binder for his/her elevated phosphorus levels. The Physician said that the medication is to be given during meals as the medication binds phosphorus from food. The physician said this is important because Resident #14 has kidney disease and he/she has elevated phosphorus levels.

Based on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were dated once opened and stored according to manufacturer's guidelines in one of three medication carts observed. Findings include: Review of the facility policy titled, Storage and Expiration Dating of Medications and Biologicals, dated as revised 6/30/25, indicated policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. 11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened.11.1 Facility staff may record the calculated expiration date based on date opened on the primary medication container.11.2 Medications with a manufacturer's expiration date expressed in month and year will expire on the last day of the month.11.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer date for that opened vial.11.4 When an ophthalmic solution or suspension has a manufacturer shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container.11.4.1 Facility staff should evaluate the continued sterility of the product based on clinical judgment or contamination of the dispenser after contact with eye, eyelid, lashes or finger. On 12/8/25 at 1:12 P.M., the surveyor observed on the C-Wing low side medication cart the following: -two bottles of latanoprost eye drops, opened and undated. Manufacture's guidelines indicate the medication is good for 6 weeks once opened. -two Novolin R pens, opened and undated. Manufacture's recommendations indicate good for 28 days once opened. -two insulin aspart pens, opened and undated. Manufacture's recommendations indicate good for 28 days once opened. -one fluticasone furoate/vilanterol inhaler, opened and undated. Manufacture's guidelines indicate the medication is good for 6 weeks once opened. -one insulin lispro pen, opened and undated. Manufacture's recommendations indicate good for 28 days once opened. -one insulin glargine pen, opened and undated. Manufacture's recommendations indicate good for 28 days once opened. -one vial insulin glargine, opened and undated, Manufacture's recommendations indicate good for 28 days once opened. -one vial insulin glargine, unopened. Manufacture's recommendations indicate to refrigerate until opened. -one bottle of dorzolamide eye drops, opened and undated. Manufacture's recommendations indicate good for 28 days once opened. -one bottle of brimodine eye drops, opened and undated. Manufacture's recommendations indicate good for 28 days once opened. During an interview on 12/8/25 at 1:21 P.M., Nurse #1 said insulins and eye drops should be dated when opened. Nurse #1 said she was going to look to see when the medications were delivered from the pharmacy and she would add opened dates based on one day after the delivery from the pharmacy. Nurse #1 said that insulin should be refrigerated until opened. During an interview on 12/8/25 at 1:31 P.M., the Assistant Director of Nursing (ADON) said that eye drops and insulins should be stored according to manufactures guidelines. The ADON said that insulin should be refrigerated until opened. During an interview on 12/10/25 at 10:55 A.M., the Director of Nursing said that nursing should date and label, and store medications according to manufacturer's recommendations.

Based on observation, record review and interview, the facility failed to provide one Resident (#93) with a therapeutic diet as ordered by the physician out of a total sample of 26 Residents. Specifically, the facility failed to ensure that Resident #93 received an easy to chew textured diet as prescribed by the physician.Findings include:Review of the facility policy titled Therapeutic and Modified Diets, dated and revised 12/5/23, indicated the following:- Therapeutic and modified diets will be provided by the attending physician or per state guidelines. The intent of this is to ensure the residents receive and consume foods in the appropriate consistency as prescribed by a physician.Review of the facility policy titled Nutrition Assessment, dated and revised 12/16/21, indicated the following:- The Registered Dietitian assesses the resident to determine nutritional needs by reviewing the collected data and completing the nutrition assessment. Nutrition Assessment also includes information such as any special food formulation.Resident #93 was admitted to the facility in September 2025 with diagnoses including Achalasia of cardio (a condition when food and liquid does not move through the esophagus to the stomach), dysphagia (difficulty swallowing), Gastroesophageal Reflux Disease and Dementia.Review of Resident #93's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview of Mental Status score of 3 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident requires supervision or touching assistance with eating.The surveyor made the following observations:- On 12/8/25 at 7:50 A.M., the surveyor entered Resident #93's bedroom, Resident #93 was not in his/her room. On his/her bed was a plastic bag of Cheez its, two bags of Life Savers hard candies and a box of [NAME] Mints.- On 12/9/25 at 8:22 A.M., the surveyor entered Resident #93's bedroom, Resident #93 was not in his/her room. Resident #93's bedside table drawer was open, sticking out was a plastic bag containing Life Savers hard candies along with red and white striped hard mint candies.- On 12/10/25 at 7:28 A.M., Resident #93 was awake, sitting up in his/her bed, the curtain was drawn, his/her door was halfway shut, and the Resident could not be seen from the hallway. Next to Resident #93's was a plastic bag containing Life Savers hard candies along with red and white striped hard mint candies. Resident #93 was eating a Life Savers mint, he/she told the surveyor that he/she eats the mints whenever he/she feels like it.Review of Resident #93's physician's orders indicated the following:- May NOT omit diet restrictions on special occasions - Dated 9/24/25- Regular diet, Easy to Chew Texture, thin consistency - Dated 11/10/25Review of Resident #93's Nutrition care plan dated and revised 10/3/25, indicated the following interventions:- supv (supervise) meals & snacks. - Dated 11/19/25- Observe and report PRN (as needed) any s/sx (signs/symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing. - Dated 10/3/25- Provide, serve diet as ordered. - Dated 10/3/25Review of Resident #93's Speech Therapy Evaluation and Plan of Treatment dated 11/11/25, indicated the following:- Reason for Therapy: Resident #93's presenting with baseline esophageal dysphagia and cognitive linguistic deficits. No s/sx (signs/symptoms) of aspiration with east to chew texture/thin liquids. Regular texture not trialed as recommendation from GI (gastroenterologist) is easy to chew texture as this time. Recommend easy to chew/thin liquids.- Malnutrition Risk Factors Identified as part of Assessment = Need for altered diet- Recommendations: What diet is recommended for the patient to swallow solids safely? = Easy to chewReview of Resident #93's Nutrition Assessment conducted by the Registered Dietitian (RD) dated 11/19/25, indicated the following:- Diet Texture: Easy to Chew- Assessment Summary: Resident #93 referred to ST (speech therapy) for swallowing as patient had recent Botox injection for achalasia and diet downgrade was recommended. Prior Medical History: Botox injection for achalasia ETC (easy to chew) diet prescribed after this tx (treatment) & provided a/o (as ordered) & tolerated well.Review of the progress notes written by the RD indicated the following:- Dated 11/10/25: Resident #93's diet was recommended to change to easy to chew r/t (related to) resident recent Botox injection for achalasia. NP (nurse practitioner) agreed.- Dated 11/11/25: Diet texture downgraded to ETC. SLP (speech language pathologist) agrees with ETC.During an interview on 12/10/25 at 9:02 A.M., Certified Nursing Assistant (CNA) #1 said Resident #93 likes to snack a lot and his/her family brings in candy and crackers often for him/her.During an interview on 12/10/25 at 9:17 A.M., CNA #2 said Resident #93 likes to snack a lot and his/her family often brings in snacks for him/her.During a follow-up interview on 12/10/25 at 9:29 A.M., CNA #1 said Resident #93's current diet is easy to chew foods which are soft foods and he/she cannot have anything that is hard or crunchy. When the surveyor asked CNA #1 if the Resident should have hard candies, CNA #1 said probably not and Resident #93 is only monitored when he/she is in the dining room.During an interview on 12/10/25 at 9:29 A.M., Unit Manager #2 said she uses her clinical judgement on what diets mean. Unit Manager #2 said easy to chew means soft, cut-up bites of food with extra sauces and gravies and that hard and crunchy foods are not allowed. Unit Manager #2 said we use the ordered diet for Resident #93. Unit Manager #2 was unaware of the bags of hard candies and crunchy foods in his/her room, she said if staff observed them then they should let nursing or herself know.During an interview on 12/10/25 at 10:09 A.M., the Speech Language Pathologist (SLP) said she assesses residents upon admission and as needed. The SLP said she follows the International Dysphagia Diet Standardization Initiative's (IDDSI) guidelines for modified diets and textured diets. Then SLP said Resident #93 has esophageal dysphagia and has a procedure every few months to help him/her swallow better and the GI doctor recommended an easy to chew diet and Resident #93 does really well on it. The SLP then said no crunchy food is allowed and the food should be able to be cut in half with a fork or spoon. The SLP then said Resident #93 should not have any hard candies or crunchy foods including cheez its.Review of the ISSDI Level 7 Regular Easy to Chew guidelines, last reviewed July 2019 (https://www.iddsi.org/images/Publications-Resources/DetailedDefnTestMethods/English/V2DetailedDefnEnglish31july2019.pdf), indicated the following:- Do not use foods that are: hard, tough, chewy.- Foods should be able to be cut or broken apart with the side of a fork or spoon.- Food Characteristics to AVOID: Chewy - lollies/candies/sweetsDuring an interview on 12/10/25 at 2:26 P.M., the Director of Nursing said Resident #93 should not have hard candies or crunchy snacks and the physician's ordered diet should be followed as he/she is at risk of choking.The surveyor attempted to reach the Registered Dietitian by the telephone number provided by the facility on 12/11/25 at 12:06 P.M. and on 12/12/25 at 1:30 P.M. but was unsuccessful with no return phone call.

Based on records reviewed and interviews for three of three sampled residents (Resident #1, #2 and #3), whose Physician's Orders included the administration of psychotropic medications, the Facility failed to ensure that they obtained signed written consent for the administration of the medications, which include providing each resident and/or their Health Care Proxy with information related to the risks and benefits of the medications, prior to administering them.Findings include:Review of the Facility Policy Massachusetts Psychotropic Medication Written Consent Policy, dated as last reviewed 09/16/2024, indicated in order to meet Section 72BB's requirements for documenting informed consent, prior to the administration of any drug included on Attachment A (Schedule of Psychotropic Drugs), the Facility will complete the Departments prescribed form (Attachment B-Informed Consent for Psychotropic Administration Form), and prior to or upon administration, include the completed form in the resident's medical record.The Policy indicated to complete the form; the drug's prescriber must discuss the following with the resident or the resident's legal representative:-the purpose for administration of the psychotropic drug listed on Attachment A;-the prescribed dosage; and-any known effect or side effect of the psychotropic medicationThe Policy indicated the discussion between the prescriber and the resident or the resident's legal representative may take place by phone and the Facility's representative must then document this discussion by completing the form including all necessary signatures within a reasonably time frame, so as not to negate informed consent.The Policy indicated written informed consent must be obtained each time a new or renewed prescription falls outside the dosage to which the resident or the resident's legal representative previously consented, or once a year, whichever is shorter.The Policy indicated written consent can be obtained in person, by fax or by means of a scanned and emailed copy of the consent form. Verbal consent by telephone, even if witnessed by a second staff member of the Facility, does not constitute written consent.1) Resident #1 was admitted to the Facility in March 2025, diagnoses included, but were not limited to, Depression, Anxiety, Post Traumatic Stress Disorder and Psychosis.Review of Resident #1's Physician's Orders, dated 03/20/25 through 05/21/25, indicated he/she had active orders for and was administered the following;- Aripiprazole (Antipsychotic) 15 milligram (mg) tablet, start date 03/20/25, give one tablet by mouth daily for Depression;- Fluoxetine (Antidepressant) 40 mg capsule, start date 03/20/25, give one capsule by mouth daily for Depression;- Hydroxyzine HCL (Anxiolytics) 25mg tablet, start date 04/08/25, take one tablet by mouth two times a day for Anxiety, and- Trazodone (Antidepressant) 50 mg tablet, take one tablet by mouth at bedtime.Review of Resident #1's Medical Record indicated Resident #1 signed written consent was obtained for the administration of Aripiprazole on 03/21/25. However, there was no documentation to support the Facility obtained signed written consent for the administration of Fluoxetine, Hydroxyzine and Trazodone (psychotropic) medications.2) Resident #2 was admitted to the Facility in August 2025, diagnoses included, but were not limited to, Schizophrenia, Bipolar, and Post Traumatic Stress Disorder.Review of Resident #2's Physician's Orders, for August 2025, indicated to administer the following;- Bupropion XL (Antidepressant) 300 milligram (mg) 24-hour tablet, start date 08/12/25, give one tablet by mouth daily for Depression;- Haloperidol (Antipsychotic) 10 mg tablet, start date 08/12/25, give one tablet by mouth at bedtime for Psychotic Disorders;- Hydroxyzine HCL (Anxiolytics) 25mg tablet, give one tablet by mouth at bedtime, and- Sertraline (Antidepressant) 100 mg tablet, start date 08/12/25, take two tablets by mouth at bedtime for Depression.Review of Resident #2's Medication Administration Record (MAR), for August 2025, indicated he/she had been administered one (1) dose of Bupropion HCL, and two (2) doses Haloperidol and Sertraline HCL.Review of Resident #2's Informed Consent for Psychotropic Administration Form, indicated that signed written consent for the administration of his/her psychotropic medications was not obtained until the day of Survey, on 08/14/25 (three (3) days after he/she had already been administrated the medications).3) Resident #3 was admitted to the Facility in August 2025, diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Chronic Respiratory Failure and Emphysema.Review of Resident #3's Physician's Orders, dated Active Orders as of 08/12/25, indicated to administer the following;- Lorazepam (Anxiolytics) 0.5 milligram (mg), start date 08/12/25, give one tablet by mouth every 8 hours as needed for Anxiety;- Olanzapine (Antipsychotic) 2.5 mg tablet, start date 08/12/25, give one tablet by mouth twice a day for Anxiety; and- Olanzapine (Antipsychotic) 2.5 mg tablet, start date 08/12/25, give one tablet by mouth every six (6) hours as needed for Anxiety.Review of Resident #3's Medication Administration Record (MAR), dated August 2025, indicated he/she had been administered three (3) doses of Lorazepam and four (4) doses of Olanzapine.However, review of Resident #3's Informed Consent for Psychotropic Administration Form, indicated that signed written consent for the administration of his/her psychotropic medications was not obtained until the day of Survey, on 08/14/25 (three (3) days after he/she had already been started on the medications).During an interview on 08/14/25 at 4:58 P.M., the Director of Nurses (DON) said there was no Informed Consent for Psychotropic Administration obtained related to Resident #1's Fluoxetine, Hydroxyzine and Trazodone, during his/her admission.The DON said Informed Consent for Psychotropic Administration for Resident #2's Bupropion XL, Haloperidol, Hydroxyzine HCL and Sertraline were not obtained upon admission or prior to administration. The DON said Informed Consent for Psychotropic Administration for Resident #3's Lorazepam and Olanzapine were not obtained upon admission or prior to administration.The DON said that it is the Facility's expectation that the Nurse admitting each resident obtain informed written consents for psychotropic medication from either the resident or the resident's responsible party, prior to administering any psychotropic medications.

Based on observations, interviews, and record review, the facility failed to provide care and treatment to prevent the development and worsening of pressure injury's (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the coccyx, hips, heels, or elbows) for six Residents (#264, #103, #97, #60, #63 and #20) out of a total sample of 30 residents. Specifically: 1. For Resident #264, the facility failed to provide care and treatment to prevent the development of pressure ulcers. Specifically, the facility failed to provide care and treatment resulting in a worsening stage 4 pressure injury to the coccyx with a major wound infection requiring antibiotics treatment, surgical debridement, hospitalization and ultimate death. 2. For Resident #103, facility failed to respond to and implement new interventions when Resident #103's wound worsened and developed signs and symptoms of infection. The facility also failed to arrange a wound clinic follow up as indicated by the Nurse Practitioner. 3a. For Resident #97, the facility failed to provide care and treatment to prevent the development of a Stage 4 pressure injury to the sacrum resulting in the development of osteomyelitis requiring antibiotics treatment, surgical debridement, and multiple hospitalization s and failed to arrange for a wound clinic follow up. 3b. For Resident #97, the facility failed to respond to and implement interventions when Resident #97 developed one Deep Tissue Injury to the left heel. 4. For Resident #60, the facility failed to implement treatments, physician orders, and care plan interventions resulting in the development of a Stage 3 pressure injury to the lower back requiring antibiotic treatment and hospitalization , and failed to respond to and implement new interventions when Resident #60 developed a Stage 2 pressure injury to the right buttock, Stage 1 pressure injury to the right lateral foot, Unstageable DTI to the right outer calf, Unstageable DTI to the right heel, and failed to arrange a wound clinic follow up as indicated by the Physician. 5. For Resident #63, the faciltiy failed to apply heel boots (boots primarily used to prevent pressure ulcers, particularly on the heels) as ordered. 6. For Resident #20, the facility failed to ensure an air mattress was set to the correct setting as ordered by the physician. Findings Include: Review of facility policy titled Skin Integrity & Pressure Ulcer/ Injury Prevention and Management, dated as revised 7/9/24 indicted the following: -Policy: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/ injury, complete wound assessment/ documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel) and WOCN (Wound, Ostomy, Continent Nurses Society) 1.A skin assessment/inspection should be performed weekly by a licensed nurse. (a) Skin observations also occur throughout points of care provided by certified nursing assistants (CNA) during activities of daily living (ADL) care. Any changes or open areas are reported to the nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed. 2.Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care. All residents upon admission are considered to be at risk for pressure injury development due to medical issues requiring nursing care related to disease process illness or need for rehabilitation. Review of facility policy titled Treatment Orders, dated as revised 4/19/22, indicated the following: -Based on the comprehensive assessment of a resident, the facility must ensure that- - A resident receives care, consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and -(ii) A resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing -Procedure: 3. The physician order is followed, as are the manufacturer's instructions for use for each product ordered. 4. Treatment order templates in [the electronic medical record] may be used. 1. Resident #264 was admitted to the facility in March 2024 with diagnoses including Parkinson's disease and dementia. Review of Resident #264's Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #264 had severely impaired cognition as indicated by staff interview on the Brief Interview for Mental Status exam (BIMS). The MDS further indicated that the Resident had one unstageable pressure ulcer and one stage 2 pressure ulcer. The MDS further said the Resident was dependent on staff for all activities of daily living. Review of Resident #264 medical records indicated the following: Review of Resident #264's Norton Plus Pressure Ulcer Scale, dated 3/22/24 indicated a score of 8 which indicated the resident was at a high risk for developing pressure ulcer. Review of the medical record indicated a care plan Focus: At risk for break in skin integrity date initiated 3/22/24. Goal: Maintain intact skin with no skin breaks through next review. Interventions: -Clean and dry skin after each incontinent episode. -Pressure reducing mattress. -Treatment as ordered Review of weekly skin integrity data collection-V1 dated 4/25/24 indicated the following: -Skin tear to bilateral upper extremities. Review of the weekly skin integrity data collection dated 4/25/24 failed to indicate that there were any skin alterations to the coccyx area. During a phone interview on 12/5/24 at 2:13 P.M., Nurse #9 said she only completed a partial skin check on 4/25/24 which included skin tears to bilateral extremities. She said that Resident #264 was being combative and sundowning. Nurse #9 further said she should have documented that a partial skin check had been completed. She also said the nursing assistants should have reported any skin changes to her during incontinence care. Nurse #9 said she was concerned with the wound care at the facility as she would at times come back after 2 days and find the same dressings she had applied to the resident's wounds. She said she brought the concerns of the nurses not completing wound treatments and just signing off on the Treatment Administration Record (TAR) to the DON, the assistant director of nursing and the two 3-11 shift supervisors. She said she also expressed the lack of competencies in wound care with the nurses at the facility especially the wound team who were giving recommendations to the physician and nurse. Review of the medical record indicates Nurse #9 neglected to complete a full skin as ordered and failed to indicate in the medical record that a full skin check had not been completed. Review of Resident #264's wound observation tool -V2 dated 4/26/24 indicated the following: Resident #264 acquired a pressure ulcer to the coccyx while at the facility, Location: Coccyx Type: Pressure Stage: Unstageable Specify: slough/eschar/necrosis 75% Overall impression: First observation, no reference Drainage amount: small Wound measurements: 5.3 cm length (L) x3.1 cm width (W) x 0.1 centimeters (cm) depth (D) Additional comments: Coccyx macerated with necrosis wound with strong odor. Infection signs: Strong odor, black, green tissue Pain: Related to wound Current treatment plan: Manuka honey (a specialized honey used in wounds due to its antibacterial properties and tissue regeneration effects) and foam dressing. Review of the wound observation tool data dated 4/26/24 neglected to indicate what the other 25% of the wound looked like. Review of physician's order dated 4/26/24 indicated the following: Wound culture and sensitivity to coccyx. Review of the electronic medical records indicated the following laboratory results for wound culture collected on 4/26/24 and reported on 4/30/24: Results as follow, Escheria coli heavy growth, skin flora isolated moderate growth and vancomycin resistant enterococcus faecalis heavy growth. Review of the medical record failed to indicate the physician was made aware of the wound culture results dated 4/30/24 resulting in continued infectious growth. Review of Resident #264 care plan date initiated 4/29/24 indicated the following focus and interventions: -The Resident has potential/actual impairment to skin integrity of the coccyx related to pressure and moisture. With the following Interventions but not limited to: -Assess location, size and treatment of skin injury. Report abnormalities failure to heal, signs and symptoms of infection, macerated to Medical Doctor. - Review of Resident #264's wound observation tool -V2 dated 5/1//24 indicated the following: Location: Coccyx Type: Pressure Stage: Unstageable Specify: Slough/Eschar Overall impression: Unchanged with 25% slough, 25% necrosis. Drainage amount: Moderate serosanguinous Wound measurements: 7.0 x 4.0 x 0.1 cm depth Additional comments: edges are macerated/peeling skin surrounding. Infection signs: no Pain: no Current treatment plan: drawtex (dressing that absorbs wound drainage) and foam dressing. Review of nurse's progress note dated 5/1/24 indicated the following: Wound culture results cannot be located. MD (medical doctor) notified; wound does not show signs of infection. MD did not want a new culture. Review of nurse's note dated 5/7/24 indicated the following: Mattress swapped out for air mattress on shift due to wound. During an interview on 11/20/24 at 10:33 A.M., the Director of Nursing (DON) said the resident with pressure ulcers will have an air mattress which is set to comfort and for nonverbal residents use the facial pain scale to determine comfort. She said if the air mattress is for intervention as a wound there should be an order. She said if the air mattress is not set properly, it would cause further skin damage/injury to the resident. Review of the medical record failed to indicate an order for the air mattress. The medical record also failed to indicate the care plan was updated with the air mattress intervention until 6/3/24. Review of Resident #264's wound observation tool - V2 dated 5/8/24 indicated the following: Location: coccyx Type: pressure Stage: unstageable Specify: slough/eschar Overall impression: Worsening 80% slough, 20% necrosis. Drainage amount: moderate serosanguinous Wound measurements: 9.0 x 5.0 x 0.1 cm depth Additional comments: edges are macerated/peeling skin surrounding with redness surrounding. Infection signs: Odor to wound. Pain: no Current treatment plan: Santyl (ointment used to remove damaged tissues from wounds) and cover with foam. Review of the nurse's note dated 5/8/24 indicated the wound was worsening and wound culture and sensitivity to be obtained. The nurse's note failed to indicate the wound culture report from 4/26/24 had been obtained and reported to the physician. Review of Physician #1's progress note dated 5/10/24 indicated the following: Patient had urine culture done with Foley change that showed Pseudomonas (a gram-negative bacteria that causes infections) of note the patient is allergic to Levaquin also his/her coccygeal wound has been getting worse with is smelly with more drainage is growing out Enterococcus and E. coli so far only once sensitivity available would also be sensitive to cefepime. [sic] Review of the medical record indicated the cefepime (antibiotic) was started on 5/10/24 for treatment of urinary tract infection due to Pseudomonas (a gram-negative bacteria that causes infections) Review of the medical records indicated orders implemented on 5/10/24 for cefepime (an antibiotic used to treat infections) intravenous 2 grams every 12 hours for wound infection and urinary tract infection for 10 days. Review of the medical record indicated that the antibiotic treatment was initiated 15 days after the initial observation of the wound with infection on 4/26/24. Review of the wound culture results date reported 5/11/24 indicated the following: -Aerobic culture wound, organism 1 heavy growth Escherichia coli. -Organism 3 heavy growth enterococcus faecalis. Review of Resident #264's wound observation tool-V2 dated 5/15/24 indicated the following: Location: Coccyx Type: pressure Stage: Unstageable Specify: slough/eschar Overall impression: unchanged 5% slough, 85% necrosis Drainage amount: Moderate purulent Wound measurements: 6.0 x 4.0 x 0.1 cm depth Additional comments: green around the edges Infection signs: odor, purulent drainage Pain: no Current treatment plan: Santyl and foam dressing. Review of the wound observation tool assessment dated [DATE] indicated the wound continued to worsen with presence of odor and purulent drainage despite being on antibiotic treatment. Record review failed to indicate the physician was notified of the wound worsening with presence of odor and purulent drainage. Review of the physician note dated 5/17/24 indicated the following: This IV (intra venous) cefepime to continue through 5/21. Reviewing labs the Enterococcus was never covered can give him/her amoxicillin for another 10 days. [sic] Review of the medical record indicated the following order dated 5/17/24: Amoxicillin (antibiotic) 500 mg give one capsule by mouth three times a day for 10 days due to enterococcus (bacteria) in the wound. Review of the medical record indicated there was a delay in treating the Enterococcus bacteria six days after receiving the wound culture results. Review of Resident #264's wound observation tool -V2 dated 5/22/24 indicated the following: Location: Coccyx Type: Pressure Stage: unstageable Specify: Slough/eschar Overall impression: unchanged 50% slough, 40% necrosis Drainage amount: Moderate purulent Wound measurements: 9.0 x 5.5 x 1.0 cm depth Tunneling/undermining: undermining from 3 o'clock to 11 o'clock Additional comments: green tissue noted throughout wound bed undermining depth noted at 3 o'clock measuring 4.5 slough and necrotic mixture that covered top of wound bed not allowing us to visualize the depths has now been debrided which allows us to see the slough on the base of the wound bed measuring larger due to debridement. Infection signs: odor to wound noted to be less strong this week, purulent drainage noted to be a smaller amount. Pain: no Current treatment plan: Santyl cover with hydrofera blue (a wound dressing used for wounds with a lot of drainage) and foam dressing. Review of Resident #264's wound observation tool-V2 dated 5/29/24 indicated the following: Location: coccyx Type: pressure Stage: unstageable Specify: slough/eschar Overall impression: improving 75% slough. Drainage amount: moderate serosanguinous, Wound measurements: 10 x 5.0 x1.4 cm depth Tunneling/undermining: undermine from 3 o'clock to 12 o'clock Additional comments: green tissue noted throughout wound bed undermining depth noted at 3 o'clock measuring 4.5 cm slough mixture that covered top of wound bed not allowing us to visualize the depths has now been debrided which allows us to see the slough on the base of the wound bed, macerated at 4-6 o'clock. Infection signs: no Pain: no Current treatment. Melgisorb (a brand of wound dressing used for wounds with moderate to heavy drainage) cover with foam. Review of the nurse's progress note dated 6/2/24 indicated the wound had odor, and physician #1 ordered Flagyl antibiotic. Review of medical records indicated orders implemented on 6/2/24 for flagyl oral capsule (flagyl oral capsule can be applied topically to decrease wound odor), apply to coccyx wound topically two times a day for 7 days. There was no dosage for the flagyl antibiotic order. Review of the Medication Administration Record (MAR) for June 2024 indicated the Flagyl antibiotic was administered six times, 6/2/24 through 6/5/24. Review of the MAR for June 2024 indicated the facility neglected to implement flagyl antibiotic order as ordered for 7 days, and the order was incomplete without a dosage. Review of the medical record TAR dated 6/2/24 through 6/5/24 failed to indicate that the wound dressing changes were done twice daily to the coccyx hence unable to determine how flagyl antibiotic was topically applied to the wound. Review of the medical record indicated the following physician note dated 6/3/24 indicated the following The patient being seen and follow-up for wound care. Concerned about the smell of his/her decubitus ulcer and was put on topical Flagyl over the weekend. The patient recently completed IV (intra venous) cefepime (antibiotic) there is question that his/her wound is worsening. Resident is on oral flagyl (antibiotic) based on prior cultures resident would generally be a candidate for cipro (antibiotic) but they are allergic. Would need to reinitiate cefepime if needed. At this point wound appears larger but not worsening with infection continue to follow closely. [sic] Review of medical record failed to indicate the physician was notified that the Resident only received flagyl for three days and the antibiotic had been discontinued on 6/5/24 and not 6/9/24 as the ordered. Review of Resident #264's wound observation tool-V2 dated 6/3/24 indicated the following: Location: left heel and right heel Type: pressure Stage: NA Specify:NA Overall impression: first observation, no reference Drainage amount: none Wound measurements: 5.0 x 3.5 x 0 cm Tunneling/undermining: NA Additional comments: NA Infection signs: no Pain: no Current treatment. Skin prep. Review of the medical record indicated the Resident continued to have skin breakdown as indicated on the wound observation tool dated 6/3/24 for both left and right heels. Review of the medical record indicated a care plan intervention of air mattress dated 6/3/24. Review of Resident #264's wound observation tool-V2 dated 6/5/24 indicated the following: Location: coccyx Type: pressure Stage: unstageable Specify: slough/eschar Overall impression: worsening, 95% slough. Drainage amount: moderate serosanguineous Wound measurements: 13 x 7.5 x 2.2 cm depth Tunneling/undermining undermines from 3 o'clock to 11 o'clock Additional comments: undermining depth noted at 3 o'clock measuring 4.5 macerated edge at 4-6 o'clock. Finished course of antibiotic 5/28. Infection signs: no Pain: no Current treatment. Aquacel ag (a wound dressing that combines hydrofiber with ionic silver to help prevent infection and promote healing) and cover with foam. Review of wound observation tool-V2 dated 6/5/24 indicated the following: Location: left heel Type: pressure Stage: 2 Specify: na Overall impression: unchanged, with clear fluid filled blister. Drainage amount: none Wound measurements: 6.0 x 4.5 x 0 cm Tunneling/undermining: no Additional comments: redness surrounding blister. Infection signs: no Pain: no Current treatment. Skin prep. Review of Resident #264's wound observation tool-V2 dated 6/5/24 indicated the following: Location: right buttock Type: pressure Stage: unstageable Specify: Deep tissue pressure injury Overall impression: first observation, no reference Drainage amount: none Wound measurements: 3.2 x 1.2 cm Tunneling/undermining: na Additional comments: deep purple Infection signs: no Pain: no Current treatment. Skin prep Review of the wound observation tool indicates that Resident #264 continued to develop new pressure ulcers. Review of Resident #264's wound observation tool-V2 dated 6/12/24 indicated the following: Location: coccyx Type: pressure Stage: unstageable Specify: slough/eschar Overall impression: unchanged Drainage amount: moderate serosanguinous, 95% slough. Wound measurements: 11.8 x 7.1 x 1.0 cm Tunneling/undermining: undermines from 3 o'clock to 11 o'clock Additional comments: undermining depth noted at 3 o'clock measuring 2.5 cm macerated edge at 4-6 o'clock finished course of antibiotic 5/28. Infection signs: no Pain: no Current treatment. Aquacel (a wound dressing that combines hydrofiber with ionic silver to help prevent infection and promote healing) cover with foam dressing. Review of Resident #264's wound observation tool-V2 dated 6/12/24 indicated the following: Location: right buttock Type: pressure Stage: unstageable Specify: Deep tissue pressure injury Overall impression: improving. Drainage amount: none Wound measurements: 0.6 x 0.6 cm Tunneling/undermining: na Additional comments: deep purple Infection signs: no Pain: no Current treatment. Skin prep Review of Resident #264's wound observation tool-V2 dated 6/12/24 indicated the following: Location: right heel Type: pressure Stage: unstageable Specify: Deep tissue injury Overall impression: unchanged Drainage amount: none Wound measurements: 5.7 x 4.4 cm Tunneling/undermining: NA Additional comments: blister that absorbed, deep purple, hard tissue, stable not open. Infection signs: no Pain: no Current treatment. Skin prep Review of Resident #264's wound observation tool-V2 dated 6/12/24 indicated the following: Location: left heel Type: pressure Stage: 2 Specify: NA Overall impression: unchanged Drainage amount: none Wound measurements: 5.0 x 5.2 cm Tunneling/undermining: NA Additional comments: clear fluid filled blister that are reabsorbed Infection signs: no Pain: no Current treatment. Skin prep. Review of Resident #264's wound observation tool-V2 dated 6/19/24 indicated the following: Location: coccyx Type: unstageable Stage: slough/ eschar Specify: NA Overall impression: unchanged, 30% slough, 30% necrosis. Drainage amount: moderate serosanguinous Wound measurements: 13 x 8.0 x 1.3 cm Tunneling/undermining: undermines 3 o'clock to 11 o'clock Additional comments: undermining depth noted at 3 o'clock measuring 2.5cm macerated edge at 3-7 o'clock, finished course of antibiotic 5/28 coccyx wound that extends to right and left buttock. 3-9 o'clock necrotic. 9-3 o'clock mixture of granulation and slough. Macerated granulated tissue extending to left and right buttock Pressure ulcer scale for healing (PUSH) score 16 (0 indicates healed ulcer) Infection signs: no Pain: no Current treatment. Aquacel then foam dressing twice a day. Review of Resident #264's wound observation tool-V2 dated 6/19/24 indicated the following: Location: right buttock Type: pressure Stage: unstageable Specify: deep tissue injury Overall impression: unchanged 50% slough in center Drainage amount: none Wound measurements: 1.0 x 0.6 x 0.1cm Tunneling/undermining: NA Additional comments: slough 50% in center, blanchable redness surrounding Pressure ulcer scale for healing (PUSH) score 5 (0 indicates healed ulcer) Infection signs: no Pain: no Current treatment. Manuka honey and foam dressing daily Review of Resident #264's wound observation tool-V2 dated 6/19/24 indicated the following: Location: right heel Type: pressure Stage: unstageable Specify: Deep tissue injury Overall impression: unchanged, 100% necrosis Drainage amount: none Wound measurements: 5.0 cm x 5.0 cm Tunneling/undermining: NA Additional comments: blister that reabsorbed with a hard and black with dark red edges, stable push score 14 Infection signs: no Pain: no Current treatment. Skin prep Review of Resident #264's wound observation tool-V2 dated 6/19/24 indicated the following: Location: left heel Type: pressure Stage: 2 Specify: NA Overall impression: unchanged, clear fluid filled blister that absorbed. Drainage amount: none Wound measurements: 5.0 x 5.0 cm Tunneling/undermining: NA Additional comments: clear fluid filled blister that reabsorbed with red edge from 9-3 push score 11 Infection signs: no Pain: no Current treatment. Skin prep Review of Resident #264's wound observation tool-V2 dated 6/26/24 indicated the following: Location: coccyx Type: pressure Stage: unstageable Specify: slough/eschar Overall impression: worsening 35% slough, 35% necrosis Drainage amount: large serosanguinous Wound measurements: 14.5 x 9.0 x 2.0cm Tunneling/undermining: undermines from 3'oclock to 11 o'clock Additional comments: undermining depth noted 3 o'clock measuring 2.5 macerated edge 3-7 o'clock finished course of antibiotic 5/28, coccyx wound that extends to right and left buttock. 3-9 o'clock necrotic and slough. 9-3 o'clock mixture of granulation, necrotic and slough. Macerated granulated tissue extending to left and right buttock. Necrotic on right side push score 17. Infection signs: Yes, odor wound cultured. Pain: no Current treatment. Santyl and foam dressing twice a day. Record review indicates despite multiple treatment with antibiotics the wounds continued to increase in size and with odor. Review of nurse's note dated 6/26/24 indicated the physician was made aware of the coccyx wound worsening. Review of medical records indicated orders implemented on 6/26/24 for amoxicillin-potassium clavulanate ( an antibiotic used for treating infections) tablet 875-125 milligram (mg), give one tablet by mouth every 12 hours for wound infection for 10 days. Review of the wound culture results date reported 6/28/24 indicated the following: -Heavy growth Escherichia coli vancomycin resistant enterococcus -Moderate growth staphylococcus aureus -Moderate growth enterococcus faecalis. Review of medical records indicated orders implemented on 6/28/24 for linezolid (an antibiotic used for treating skin infections) 600 mg give one tablet by mouth every 12 hours for infection for 10 days. Review of Resident #264's wound observation tool-V2 dated 6/26/24 indicated the following: Location: right buttock Type: pressure Stage: unstageable Specify: slough/eschar Overall impression: worsening 75% slough. Drainage amount: scant serosanguinous Wound measurements: 0.7 x 0.7 x 0.1cm Tunneling/undermining: NA Additional comments: slough 75% in center blanchable redness surrounding push score 6 Infection signs: no Pain: no Current treatment. Santyl and foam dressing twice daily. Review of wound observation tool-V2 dated 6/26/24 indicated the following: Location: left heel Type: pressure Stage: 2 Specify: Na Overall impression: unchanged Drainage amount: none Wound measurements: 5.4 x 5.0 cm Tunneling/undermining: na Additional comments: clear fluid filled blister that reabsorbed with red edge from 9-12 hard skin between 12-3. Push score 11 Infection signs: no Pain: no Current treatment: Skin prep. Review of wound observation tool-V2 dated 6/26/24 indicated the following: Location: right heel Type: pressure Stage: unstageable Specify: deep tissue injury Overall impression: unchanged 100% necrotic Drainage amount: none Wound measurements: 5.8 x 4.4 cm Tunneling/undermining: NA Additional comments: blister that reabsorbed hard and black with light purple edges, stable push score 14. Infection signs: no Pain: no Current treatment: skin prep. Review of wound observation tool-V2 dated 7/3/24 indicated the following: Location: coccyx Type: pressure Stage: unstageable Specify: slough/eschar Overall impression: worsening 90% necrosis. Drainage amount: large serosanguinous Wound measurements: 15 x 10 x 2.0 cm depth Tunneling/undermining: undermining 3-11 o'clock Additional comments: undermining depth noted at 3 o'clock measuring 2.5cm macerated edge at 3-7 o'clock on antibiotic, coccyx wound extends to right and left buttock. 3-9 o'clock necrotic area. 9-3 o'clock granulation. Macerated granulated tissue extending to left and right buttock push score 17. Infection signs: yes Pain: no Current treatment. Santyl and foam dressing. Review of the medical record wound observation tool dated 7/3/24 indicates the coccyx wound was worsening with 90% necrosis (dead tissue) and increased in size despite being treated with santyl (an ointment used to lift off dead tissue). Review of wound observation tool-V2 dated 7/3/24 indicated the following: Location: right buttock Type: pressure Stage: unstageable Specify: slough/eschar Overall impression: unchanged 50% slough, 50% necrosis. Drainage amount: small serosanguinous Wound measurements: 0.9 x 0.8 x 0.1 cm Tunneling/undermining: NA Additional comments: slough 50% on left side blanchable redness surrounding push score 7 Infection signs: no Pain: no Current treatment: Santyl with foam dressing. Review of wound observation tool-V2 dated 7/3/24 indicated the following: Location: right heel Type: pressure Stage: unstageable Specify: deep tissue injury Overall impression: improving, 100% necrosis in wound bed Drainage amount: none Wound measurements: 4.7 x 4.4 cm Tunneling/undermining: NA Additional comments: blister that reabsorbed hard and black stable push score 13 Infection signs: no Pain: no Current treatment: skin prep Review of wound observation tool-V2 dated 7/3/24 indicated the following: Location: left heel Type: pressure Stage: 2 Specify: NA Overall impression: unchanged Drainage amount: none Wound measurements: 5.0 x 4.8cm Tunneling/undermining: NA Additional comments: clear fluid filled blister that reabsorbed with red edge from 11-5 o'clock, hard from 6 o'clock to 9 o'clock with slight discoloration push score 11 Infection signs: no Pain: no Current treatment: skin prep. Review of wound observation tool-V2 dated 7/3/24 indicated the following: Location: Left lateral foot Type: pressure Stage: unstageable Specify: deep tissue injury Overall impression: first observation, no reference Drainage amount: none Wound measurements: 0.5 x 0.5 cm Tunneling/undermining: NA Additional comments: deep purple with blanchable redness surrounding push score 5 Infection signs: no Pain: no Current treatment: skin prep. Review of physician #2's (Physician #2 was covering for Physician #1 who was on vacation) progress note dated 7/3/24 indicated the following: The patient is seen in follow-up as requested by nursing. The patient has been noted with foul smelling discharge from a large chronic sacral pressure wound. On examination the wound is with large amount of foul-smelling discharge, necrotic. I discussed with patient's spouse, nursing manager and director of nursing. This morning the resident is unlikely to heal without extensive debridement and antibiotic therapy. Superficial culture should not be relied on to guide antibiotic therapy as the frequently represent colonization. Spouse agrees with my assessment and wants patient to be transferred to the hospital for continuation of

Based on record review, observations and interviews, the facility failed to protect four Residents (#264, #97, #60 and #103), from neglect, out of a total sample of 30 residents. Specifically: 1. For Resident #264, the facility neglected to complete a full weekly skin check as ordered. Failed to acknowledge and respond to initial wound cultures completed on 4/26/24. Failed to notify Medical Doctor of the wound culture results 4/30/24. Failed to initiate Flagyl (antibiotic) treatment as ordered and without dosage, resulting in a worsening stage 4 pressure injury to the coccyx with a major wound infection requiring antibiotics treatment, surgical debridement, hospitalization and resulting in the resident's ultimate death. 2a. For Resident #97, the facility failed to provide care and treatment to prevent the development of pressure ulcers. Specifically, the facility failed to provide care and treatment resulting in the development of a stage 4 pressure injury to the sacrum resulting in the development of osteomyelitis requiring antibiotics treatment, surgical debridement, and multiple hospitalization s, and failed to arrange a wound clinic follow up. 2b. For Resident #97, the facility failed to respond to and implement interventions when Resident #97 developed one deep tissue pressure injury to the left heel. 3. For Resident #60, the facility failed to implement treatments, physician orders, and care plan interventions resulting in the development of a Stage 3 pressure injury to the lower back requiring antibiotic treatment and hospitalization , and failed to respond to and implement new interventions when Resident #60 developed a Stage 2 pressure injury to the right buttock, Stage 1 pressure injury to the right lateral foot, Unstageable DTI to the right outer calf, Unstageable DTI to the right heel, and failed to arrange a wound clinic follow up as indicated by the Physician. 4. For Resident #103, the facility failed to respond to and implement new interventions when a sacral wound worsened and developed signs and symptoms of infection resulting in hospitalization from [DATE] through 11/6/24 for worsening wounds, treatment with intravenous (IV) antibiotics for osteomyelitis (a bone infection), and the need for ileostomy formation for fecal diversion away from the wound. The facility also failed to arrange a wound clinic follow up as indicated by the Nurse Practitioner. Findings include: Neglect, as defined at S483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility policy titled 'Abuse-prevention' last reviewed July 2023, indicated the following but not limited to: -Assure that residents are free from neglect by having the structures and process to provide needed care and services to all residents, which includes, but not limited to, the provision of a facility assessment to determine what resources are necessary to care for its residents competently. 1. Resident #264 was admitted to the facility in March 2024 with diagnoses including Parkinson's disease and dementia. Review of Resident #264's Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #264 had severely impaired cognition as indicated by staff interview on the Brief Interview for Mental Status exam (BIMS). The MDS further indicated that the Resident had one unstageable pressure ulcer and one stage 2 pressure ulcer. The MDS further said the Resident was dependent on staff for all activities of daily living. Review of Resident #264 medical records indicated the following: Review of Resident #264's Norton Plus Pressure Ulcer Scale, dated 3/22/24 indicated a score of 8 which indicated the resident was at a high risk for developing pressure ulcer. Review of the medical record indicated a care plan Focus: At risk for break in skin integrity date initiated 3/22/24. Goal: Maintain intact skin with no skin breaks through next review. Interventions: -Clean and dry skin after each incontinent episode. -Pressure reducing mattress. -Treatment as ordered Review of weekly skin integrity data collection-V1 dated 4/25/24 indicated the following: -Skin tear to bilateral upper extremities. Review of Resident #264's medical record indicated Nurse #9 neglected to complete a full skin check as ordered and failed to indicate in the medical record that a full skin check had not been completed. During a phone interview on 12/5/24 at 2:13 P.M., Nurse #9 said she only completed a partial skin check on 4/25/24 which included skin tears to bilateral extremities. Nurse #9 said she did not check Resident #264's coccyx. She said that Resident #264 was being combative and sundowning. Nurse #9 further said she should have documented that a partial skin check had been completed. Nurse #9 said she was concerned with the wound care at the facility as she would at times come back after two days and find the same dressings she had applied to the resident's wounds. She said she brought the concerns of the nurses not completing wound treatments and just signing off on the Treatment Administration Record (TAR) to the Director of Nursing (DON), the Assistant Director of Nursing and the two 3-11 shift supervisors. She said she also expressed the lack of competencies in wound care with the nurses at the facility especially the in house wound team who were giving recommendations to the physician and nurse. Review of Resident #264's wound observation tool -V2 dated 4/26/24 indicated the following: Resident #264 acquired a pressure ulcer to the coccyx while at the facility, Location: Coccyx Type: Pressure Stage: Unstageable Specify: slough/eschar/necrosis 75% Overall impression: First observation, no reference Drainage amount: small Wound measurements: 5.3 cm length (L) x3.1 cm width (W) x 0.1 centimeters (cm) depth (D) Additional comments: Coccyx macerated with necrosis wound with strong odor. Infection signs: Strong odor, black, green tissue Pain: Related to wound Current treatment plan: Manuka honey (a specialized honey used in wounds due to its antibacterial properties and tissue regeneration effects) and foam dressing. Review of the wound observation tool data dated 4/26/24 failed to indicate a description of the other 25% of the wound. Review of physician's order dated 4/26/24 indicated the following: Wound culture and sensitivity to coccyx. Review of the electronic medical records indicated the following laboratory results for wound culture collected on 4/26/24 and reported on 4/30/24 to the facility: Results as follow, Escheria coli heavy growth, skin flora isolated moderate growth and vancomycin resistant enterococcus faecalis heavy growth. Review of the medical record failed to indicate the physician was made aware of the wound culture results dated 4/30/24. Review of Resident #264 care plan date initiated 4/29/24 indicated the following focus and interventions: -The Resident has potential/actual impairment to skin integrity of the coccyx related to pressure and moisture. With the following Interventions but not limited to: -Assess location, size and treatment of skin injury. Report abnormalities failure to heal, signs and symptoms of infection, macerated to Medical Doctor. - Review of Resident #264's wound observation tool -V2 dated 5/1//24 indicated the following: Location: Coccyx Type: Pressure Stage: Unstageable Specify: Slough/Eschar Overall impression: Unchanged with 25% slough, 25% necrosis. Drainage amount: Moderate serosanguinous Wound measurements: 7.0 x 4.0 x 0.1 cm depth Additional comments: edges are macerated/peeling skin surrounding. Infection signs: no Pain: no Current treatment plan: drawtex (dressing that absorbs wound drainage) and foam dressing. Review of nurse's progress note dated 5/1/24 indicated the following: Wound culture results cannot be located. MD (medical doctor) notified; wound does not show signs of infection. MD did not want a new culture. Review of nurse's note dated 5/7/24 indicated the following: Mattress swapped out for air mattress on shift due to wound. Review of the medical record indicated Resident #264 air mattress was not applied until 11 days after the coccyx wound was first identified (4/26/24). Review of Resident #264's wound observation tool - V2 dated 5/8/24 indicated the following: Location: coccyx Type: pressure Stage: unstageable Specify: slough/eschar Overall impression: Worsening 80% slough, 20% necrosis. Drainage amount: moderate serosanguinous Wound measurements: 9.0 x 5.0 x 0.1 cm depth Additional comments: edges are macerated/peeling skin surrounding with redness surrounding. Infection signs: Odor to wound. Pain: no Current treatment plan: Santyl (ointment used to remove damaged tissues from wounds) and cover with foam. Review of the nurse's note dated 5/8/24 indicated the wound was worsening and wound culture and sensitivity to be obtained. Review of Physician #1's progress note dated 5/10/24 indicated the following: Patient had urine culture done with Foley change that showed Pseudomonas (a gram-negative bacteria that causes infections) of note the patient is allergic to Levaquin also his/her coccygeal wound has been getting worse with is smelly with more drainage is growing out Enterococcus and E. coli so far only once sensitivity available would also be sensitive to cefepime. [sic] Review of the medical record indicated orders implemented on 5/10/24 for cefepime (an antibiotic used to treat infections) intravenous 2 grams every 12 hours for wound infection and urinary tract infection for 10 days. Review of the medical record indicated that the antibiotic treatment was initiated 15 days after the initial observation of the wound with infection on 4/26/24. Review of Resident #264's wound observation tool-V2 dated 5/15/24 indicated the following: Location: Coccyx Type: pressure Stage: Unstageable Specify: slough/eschar Overall impression: unchanged 5% slough, 85% necrosis Drainage amount: Moderate purulent Wound measurements: 6.0 x 4.0 x 0.1 cm depth Additional comments: green around the edges Infection signs: odor, purulent drainage Pain: no Current treatment plan: Santyl and foam dressing. Review of the wound observation tool assessment dated [DATE] indicated the wound continued to worsen with presence of odor and purulent drainage despite being on antibiotic treatment. Record review failed to indicate the physician was notified of the wound worsening with presence of odor and purulent drainage. Review of the physician note dated 5/17/24 indicated the following: This IV (intravenous) cefepime to continue through 5/21. Reviewing labs the Enterococcus was never covered can give him/her amoxicillin for another 10 days. [sic] Review of the medical record indicated the following order dated 5/17/24: Amoxicillin (antibiotic) 500 mg give one capsule by mouth three times a day for 10 days due to enterococcus (bacteria) in the wound. Review of the medical record indicated there was a delay in treating the Enterococcus bacteria for six days after the facility received the wound culture results. Review of Resident #264's wound observation tool-V2 dated 5/29/24 indicated the following: Location: coccyx Type: pressure Stage: unstageable Specify: slough/eschar Overall impression: improving 75% slough. Drainage amount: moderate serosanguinous, Wound measurements: 10 x 5.0 x1.4 cm depth Tunneling/undermining: undermine from 3 o'clock to 12 o'clock Additional comments: green tissue noted throughout wound bed undermining depth noted at 3 o'clock measuring 4.5 cm slough mixture that covered top of wound bed not allowing us to visualize the depths has now been debrided which allows us to see the slough on the base of the wound bed, macerated at 4-6 o'clock. Infection signs: no Pain: no Current treatment. Melgisorb (a brand of wound dressing used for wounds with moderate to heavy drainage) cover with foam. Review of the nurse's progress note dated 6/2/24 indicated the wound had odor, and physician #1 ordered Flagyl antibiotic. Review of medical records indicated orders implemented on 6/2/24 for flagyl oral capsule (flagyl oral capsule can be applied topically to decrease wound odor), apply to coccyx wound topically two times a day for 7 days. Review of the MAR (Medication Administration Record) for June 2024 indicated the facility neglected to implement flagyl antibiotic, as ordered, for 7 days, and the order was incomplete without a dosage. Review of the medical record TAR (Treatment Administration Record) dated 6/2/24 through 6/5/24 failed to indicate that the wound dressing changes were done as ordered, and therefore there was no evidence that the flagyl antibiotic had been applied as ordered. Review of the medical record indicated the following physician note dated 6/3/24, The patient being seen and follow-up for wound care. Concerned about the smell of his/her decubitus ulcer and was put on topical Flagyl over the weekend. The patient recently completed IV (intra venous) cefepime (antibiotic) there is question that his/her wound is worsening. Resident is on oral flagyl (antibiotic) based on prior cultures resident would generally be a candidate for cipro (antibiotic) but they are allergic. Would need to reinitiate cefepime if needed. At this point wound appears larger but not worsening with infection continue to follow closely. [sic] Review of medical record failed to indicate the physician was notified that the Resident only received flagyl for three days and not for seven days as ordered. Review of wound observation tool-V2 dated 7/3/24 indicated the following: Location: coccyx Type: pressure Stage: unstageable Specify: slough/eschar Overall impression: worsening 90% necrosis. Drainage amount: large serosanguinous Wound measurements: 15 x 10 x 2.0 cm depth Tunneling/undermining: undermining 3-11 o'clock Additional comments: undermining depth noted at 3 o'clock measuring 2.5 cm macerated edge at 3-7 o'clock on antibiotic, coccyx wound extends to right and left buttock. 3-9 o'clock necrotic area. 9-3 o'clock granulation. Macerated granulated tissue extending to left and right buttock push score 17. Infection signs: yes Pain: no Current treatment. Santyl and foam dressing. Review of physician #2's (Physician #2 was covering for Physician #1) progress note dated 7/3/24 indicated the following: The patient is seen in follow-up as requested by nursing. The patient has been noted with foul smelling discharge from a large chronic sacral pressure wound. On examination the wound is with large amount of foul-smelling discharge, necrotic. I discussed with patient's spouse, nursing manager and director of nursing. This morning the resident is unlikely to heal without extensive debridement and antibiotic therapy. Superficial culture should not be relied on to guide antibiotic therapy as the frequently represent colonization. Spouse agrees with my assessment and wants patient to be transferred to the hospital for continuation of care. Review of the hospital medical record dated 7/3/24 indicated the following: Resident presents from nursing home for evaluation of worsening pressure ulcers of heels and coccyx. Reportedly today there was a different doctor on the wound team who insisted the patient come to the emergency department for further evaluation of right heel and coccyx pressure ulcers. During an interview on 11/20/24 at 10:45 A.M., Resident #264's Spouse said the nursing care was horrible. The Spouse further said that during a family team meeting on 6/25/24 , the family requested for Resident #264 to be sent to the hospital for further wound treatment and they were told by the facility that the facility had seen worse wounds than Resident #264 had. The Spouse further said that when Resident #264 was sent to the hospital in July, the Resident was never cleaned, when they got to the hospital, the nurse at the hospital uncovered the Resident's wound dressing, which had feces in them. The Spouse said that Resident #264's wound needed debridement and ultimately the resident passed away from the wound complications. During an interview on 11/20/24 at 10:57 A.M., Resident #264's Representative #2 said during a team family meeting with the Social Worker, Physical Therapist, and Director of Nursing in the room, had asked at what point do they refer Resident to outside care, they said that they had seen worse cases. Resident Representative #2 said when the covering Doctor came to the facility, he sent the Resident to the hospital for severe infection in the wound that required debridement. Representative #2 said the hospital said the Resident incurred fractures to the coccyx bones due to the extent of the infection that ultimately resulted in Resident #264's death. During an interview on 11/21/24 at 9:13 A.M., Unit Manager #1 and Unit Manager #2 said that they are the wound nurses in the facility and are both Licensed Practical Nurses. They said they took an online course through the facility and an online test which took approximately 8 hours total. They said once the online course was completed, they were considered effective on their own for wound care in the facility. They said no one comes in or completes in-person competencies for wound care with them. Unit Manager #1 and Unit Manager #2 said that at this time they are the only ones rounding as the wound team for all the wounds in the facility. Unit Manager #1 and Unit Manager #2 said that they observe the wounds weekly and make recommendations for treatments to the Physician or Nurse Practitioner. Unit Manager #1 and Unit Manager #2 said they make their recommendations based of their assessment of the wound. If the current treatment is working, then they will continue with it but if it isn't working, the wound is stagnant or not changing or improving, then they will change the treatment. They said if they change a treatment recommendation, they do not specifically document why they are changing the treatment recommendations. Unit Manager #1 and Unit Manager #2 said that a worsening wound would be one with more drainage, redness, signs of infection, and would expect a dressing recommendation to change based on an assessment of a worsening wound as mentioned. Unit Manager #2 said up until recently she did not know how to stage wounds. When asked about referring residents to a wound clinic, they said they do not often refer residents to the wound clinic and manage them in house. They also said that in general they don't see wounds worsening in the facility or wound infections occurring. They said a weekly skin check consisted of assessing a resident's skin from head to toe and documenting any concerns, they said for Resident #264, the skin check that was completed on 4/25/24 was inaccurate as an unstageable pressure ulcer was identified the following day. Unit Manager #2 said Resident #264 was not a concern on her unit with any kind of increased behaviors, Unit Manager #2 said that Resident #264's wounds got infected when Physician #1 was on vacation and that a covering physician sent the Resident to the hospital and that the Resident never returned to the facility. During an interview on 11/20/24 at 10:33 A.M., the Director of Nursing (DON) said the facility does not have a wound doctor, they have a wound team that consist of the Unit Managers from unit A and B, she said the Unit Managers do weekly wound rounds and they give wound recommendations based on their knowledge and expertise. She said transportation with stretcher has been an issue hence unable to send residents to the wound clinic. The DON said she was not part of the wound team; the wound team would go to her if they had a question, or they reach out to corporate. The DON said she was not sure how often the MD/NP Medical Director/Nurse Practitioner looked at the wounds. The DON said that during care the certified nursing assistants would report any skin issues to the nurses and that Resident #264's skin issue should have been identified sooner. The DON said if a wound was getting worse it would have the symptoms of redness, increased slough or drainage and foul odor. For preventative measures, the DON said the residents with pressure ulcers will have an air mattress which is set to comfort. She said if the air mattress is not set properly, it would cause further skin damage/injury to the resident. For Resident #264, the DON said she does not recall the family asking for the Resident to be sent out to the hospital. The DON said that Resident #264 wounds got worse when the Medical Director was on vacation and the covering physician sent the resident to the hospital as the wound required sharps debridement. During an interview on 11/26/24 at 10:11 A.M., for Resident #264 the DON said neglect is defined as not providing care that a resident required. When the surveyor asked the DON if not providing care that a resident required causing physical harm if that was considered neglect she said yes. During an interview on 11/21/24 at 1:34 P.M., CNA #2 said during care they watch for bruises, skin tears, pressure areas on bony areas and notify the nurse, if the resident refuses care they document. During an interview on 11/22/24 at 6:45 A.M., CNA #1 who was the assigned CNA for Resident #264 the night prior to the identification of the coccyx wound on 4/26/24 said if there were any skin concerns noted on the Resident she would have reported to the nurse. During an interview on 11/22/24 at 8:43 A.M., the Regional Director of Clinical Services said that there is not a wound physician who currently rounds in the facility. During an interview on 11/22/24 at 9:38 A.M., Physician #1 said that his expectation is that nurses who are competent in wound care perform wound rounds and make recommendations to him about what residents' needs are and what residents he needs to visualize the wounds of himself. He said he is not a wound expert, and he relies on the wound team for wound treatment recommendations and implementation of new orders. For Resident #264, Physician #1 said he treated the Resident with multiple courses of antibiotics. He said if the wound got bigger with slough and systemic fever, the resident would have been sent to the hospital for debridement. He said Resident #264 should have been sent to the hospital sooner. During an interview on 11/25/24 at 12:25 P.M., Physician #2 said he is an infectious disease specialist and he saw Resident #264 on the day he sent the resident to the hospital. He described seeing the wound as a large sacral ulcer with gangrene (dead tissue), necrotic tissue (dead tissue due to lack of blood flow). He said the presentation of gangrene and necrosis tends to be infection and the wound needed extensive debridement. Review of the hospital discharge record dated 7/3/24 indicated the following: Patient has ongoing chronic pressure ulcers in the coccyx and heel. Apparently, patient had a new dressing placed on the day of presentation, when asked further wound team in the facility, the wound appeared significantly worsened after which the patient was sent to the emergency department for further evaluation. The patient had a large wound in the coccyx with soiled dressing and a deep tissue injury to right heel. A cat scan (CT) of pelvis indicated the following: Large broad decubitus ulceration and with extension to the coccygeal bone and underlying bony changes of Cx2 and Cx3 coccygeal segments most consistent with osteomyelitis. Deep extension of soft tissue stranding, and gas as described. Patient was discharge to hospice care. [sic] Review of the hospice care medical records dated 7/28/24 indicated the following: Medical Examiner Case Assessment: Reason for assigned case: Other. Describe the rational for designation of case: Neglect. Will the injury be included in the death certificate: Yes, as primary cause of death. What will be listed as primary cause of death: Osteomyelitis. Injury: Unstageable wound to sacrum. 48671 2a. Resident #97 was admitted to the facility in October 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, dysphagia, cognitive communication deficit, and anxiety. Review of Resident #97's Minimum Data Set (MDS) assessment, dated 9/4/24, indicated that Resident #97 had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15, and is dependent on staff for all activities of daily living tasks. The MDS indicated Resident #97 was at risk for developing pressure injuries and indicated the use of a pressure reducing device for chair and pressure reducing device for bed. Review of Resident #97's Braden Scale for Predicting Pressure Injury Risk, dated 11/5/24, indicated a score of 11 indicating the Resident is at high risk for developing pressure injuries. Review of the initial admission paperwork from October 2023 indicated one R (right) medial foot blister surrounding skin red and blanching. Resident #97 was admitted to the facility in October 2023 and developed an unstageable right buttock wound on 11/22/23 and a Left Heel DTI on 11/28/23 with recommendations for heel booties. Review of the medical record failed to indicate physician treatment orders or care plan interventions were implemented. Review of Resident #97's Wound Observation Tool, dated 11/22/23, indicated: Right buttock Worsening, granulation tissue, slough tissue, necrotic Tissue present (eschar) present (brown, black, leather). Length 1.5cm. x Width 1.0cm. Depth 0.1cm. Encourage offloading. Treatment orders: Wound care to right buttocks. Clean with ns (NS), pat dry. Apply manuka honey to wound bed and cover with allevyn or equivalent foam dressing. Every day shift and as needed. Dated 11/22/23. Review of the physician progress note dated 11/24/23 indicated no skin rashes or pressure ulcers. Review of the November 2023 Treatment Administration Record (TAR) indicated that the physician order for manuka honey treatment to the right buttock was not documented until 11/24/23 and failed to indicate the treatment order was completed as ordered on 11/26/23, the TAR was left blank and contained no documentation. Review of the physician progress note dated 12/6/23 indicated, coccygeal ulcer with mild redness around it. Possible wound infection based on patient's decreased energy level and foul odor. During an interview on 11/22/24 at 9:36 A.M., Physician #1 (Also the facility Medical Director) said the right buttock wound is referenced as the coccygeal ulcer in the visit note. Review of the medical record indicated that on 12/6/23 the wound to the right buttock deteriorated and required antibiotic therapy and a physician order for Keflex (an antibiotic) 500 mg. (milligrams), 3 times per day for 7 days was ordered on 12/6/23. Further review of Resident #97's medical record indicated the following physician orders: -Wound care to right buttocks. Clean with ns (NS), pat dry. Apply Santyl (collagenase ointment for wounds) to wound bed and cover with allevyn (highly absorbent foam dressing) or equivalent foam dressing. Every day shift every other day and PRN (as needed). Dated 12/8/23. Review of the December 2023 Treatment Administration Record (TAR) indicated that the physician order for Santyl treatment to the right buttock was not documented as completed on 12/8, 12/11 or 12/13, the TAR was left blank and contained no documentation. Review of the Nurse Practitioner Progress note dated 12/12/23 indicated Resident #97's wound is not improving per wound team. Coccyx decubiti. No improvement with recent Keflex. Last dose will be 12/13/2023 continue wound team consult and daily dressings with Santyl for debridement. Review of the weekly wound observation tool dated 12/13/23, indicated the unstageable right buttock pressure wound was showing signs of infection with purulent drainage and order. Resident #97 was documented to have pain and was yelling out. Length 4.5 cm. x Width 1.5 cm. x Depth 1.5 cm. Slough, Eschar. Extent of necrosis is 80% thin light brown. Necrotic tissue peeling up from 4-8 o'clock. Thin light brown color. Red irritation/rash scattered around. Moderate serosanguineous drainage. Treatment in place: Wound care to buttocks. Clean with NS, pat dry. Apply Santyl to wound bed and cover with allevyn or equivalent foam dressing. Encourage offloading. MD not notified, not new area. The wound observation tool indicated the physician was not notified of the of the wound observation tool assessment on 12/13/23. Review of the care plan failed to indicated there was evidence that offloading of the coccyx wound was implemented. Review of Resident #97's medical record indicated he/she was hospitalized on [DATE] through 12/20/24 due to worsening mental status and fever. Review of the hospital discharge summary dated 12/20/23 indicated the following: admitted for treatment of cellulitis at the sacral wound and osteonecrosis of the left femoral head. CT (Computed Tomography medical imaging scan) showing air in soft tissue of the right medial buttock consistent with sacral ulcer. Incidental finding of left hip avascular necrosis with mild degenerative change noted. Patient to follow-up with [NAME] wound care. Referral sent at discharge, please follow up for making and attendance to that appointment. Avoid direct pressure to the area, frequent pressure offloading. Discharge Wound Care Recommendations included: BID (twice daily) dressing changes. Santyl, Dakins (antiseptic solution used for wound cleaning) soaked wet to dry, cover with 4x 4 gauze. Turn q2h (every 2 hours) hob (head of bed) <30 (less than). No sitting in chair >1hr (greater than one hour) use cushion. Air mattress. Avoid direct pressure to the area, frequent pressure offloading. Review of the re-admission facility physician progress note dated 12/20/23, indicated: Patient hospitalized with fever, CT done which showed hematoma. MRI showed cellulitis but no osteomyelitis, had a bedside debridement by plastic surgery on December 17th. He/she is in for twice daily dressing changes with Dakin's. Osteonecrosis of the left femoral head. Further review of the medical record failed to indicate a physician treatment order for Santyl, Dakins soaked wet to dry, cover with 4 x 4 gauze was ordered, and contained no treatment documentation. Review of Resident #97's medical record failed to indicate that a follow up appointment at the wound clinic was arranged by facility staff. Review of Resident #97's skin integrity care plan dated 10/5/23, and last revised 9/18/24, indicated the following interventions: -Weekly skin checks -Treatments as ordered -Clean and dry skin after each incontinent episode. -Assess location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. -Follow facility protocols for treatment of injury. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of Resident #97's care plan failed to indicate the following interventions were implemented: heel booties, head of bed <30 degrees or less, no sitting in chair greater than one hour, use of cushion, and an air mattress. Review of Resident #97's Weekly Skin Integrity Data Collection form dated 12/21/23, indicated the following: Skin intact: No, discolorations scattered to bilateral arms, open coccyx wound, o [TRUNCATED]

Based on observations, interviews and record review, the facility failed to ensure it was administrated in a manner that enabled the facility to ensure that systems were in place to provide competent clinical care and clinical oversight for the treatment to prevent the development and worsening of pressure injuries. Specifically, the facility administrator failed to: 1. Provide nursing staff education, training and competencies to demonstrate competency in providing safe and effective wound care management. 2. Identify concerns outlined by the Medical Director in the Quality Assurance and Performance Improvement (QAPI) program related to documentation, wound dressings, lab services and wound staging and documentation. 3. Implement an effective wound care program that is supervised by a physician for pressure ulcer (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care per the Facility Assessment Tool. As a result of these failures, three Residents (#264, #97, #103) developed pressure injuries that worsened, became infected, required hospitalization , required intravenous antibiotics with surgical intervention and for one of the three Residents, resulted in death. Findings include: During the survey process it was identified that the Administration's failure to perform wound care competencies for nursing staff that were delegated to assume the responsibilities of wound care management resulted in a failure to perform skin checks and wound evaluations, implement physician orders, updated the physician and plan of care when significant changes occurred, and the development of a stage 4 pressure ulcer with purulent drainage and odor. Review of the Facility Assessment Tool, dated and revised [DATE], as reviewed with the QAPI committee, indicated the facility last reviewed the Wound Care [NAME] on [DATE]. The section Action needed by committee to ensure policies meet professional standards for the Wound Care [NAME] was blank. Further review of the Facility Assessment Tool under the section Services and Care We Offer Based on our Residents' Needs indicated the following: - General Care: Skin Integrity - Specific Care of Practices: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). - Is the facility able to perform all care activities mentioning in column B (General Care: Skin Integrity): Yes The Facility Assessment Tool continues to say that the facility employs a Wound Care Nurse for each of the three Resident units in the facility. The staffing data for the Wound Care Nurse position is blank for all three units outlined. 1. The facility failed to provide nursing staff guidance in which staff are expected to demonstrate competency with the activities listed in the training requirements for effective wound care management. According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of 18 personnel files of actively working clinical nursing staff in the facility on [DATE] and [DATE] indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Further review of the education files indicated licensed clinical staff did not have the necessary skills to evaluate, document, or recognize a change in condition related to skin integrity and proper wound management. Review of 31 out of 36 licensed nurses working in the facility, educational records failed to indicate competencies were completed, per the Facility Assessment. Competencies reviewed included Skin and Wound Care. There was no documented evidence that licensed clinical staff had the required clinical training or that competencies were completed as indicated in the facility assessment. Review of 18 personnel files of actively working clinical nursing staff in the facility on [DATE] and [DATE] indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Further review of the education files indicated licensed clinical staff did not have the necessary skills to evaluate, document, or recognize a change in condition related to skin integrity and proper wound management. Review of 31 out of 36 licensed nurses working in the facility, educational records failed to indicate competencies were completed, per the Facility Assessment. Competencies reviewed included Skin and Wound Care. There was no documented evidence that licensed clinical staff had the required clinical training or that competencies were completed as indicated in the facility assessment. Review of the education files for two out of two designated wound nurses indicated there was no documented evidence that competencies were completed as indicated in the Wound Care Manual - Life Care Center Wound Tool Box. Unit Manager #1 had documented Certified Skin Champion certificate on file dated [DATE] but failed to complete the required clinical competency for skills validation. Unit Manager #2 had documented Certified Skin Champion certificate on file dated [DATE] but failed to complete the required clinical competency for skills validation. During an interview on [DATE] at 1:38 P.M., Staff Development Coordinator (SDC) said, she manages the orientation process and reviews a nursing checkoff list verbally to ensure staff are competent. The SDC said not everyone will have hands-on nursing competencies and said she will verbalize what needs to be done. The SDC said she will sign off the competency packet before they work on the unit, but she will not complete the hands on competency with each nurse, she will verbalize only. The SDC said she started working in the facility four months ago and said a lot of competencies were not done for a lot of clinical staff, so she was playing catch up. The SDC did not observe nursing staff completing the neccessary skills to perform clinical nursing care as it relates to wound management and pressure ulcers, therefore was unable to ensure the competencies were demonstrated effectively. During an interview on [DATE] at 9:20 A.M., The Nursing Home Administrator said it is her expectation that clinical staff have the necessary training and clinical competencies per the facility assessment, to care for the residents in the facility and the wound team has been educated on wound care tool box (a wound care manual developed by the facility used for wound care treatment). During an interview on [DATE] at 10:12 A.M., the Nursing Home Administrator, Director of Nurses (DON) and Regional Director of Clinical Services said staff competencies are based off the requirements outlined in the facility assessment and it is the expectation upon hire and annually that staff have training and competencies completed. The DON said all Nurses must have clinical competencies completed upon hire and annually to assess and provide care. 2. Review of the facility policy titled QAPI - Program Design and Scope, dated and revised [DATE], last reviewed [DATE], indicated the following: Policy: - The facility will have a QAPI program that is ongoing, comprehensive and capable of addressing the full range of care and services it provides. - At a minimum, the QAPI program will: - Address all systems of care and management practices - Include clinical care, quality of life and resident choice - Utilize the best available evidence to define measure indicators of quality and facility goals that reflect the processes of care and facility operations that have been shown to be predictive of desired outcomes for residents - Reflect the complexities, unique care and services that the facility provides. Procedure: - The facility will ensure QAPI programs address systems of care and management practices. Systems of care are the processes in place to achieve an expected clinical outcome. For example, the system for prevention of pressure ulcers also involves the system for ensuring adequate nutrition, as well was the systems for identification of changes in condition and infection prevention. Review of the facility policy titled Quality Assurance & Performance Improvement (QAPI) Plan for the Facility 2024 signed by the Facility Executive Director on [DATE] and the Medical Director on [DATE] indicated the following: - Purpose: The QAPI program is to utilize an ongoing, data driven, proactive approach to advance the quality if life and quality of care for all residents at our facility. QAPI principles will drive our facility decisions to promote excellence in all resident and staff-related areas. All facility associates will be encouraged to be involved in identifying opportunities for improvement, partake in QAPI teams, imbed QAPI activities in all core processes and providing ongoing feedback. - Governance and Leadership: The governing body is ultimately responsible for overseeing the QAPI Committee. The Executive Director has direct oversight responsibility for all functions of the QAPI committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. Review of the facility's QAPI plan indicated monthly documentation titled Medical Director Oversight Committee (MDOC) Meeting Minutes completed by the Medical Director of the facility which included the following discussion points: - Dated and signed by the Medical Director and Executive Director [DATE]: - Based on the topics reviewed in QAPI, are there additional quality of care areas that should be reviewed? This was checked yes with the following documentation Assessment documentation, communication, timely intervention. - Are there any compliance or regulatory concerns? This was checked yes with the following documentation Documentation. - Are there any opportunities or changes needed to education programs for staff? This was checked yes with the following documentation orientation enhancement. - Are there any issues based on consultant reports (pharmacy, nutrition, wound), this was check off yes with the following documentation Dressings & compliance. - Dated and signed by the Medical Director and Executive Director on [DATE]: - Based on the topics reviewed in QAPI, are there additional quality of care areas that should be reviewed? This was checked yes with the following documentation Lab services. - Are there any opportunities or changes needed to education programs for staff? This was checked yes with the following documentation documentation. - Any concerns with Event Management Program (e.g. incident reports, falls, skin tears)? This was checked yes with the following documentation thoroughness of investigation and immediate implementation of new interventions. - Dated and signed by the Medical Director and Executive Director on [DATE]: - Are there any issues based on consultant reports (pharmacy, nutrition, wound)? This was checked yes with the following documentation Wounds - staging, documentation. - Any concerns with Event Management Program (e.g. incident reports, falls, skin tears)? This was checked yes with the following documentation need improved detail and investigation root cause. Further review of the MDOC Meeting Minutes failed to indicate that any of the areas that were checked off as yes were addressed through the QAPI process to indicate that the facility developed, implemented, and maintained a comprehensive QAPI plan when these concerns were identified. During an interview on [DATE] at 10:49 A.M., the Nursing Home Administrator (NHA) said she has noticed trends with wounds in the facility. During an interview on [DATE] at 11:43 A.M., with the NHA, the QAPI program was Reviewed. The NHA said she looks for patterns and trends of what is going on in the facility for what to include in QAPI to improve the quality of the facility. The NHA said any plans that are put in place as a result of QAPI are monitored over time to see what is effective and if they are not improving we discuss as a team. The NHA did not mention that wound care has been a part of QAPI this year. The NHA continued to say the facility's wound nurses have not been a part of QAPI. The surveyor showed the NHA the Medical Director Oversight Committee (MDOC) Meeting Minutes that was in the QAPI plan. When asked if there has been any follow up to the identified concerns, especially related to wounds in the facility, the NHA said no and the Medical Director's concerns should have been addressed with follow up QAPI plans. The surveyor asked the NHA if there was any other documentation in the QAPI plan related to pressure ulcers or skin wounds and the NHA said there was not. The surveyor reviewed the QAPI plan and did not identify any information related to wounds including the identification of a problem or any improvement activities. 3. According to the Mayo Clinic, complications and outcomes of Stage 4 pressure ulcers include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization . It may develop within the first 2 weeks of pressure ulcer formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). During Resident #264, #97 and #103's stay in the facility, the Administrator failed to ensure that the physician provided oversight to ensure the appropriateness and quality of medically related care and recommendations made by facility staff were provided to the residents which resulted in worsening pressure wounds which further resulted in hospitalization , osteomyelitis, and for one resident, death. Resident #264 developed multiple pressure ulcers at the facility, specifically a sacral pressure ulcer that worsened in presentation of size and symptoms of infection which included gangrene and necrosis. The wound worsened at the facility despite being treated with antibiotics for multiple infections and eventually required hospitalization on [DATE] where the Resident underwent surgical debridement due to osteomyelitis of the coccygeal and ultimately died on [DATE] as a result of neglect. Resident #97 developed a Stage 4 pressure injury to the sacrum and development of osteomyelitis requiring antibiotics treatment, surgical debridement, and multiple hospitalization s. Resident #97 then developed two Stage 2 pressure injuries, one Deep Tissue Injury, and failed to arrange a wound clinic follow up for deteriorating wounds. Resident #103 was admitted with a sacral pressure ulcer wound that worsened in the facility. Despite documentation of a worsening wound and signs of infection in the wound, treatment and interventions in the place for the wound remained the same, eventually resulting in hospitalization from [DATE] through [DATE] for worsening wounds, treatment with intravenous (IV) antibiotics for osteomyelitis (A bone infection), and the need for ileostomy formation for fecal diversion away from the wound. Resident #103 was discharged back to the facility with Negative Pressure Wound Therapy (a medical technique used to accelerate wound healing by applying negative pressure to the wound site) for wound management. During an interview on [DATE] at 8:43 A.M., the Regional Director of Clinical Services said that there is not a wound physician who currently rounds in the facility. During an interview on [DATE] at 9:38 A.M., Physician #1 said that his expectation is that nurses who are competent in wound care perform wound rounds and make recommendations to him about what resident's need are and what residents he needs to visualize the wounds of himself. He said he is not a wound expert, and he relies on the wound team to be assessing and implementing the correct orders for wound management. Physician #1 said that he does not believe he is always notified when the wound team changes a treatment order for a resident. He said it is possible that with sooner action to Resident #103's wound worsening the need for hospitalization and ileostomy formation could have been prevented but he can't say with certainty. For Resident #264, Physician #1 said he treated the Resident with multiple courses of antibiotics. He said if the wound got bigger with slough, systemic fever the resident would have been sent to the hospital for debridement. He said Resident #264 should have been sent to the hospital sooner. For Resident #97, Physician #1 said he/she was treated with antibiotics at the end of December but he/she probably should have gone out sooner to the wound clinic for debridement and said he goes by what the wound nurses tell him and he was not aware of the situation as he did not visualize the wounds during that time. During a follow up interview on [DATE] at 10:16 A.M., Physician #1 said, I am not a wound care expert and he is really relying on the wound care team to utilize the best treatment option. During an interview on [DATE] at 11:43 A.M., the NHA said she should have addressed the physician's concerns regarding wound care that he mentioned in QAPI. Refer to F837

Based on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to: 1. Ensure the licensed nursing staff were trained and demonstrated competency to identify, assess, evaluate, intervene, and respond to a significant change in condition of a wound, for four Residents (#264, #97, #60, #103), out of a total sample of 30 Residents. 2. Ensure that 31 out of 36 staff education records reviewed, had completed education and competencies and were completed and documented annually, per the Facility Assessment. As a result of these failures, three Residents (#264, #97, #60, and #103) developed pressure injuries that worsened, became infected, required hospitalization , required intravenous antibiotics with surgical intervention and for one of the three Residents, resulted in death. Findings include: 1. According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies and training in areas as indicated in the facility assessment: - Activities of Daily Living: Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment, supporting resident independence in doing as much of these activities by himself/herself. - Mobility and fall/fall with injury prevention: Transfers, ambulation, restorative nursing, contracture prevention/care, supporting resident independence in doing as much of these activities by him or herself. - Bowel/bladder: Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence, and promote resident dignity. - Skin Integrity: Pressure injury prevention and care, skin care, wound care, surgical and other skin wounds. - Infection Prevention and Control: Identification and containment of infections, prevention of infections. - Management of Medical Conditions: Assessment, early in identification of problem/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD), gastroenteritis, infections such as UTI and gastroenteritis, pneumonia, hypothyroidism. - Nutrition: Individualized dietary requirements, liberalized diets, specialized diets, IV nutrition, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions, hypodermoclysis. Review of the Facility Assessment, dated as reviewed with the QAPI committee, in [DATE], indicated the following: - Part 1 Facility Profile Wound Care Manual Annual Review Date [DATE] - Part 5 Training and Competencies Competent Support and Care for our Resident Population Every Day and During Emergencies: Infection control - a facility must include as part of its infection prevention and control program mandatory training that includes written standards, policies, and procedures for the program. Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. All staff during orientation, annually and as needed. Competency: Person Centered Care Resident Assessment Medication Administration - Part 6- Facility Resources- Medical Equipment Low-air Loss Mattress. Required -Yes. Wound Vac-. Required - No. - Part 7- Healthcare Related Contracts, [NAME], or Other Agreements. Medical Director Contract Working with Medical Practitioners Describe your plan to recruit and retain enough medical practitioners e.g., physicians, nurse practitioners) who are adequately trained and knowledgeable in the care of your resident/patients, including how you will collaborate with them to ensure the facility has appropriate medical practices for the needs and scope of your population: - The facility is in contract with Post Acute EMS which provides the facility with medical practitioners 5 days a week on-site and on call services. Describe how the management and staff familiarize themselves with what they should expect from the medical practitioners and other healthcare professionals related to standards of care and competencies that are necessary to provide the level and type of support and care needed for your resident population. For example, do you share expectations from providers that see residents in your nursing home on the use of standards, protocols, or other information developed by your medical director? Do you have discussions on what providers and staff expect of each other in terms of the care delivery process and clinical reasoning essential to providing high quality? - Management team and staff are well trained on long term care/skilled nursing facility regulations. The staff have opened dialogue with medical practitioners about residents' current needs and how prescribed interventions are working for the resident, or not providing the desired outcomes. The medical directors oversight and attendance at monthly QAPI provides a platform for discussion of trends and patterns. Describe process for overseeing these services and how those services will meet resident needs and regulatory, operational, maintenance, and staff training requirements. - Clinical outcomes are measured and tracked at the monthly QAPI meeting. Policies and procedures are updated as needed according to regulatory requirements and are reviewed by the IDT on an annual basis or as needed. List health information technology resources such as systems for electronically managing patient records and electronically sharing information with other organizations. - The electronic health record the facility uses are Point Click Care (medical and administrative) and Optima/Net Health (therapy). The facility also utilizes hardware such as laptops, Wi-Fi servers, telephones, iPads, fax. The facility failed to provide training and demonstrated competency in Quality of Care related to wound treatment orders. Skin Integrity: Pressure injury prevention and care, skin care, wound care, surgical and other skin wounds. Resident #264 developed multiple pressure ulcers at the facility, specifically a sacral pressure ulcer that worsened in presentation of size and symptoms of infection which included gangrene and necrosis. The wound worsened at the facility despite being treated with antibiotics for multiple infections and eventually required hospitalization on [DATE] where the Resident underwent surgical debridement due to osteomyelitis of the coccygeal and ultimately died on [DATE] as a result of neglect. Resident #97 developed a Stage 4 pressure injury to the sacrum resulting in the development of osteomyelitis requiring antibiotics treatment, surgical debridement, and multiple hospitalization s. Resident #97 then developed one Deep Tissue Injury, and failed to arrange a wound clinic follow up for deteriorating wounds. Resident #60, developed a Stage 3 pressure injury to the lower back requiring antibiotic treatment and hospitalization , and failed to respond to and implement new interventions when Resident #60 developed a Stage 2 pressure injury to the right buttock, Stage 1 pressure injury to the right lateral foot, Unstageable DTI to the right outer calf, Unstageable DTI to the right heel, and failed to arrange a wound clinic follow up as indicated by the Physician. Resident #103 was admitted with a sacral pressure ulcer wound that worsened in the facility. Despite documentation of a worsening wound and signs of infection in the wound, treatment and interventions in the place for the wound remained the same, eventually resulting in hospitalization from [DATE] through [DATE] for worsening wounds, treatment with intravenous (IV) antibiotics and multiple surgical debridements for osteomyelitis (A bone infection) and the need for ileostomy formation for fecal diversion away from the wound. Resident #103 was discharged back to the facility with Negative Pressure Wound Therapy (a medical technique used to accelerate wound healing by applying negative pressure to the wound site) for wound management. 2. Review of 18 personnel files of actively working clinical nursing staff in the facility on [DATE] and [DATE] indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Further review of the education files indicated licensed clinical staff did not have the necessary skills and competency to evaluate, document, or recognize a change in condition related to skin integrity and proper wound management. Review of 31 out of 36 licensed nurses working in the facility, educational records failed to indicate competencies were completed, per the Facility Assessment. Competencies reviewed included Skin and Wound Care. There was no documented evidence that licensed clinical staff had the required clinical training or that competencies were completed as indicated in the facility assessment. Review of the Facility Wound Care Manual - Life Care Center Wound Care Tool Box, indicated the following: CWC-Certified Wound Care Champion The Facility's Wound Care Program utilized professional standards from both organizations, the NPIAP (National Pressure Injury Advisory Panel) and WOCN (wound, ostomy, and continence nurse), and has developed a national wound certification and credentialed program designed as CWC (Certified Wound Care-Champions). The certification program is accredited by ANCC (American Nurses Credentialing Center) and consists of five plus hours of didactic lesson with knowledge validation of online examination. Awards 7 CE's (continuing education) for nursing and may be accepted for Therapy. Competency and skills is validated on site in simulated or resident care situations. The facility failed to ensure clinical competency was demonstrated as indicated in per the facility assessment and Wound Care Manual. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, indicated: Title: Accepting, Verifying, Transcribing and Implementing Prescriber Orders According to The Massachusetts Board of Registration in Nursing (Board) is created and authorized by Massachusetts General Laws (M.G.L.) c. 13, SS 13, 14, 14A, 15 and 15D, and M.G.L. c. 112, SS 74 through 81C to protect the health, safety, and welfare of the citizens of the Commonwealth through the regulation of nursing practice and education. In addition, M.G.L. c. 30A, S 8 authorizes the Board to make advisory rulings with respect to the applicability to any person, property or state of facts of any statute or regulation enforced or administered by the Board. Each nurse is required to practice in accordance with accepted standards of practice and is responsible and accountable for his or her nursing judgments, actions, and competency. The Board's regulation at 244 CMR 9.03(6) requires all nurses to comply with any other law and regulation related to licensure and practice. -The nurse is accountable for ensuring that any orders he or she implements are reasonable based on the nurse's knowledge of that particular patient's care needs at that time and must also ensure that the orders (whether written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) originate from an authorized prescriber, pursuant to established protocols of the organization. - It is not within the scope of Licensed Practical or Registered Nurse practice to alter or change the directions provided for in orders from a duly authorized prescriber. Licensed nurses are not authorized to prescribe, renew/refill, or extend a prescription that has expired prior to receipt of an order from duly authorized prescriber. Standing Order / Protocol: Standing orders/protocols include written authorization from a duly authorized prescriber that indicates evidence based practice standards for a specific medication or activity to be implemented by the nurse. Standing orders/protocols are applicable to a specific patient or specific situation and directions remain consistent during implementation. Standing orders / protocols cannot authorize the nurse to: -alter the standing order / protocol once initiated (e.g., independently initiate new medications); -determine choice of intervention based upon a menu of medications, dosing instructions or actions; and/or -prescribe, renew/refill, or extend a prescription that has expired. In 3.04(1): A licensed practical nurse bears full responsibility for the quality of health care she or he provides to patients or health care consumers. (2) A licensed practical nurse participates in direct and indirect nursing care, health maintenance, teaching, counseling, collaborative planning and rehabilitation, to the extent of his or her generic and continuing education and experience in order to: (a) assess an individual's basic health status, records and related health data; (b) participate in analyzing and interpreting said recorded data, and making informed judgments as to the specific elements of nursing care mandated by a particular situation; (c) participate in planning and implementing nursing intervention, including appropriate health care components in nursing care plans that take account of the most recent advancements and current knowledge in the field; (d) incorporate the prescribed medical regimen into the nursing plan of care; (e) participate in the health teaching required by the individual and family so as to maintain an optimal level of health care; (f) when appropriate, evaluate outcomes of basic nursing intervention and initiate or encourage change in plans of care; and (g) collaborate, cooperate and communicate with other health care providers to ensure quality and continuity of care. During an interview on [DATE] at 11:42 A.M., The Director of Nurses (DON) said the facility has two Licensed Practical Nurses (LPN) with wound certification and said clinical demonstrated competency is required after the Wound Tool 7 hour certification course (The facility's wound care program which provides staff the title of Certified Wound Care-Champion). The DON said all staff upon hire and annually must have clinical wound competencies completed. The DON said the LPN's (wound nurses) manage weekly wound rounds and collect assessment data. The DON said the facility does not have anyone to interpret data and no other clinical oversight of the wound program and said they did have a Registered Nurse on the team but she left four months ago. The DON said clinical competency is provided by the Staff Development Coordinator (SDC) and said it is the expectation for all nurses to have training and clinical wound competency upon hire and annually. During a follow up interview on [DATE] at 12:33 P.M., the DON said she is made aware of infections and worsening wounds and said if a wound looks infected, the wound nurses will update the physician. The DON said, I had concerns with wounds, and I had the infection preventionist do oversight with the wound team and other staff because we had residents hospitalized with infections. The DON continued to say she did not complete the seven hour wound training certification and said just the two nurses are certified in the facility. The DON said the facility follows the Wound Care Manual - Life Care Center Wound Tool Box and staff complete training and wound competencies following this program. Review of the education files for two out of two designated wound nurses indicated there was no documented evidence that competencies were completed as indicated in the Wound Care Manual - Life Care Center Wound Tool Box. Unit Manager #1 had documented Certified Skin Champion certificate on file dated [DATE] but failed to complete the required clinical competency for skills validation. Unit Manager #2 had documented Certified Skin Champion certificate on file dated [DATE] but failed to complete the required clinical competency for skills validation. Further review of the education files indicated Unit Manager #1 and Unit Manager #2 were Licensed Practical Nurses. During an interview on [DATE] 8:43 A.M., Regional Director of Clinical Services said the facility's philosophy is to have wound certified nurses and rehabilitation person in the building and said they have two wound nurses that are LPNs. The Regional Director of Clinical Services said the LPN's can assess wounds because it is within the nurse practice act for the state of Massachusetts. The Regional Director of Clinical Services said wound nurses need to complete and pass the seven hour facility wound care certification course and have clinical competency to assess the wounds. The Regional Director of Clinical Services said nursing staff must have training and clinical competency to do wound care upon hire and annually said nurses can reach out to her and the DON with wound questions. The Regional Director of Clinical Services said the wound tool box protocol should be followed and said a competency is required after completion of the online course. During an interview on [DATE] at 1:38 P.M., Staff Development Coordinator (SDC) said, she manages the orientation process and reviews a nursing checkoff list verbally to ensure staff are competent. The SDC said not everyone will have a hands-on nursing competencies and said she will verbalize what needs to be done. The SDC said she will sign off the competency packet before they work on the unit but she will not complete the hands on competency with each nurse, she will verbalize only. The SDC continued to say she started working in the facility four months ago and said a lot of competencies were not done for a lot of clinical staff so she was playing catch up. During an interview on [DATE] 8:56 A.M., Unit Manager #1 said she took an online wound course and said she is one of the certified wound nurses who completes weekly wound rounds. Unit Manager #1 said each unit follows the Wound Tool Box and said she will assess and document the healing progress and said if a wound is not improving or is getting infected, the wound nurses will use their professional judgement for new treatment options and run it by the doctor, and he usually approves it. Unit Manager #1 said she did not complete a wound competency after the online course in person or in a simulated setting. During an interview on [DATE] at 9:14 A.M. Unit Manager #2 said she completed the online wound course and is one of the wound nurses who conducts weekly wound rounds in the facility. Unit Manager #2 said she and the other wound nurse will give wound recommendations based on the training and seminars and enter new treatment orders based off what they see during wound rounds. Unit Manager #2 said up until recently I did not know how to stage wounds. Unit Manager #2 said once the course is completed the wound nurses were effective on their own and said no one completed an in person competency or observation during any wound rounds. Unit Manager #2 said she did not complete a wound competency after the online course in person or in a simulated setting. During an interview on [DATE] at 9:38 A.M., Physician #1 (who is also the Medical Director of the facility) said he does not visualize many wounds and said if the wound nurses tell him a wound is getting worse, the wound nurses put in new treatments. Physician #1 said I let them decide. I do not know what they order, they are the wound team. I do not know about wounds. Physician #1 continued to say I feel they can accurately assess them. They determine what is needed and put orders in. I don't review the orders they put in. Physician #1 said he expects the wound team to be certified and competent in wounds and said I don't know the rules for what certification is needed. I am assuming the facility takes care of that and they are competent in their wound skills as wound certified nurse's doing the wound rounds. During a follow up interview on [DATE] at 10:16 A.M., Physician #1 said I am not a wound care expert and he is really relying on the wound care team to utilize the best treatment option. During an interview on [DATE] at 9:20 A.M., The Nursing Home Administrator said it is her expectation that clinical staff have the necessary training and clinical competencies per the facility assessment, to care for the residents in the facility and the wound team has been reconstructed and educated on wound care tool box. During an interview on [DATE] at 10:12 A.M., with the Nursing Home Administrator, Director of Nurses (DON) and Regional Director of Clinical Services said staff competencies are based off the requirements outlined in the facility assessment and it is the expectation upon hire and annually that staff have training and competencies completed. The DON said all Nurses must have clinical competencies completed upon hire and annually to assess and provide care. During an interview on [DATE] at 10:50 A.M., the Massachusetts Board of Registration in Nursing said Licensed Practical (LPN) Nurses can function independently, however a Registered Nurse (RN) is responsible for a systemic evaluation and the LPN at a minimum must have documented training and demonstrated clinical competency in wound care. LPN, although bearing full responsibility, does not bear ultimate responsibility. LPN regulations under 3.04, the word participate is used. The RN bears the ultimate responsibility for the quality of nursing care he or she provides to individuals and groups. Although the LPN works under his or her own license and bears responsibility and accountability for their judgments and actions, the RN would need to be involved in the aspects outlined in 3.02 (2) and 3.04 (2). Refer to F686, F835, F837, and F841

Based on interview, record review and the Facility Assessment, the facility failed to ensure the Governing Body provided oversight and accountability for quality of care related to comprehensive wound care management. Specifically: 1. The Governing Body failed to ensure the facility provided consistent and effective nursing staff education and training to provide competent quality of care and effective wound care management as outlined per the Facility Assessment. 2. The Governing Body failed to ensure the facility had implemented an effective wound care program that is supervised by a physician for pressure ulcer (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care. As a result of these failures, three Residents (#264, #97, #103) developed pressure injuries that worsened, became infected, required hospitalization , required intravenous antibiotics with surgical intervention and for one of the three Residents, resulted in death. Findings include: Review of the facility policy titled QAPI - Program Design and Scope, revised [DATE], last reviewed [DATE], indicated the following: - The authority for the planning and implementation of the Quality Assurance Performance Improvement (QAPI) program is delegated by the Board of Directors to the Divisional/Regional teams and the Executive Director at the facility. - The Executive Director assumes responsibility for the implementation and coordination of the Quality Assessment and Assurance (QAA) activities as defined in the facility's QAPI plan. The QAPI program is designed to sustain during times of transitions in leadership or staffing. - The Executive Director will assure the QAPI plan is reviewed annually by the QAA Committee. The QAA committee will make any necessary revision to the plan on an ongoing basis as indicated. Any changes to the plan will be communicated to the residents/patients, families, and associates through meetings and other means that are agreed upon by the QAA committee as they occur. Review of the facility policy titled Governing Body, revised [DATE], last reviewed [DATE], indicated the following: - Policy: The facility has an active (engaged and involved) governing body that is responsible for establishing and implementing policies regarding the management of the facility. - At least quarterly or more often if needed, the Executive Director reports to the governing body including, how the governing body responds back to the Executive Director and what specific types of problems and information (i.e., survey results, allegations of abuse or neglect, complaints, etc.) are reported or not reported directly to the governing body. - The Executive Director is held accountable and reports information about the facility's management and operation (i.e., audits, budgets, staffing, supplies, etc.) which is reviewed during facility visits from the regional/division team. 1. Review of the Facility Assessment Template, dated and last revised [DATE] included but was not limited to the following: Persons involved in completing the facility assessment: Executive Director (Nursing Home Administrator), Director of Nursing, Medical Director, Regional [NAME] President and the Regional Director of Clinical Services. - Review of the Facility Assessment Tool indicated the facility last reviewed the Wound Care [NAME] on [DATE]. The section Action needed by committee to ensure policies meet professional standards for the Wound Care [NAME] was blank. Further review of the Facility Assessment Tool under the section Services and Care We Offer Based on our Residents' Needs indicated the following: - General Care: Skin Integrity - Specific Care of Practices: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). - Is the facility able to perform all care activities mentioning in column B (General Care: Skin Integrity): Yes The Facility Assessment Tool continues to say that the facility employs a Wound Care Nurse for each of the three Resident units in the facility. The staffing data for the Wound Care Nurse position is blank for all three units outlined. - Under the section Competent Support and Care for our Resident Population Every Day and During Emergencies: - Topic: Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing [sic] rather than helping relieve suffering and improve quality of life. - Which Staff are Training and what frequency: Direct care staff during orientation, annually and as needed. Under the section Working with Medical Practitioners, indicated the following: - the management team and staff are well trained on long term care/skilled nursing facility regulations. The staff have an open dialogue with medical practitioners about residents' current needs and how prescribed interventions are working for the resident, or not providing the desired outcomes. The medical director's oversight and attendance at monthly QAPI provides a platform for discussion of trends and patterns. - clinical outcomes are measured and tracked at the monthly QAPI meeting. Policies and procedures are updated as needed according to regulatory requirements and are viewed by the IDT on an annual basis or as needed. Review of the Facility Wound Care Manual - Life Care Center Wound Care Tool Box, indicated the following: CWC-Certified Wound Care Champion - The Facility's Wound Care Program utilized professional standards from both organizations, the NPIAP (National Pressure Injury Advisory Panel) and WOCN (wound, ostomy, and continence nurse), and has developed a national wound certification and credentialed program designed as CWC (Certified Wound Care-Champions). The certification program is accredited by ANCC (American Nurses Credentialing Center) and consists of five plus hours of didactic lesson with knowledge validation of online examination. Awards 7 CE's (continuing educations) for nursing and may be accepted for Therapy. Competency and skills is validated on site in simulated or resident care situations. Review of 18 personnel files of actively working clinical nursing staff in the facility on [DATE] and [DATE] indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Further review of the education files indicated licensed clinical staff did not have the necessary skills to evaluate, document, or recognize a change in condition related to skin integrity and proper wound management. Review of 31 out of 36 licensed nurses working in the facility, educational records failed to indicate competencies were completed, per the Facility Assessment. Competencies reviewed included Skin and Wound Care. There was no documented evidence that licensed clinical staff had the required clinical training or that competencies were completed as indicated in the facility assessment. During an interview on [DATE] at 9:20 A.M., The Nursing Home Administrator said it is her expectation that clinical staff have the necessary training and clinical competencies per the facility assessment, to care for the residents in the facility and the wound team has been educated on the facility's wound care toolbox (a wound care manual developed by the facility used for wound care treatment). During an interview on [DATE] at 8:43 A.M., the Regional Director of Clinical Services said we have a QAPI process for the wounds in the facility and the wound nurses provide data for QAPI and it allows us to track what is going on in the facility. The Regional Director of Clinical Services continued to say QAPI is the biggest tool for monitoring wound progress and treatment, she said she does not attend QAPI, but she will review QAPI discussions after the fact. During an interview on [DATE] at 10:12 A.M. with the Regional Director of Clinical Services, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) they said the Governing Body is very involved in the building. The DON said if concerns are identified through the QAPI process the facility would do their part in the building and if they feel like they need more support whether it is equipment or something else they would reach out to the Governing Body. Additionally, they said staff competencies are based off the requirements outlined in the facility assessment and it is the expectation upon hire and annually that staff have training and competencies completed. The DON said all nurses must have clinical competencies completed upon hire and annually to assess and provide care. During an interview on [DATE] at 10:45 A.M., the Director of Nursing said the governing body of the facility is involved with wound care in the facility and if there were any issues, we would identify them in QAPI and make a plan from the results. During an interview on [DATE] at 10:49 A.M., the Nursing Home Administrator (NHA) said she has noticed trends with wounds in the facility. During an interview on [DATE] at 11:43 A.M., with the NHA, the QAPI program was reviewed. The NHA said she looks for patterns and trends of what is going on in the facility for what to include in QAPI to improve the quality of the facility. The NHA said any plans that are put in place as a result of QAPI are monitored over time to see what is effective and if they are not improving, we discuss as a team and these results should be in the QAPI plan. When asked what has the facility been working on this part year for QAPI the NHA did not mention that wound care has been a part of QAPI this year. The NHA continued to say the facility's wound nurses have not been a part of QAPI. The surveyor and the NHA reviewed the attendance sheets for each month of QAPI and the wound care nurses were not in attendance. The surveyor showed the NHA the Medical Director Oversight Committee (MDOC) Meeting Minutes that was in the QAPI plan. When asked if there has been any follow up to the identified concerns, especially related to wounds in the facility, the NHA said no, and the Medical Director's concerns should have been addressed with follow up QAPI plans. The surveyor asked the NHA if there was any other documentation in the QAPI plan related to pressure ulcers or skin wounds and the NHA said there was not. The surveyor reviewed the QAPI plan and did not identify any information related to wounds including the identification of a problem or any improvement activities. 2. According to the Mayo Clinic, complications and outcomes of Stage 4 pressure ulcers include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization . It may develop within the first 2 weeks of pressure ulcer formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). During Resident #264, #97 and #103's stay in the facility, the Governing Body failed to ensure that the facility and physician provided oversight to ensure the appropriateness and quality of medically related care and recommendations made by facility staff were provided to the residents which resulted in worsening pressure wounds which further resulted in hospitalization , osteomyelitis, and for one resident, death. Resident #264 developed multiple pressure ulcers at the facility, specifically a sacral pressure ulcer that worsened in presentation of size and symptoms of infection which included gangrene and necrosis. The wound worsened at the facility despite being treated with antibiotics for multiple infections and eventually required hospitalization on [DATE] where the Resident underwent surgical debridement due to osteomyelitis of the coccygeal and ultimately died on [DATE] as a result of neglect. Resident #97 developed a Stage 4 pressure injury to the sacrum and development of osteomyelitis requiring antibiotics treatment, surgical debridement, and multiple hospitalization s. Resident #97 then developed two Stage 2 pressure injuries, one Deep Tissue Injury, and failed to arrange a wound clinic follow up for deteriorating wounds. Resident #103 was admitted with a sacral pressure ulcer wound that worsened in the facility. Despite documentation of a worsening wound and signs of infection in the wound, treatment and interventions in place for the wound remained the same, eventually resulting in hospitalization from [DATE] through [DATE] for worsening wounds, treatment with intravenous (IV) antibiotics and surgical debridement for osteomyelitis (A bone infection), and the need for ileostomy formation for fecal diversion away from the wound. Resident #103 was discharged back to the facility with Negative Pressure Wound Therapy (a medical technique used to accelerate wound healing by applying negative pressure to the wound site) for wound management. During an interview on [DATE] at 10:34 A.M., the Regional Director of Clinical Services said Residents with wounds can be sent out to a wound clinic if needed but transportation has been an issue lately. She continued to say the Physician or Nurse Practitioner will look at the wounds if needed. During an interview on [DATE] at 11:43 A.M., the Director of Nurses said if a recommendation is made to be seen in the wound clinic, she would expect that an appointment is made, however, the facility has trouble getting transportation to and from appointments at this time. During an interview on [DATE] at 8:43 A.M., the Regional Director of Clinical Services said that there is not a wound physician who currently rounds in the facility. She continued to say transportation has been an issue and if needed, the facility has an affiliation with doctor who specializes in wounds, but he has not come to the facility. She then said the facility does not have any contracts with outside wound companies. During an interview on [DATE] at 9:38 A.M., Physician #1 said that his expectation is that nurses who are competent in wound care perform wound rounds and make recommendations to him about what resident's need are and what residents he needs to visualize the wounds of himself. He said he is not a wound expert, and he relies on the wound team to be assessing and implementing the correct orders for wound management. Physician #1 said that he does not believe he is always notified when the wound team changes a treatment order for a resident. He said it is possible that with sooner action to Resident #103's wound worsening the need for hospitalization and ileostomy formation could have been prevented but he can't say with certainty. For Resident #264, Physician #1 said he treated the Resident with multiple courses of antibiotics. He said if the wound got bigger with slough, systemic fever the resident would have been sent to the hospital for debridement. He said Resident #264 should have been sent to the hospital sooner. For Resident #97, Physician #1 said he/she was treated with antibiotics at the end of December but he/she probably should have gone out sooner to the wound clinic for debridement and said he goes by what the wound nurses tell him and he was not aware of the situation as he did not visualize the wounds during that time. During a follow up interview on [DATE] at 10:16 A.M., Physician #1 said, I am not a wound care expert and he is really relying on the wound care team to utilize the best treatment option. During an interview on [DATE] at 8:08 A.M., the Nurse Practitioner said she has not been notified of the facility having trouble getting transportation for Residents who need to leave the facility for wound care. During an interview on [DATE] at 11:43 A.M., the Nursing Home Administrator said she should have addressed the physician's concerns regarding wound care that he mentioned in QAPI.

Based on review of the Facility Assessment and interviews, the facility failed to conduct and document a facility wide assessment that accurately reflected the resources necessary to care for it's residents. Specifically, the facility failed to ensure licensed nursing staff were competent in wound care. Findings include: Review of the Facility Assessment, dated as reviewed with the QAPI committee, in [DATE], indicated the following: -Facility Profile indicated the average daily census range: 103 - 108 Part 1 Facility Profile - Wound Care Manual Annual Review Date [DATE] - Review of the diagnosis potentially treated at the facility include, Aphasia, Behavioral Health Disorders (Anxiety /Personality/ Dissociative), Bipolar Disorder, Blood Disorders-DVT, PE, Bleeding, Anemia, Sickle Cell, Bowel Disease- GERD, PUD, Crohn's Inflammatory Bowel Disease, Cancer Care- Prostate, Lung, Colon, Pancreatic, Breast Bone, Communication Barriers (Another Language, Aphasis), Congestive Heart Failure and other respiratory failures, COPD, Chronic Lung Disease, Chronic Bronchitis, Asthma, Coronary Artery Disease, CVA/ Sroke /TIA, Dementia- Alzheimer's or Non-Alzheimer's Dementia, Diabetes- Type I or II, Dialysis- Hemodialysis, Peritoneal, Downs Syndrome/ Autism/ Cerebral Palsy, Drug Use or Abuse (Alcohol Dependence/ Substance Dependance), Dysthrithmias - Afib, Angina, Pace Makers, Defibrillators, Hearing Impairment or Loss, Hemiparesis/Hemiplegia, Huntington's Disease, Hypertension, Hypotension- Orthostatic, Impaired Cognition- not related to dementia, Infections-C-diff, Norovirus, Infections COVID-19, Influenza, TB, Legionella, Infections MRSA/ VRE/CRE/MDRO, Infections-UTI, Soft Tissue, Respiratory, Multiple Sclerosis, Neuropathy, Obesity-Morbid, Orthopedics-Arthritis, Osteoporosis, Orthopedics- Joint Replacement (Hip, Knee, Shoulder), Orthopedics- S/P Fracture Repair, S/P fracture, Paraplegia/Quadriplegia, Parkinsons Disease, Pneumonia, Psychosis (Hallucinations /Delusions), PTSD- Post traumatic stress disorder, PVD-Arterial or Venous, Renal Disorders-ESRD, Acute Renal Failure, Renal Insufficiency, Schizophrenia/Schizoaffective, Seizure Disorder, Substance Use Disorders (SUD), Suicidal History or Ideation, Tourette's Disease, Traumatic Brain Injuries, Vision Disorders-Cataract, Glaucoma, Macular Degeneration, Wounds - Venous, Arterial, Pressure, Surgical, Traumatic. Part 3: Services and Care Offered - Services and Care Offered Based on our Resident Needs - Skin Integrity- Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). - Therapy - PT, OT, Speech/Language, Respiratory, Music, Art, management of braces, splints, CPI. - Management of Medical Conditions: Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD), , Infections such as UTI, and gastroenteritis, pneumonia, hypothyroidism. Workforce Profile Direct Care Staff- Wound Care Nurse, Employee. Part 5 Training and Competencies -Competent Support and Care for our Resident Population Every Day and During Emergencies: Infection control - a facility must include as part of its infection prevention and control program mandatory training that includes written standards, policies, and procedures for the program. -Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. All staff during orientation, annually and as needed. Which Staff are Trained and what frequency? All staff during orientation, annually and as needed. Competency: Person Centered Care Resident Assessment Medication Administration Part 6- Facility Resources- Medical Equipment - Low-air Loss Mattress. Required -Yes. - Wound Vac-. Required - No. Part 7- Healthcare Related Contracts, [NAME], or Other Agreements. - Medical Director Contract Working with Medical Practitioners: - Describe your plan to recruit and retain enough medical practitioners (e.g., physicians, nurse practitioners) who are adequately trained and knowledgeable in the care of your resident/patients, including how you will collaborate with them to ensure the facility has appropriate medical practices for the needs and scope of your population: The facility is in contract with Post Acute EMS which provides the facility with medical practitioners 5 days a week on-site and on call services. - Describe how the management and staff familiarize themselves with what they should expect from the medical practitioners and other healthcare professionals related to standards of care and competencies that are necessary to provide the level and type of support and care needed for your resident population. For example, do you share expectations from providers that see residents in your nursing home on the use of standards, protocols, or other information developed by your medical director? Do you have discussions on what providers and staff expect of each other in terms of the care delivery process and clinical reasoning essential to providing high quality?: Management team and staff are well trained on long term care/skilled nursing facility regulations. The staff have opened dialogue with medical practitioners about residents' current needs and how prescribed interventions are working for the resident, or not providing the desired outcomes. The medical directors oversight and attendance at monthly QAPI provides a platform for discussion of trends and patterns. - Describe process for overseeing these services and how those services will meet resident needs and regulatory, operational, maintenance, and staff training requirements: Clinical outcomes are measured and tracked at the monthly QAPI meeting. Policies and procedures are updated as needed according to regulatory requirements and are reviewed by the IDT on an annual basis or as needed. The facility failed to provide training and demonstrated competency in quality of care related to wound treatment orders and skin integrity incuding pressure injury prevention and care, skin care, wound care, surgical and other skin wounds. Review of 18 personnel files of actively working clinical nursing staff in the facility on [DATE] and [DATE] indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Further review of the education files indicated licensed clinical staff did not have the necessary skills to evaluate, document, or recognize a change in condition related to skin integrity and proper wound management. Review of 31 out of 36 educational records for licensed nurses working in the facility, failed to indicate competencies were completed, per the Facility Assessment. Competencies reviewed included Skin and Wound Care. There was no documented evidence that licensed clinical staff had the required clinical training or that competencies were completed as indicated in the facility assessment. During an interview on [DATE] at 1:38 P.M., Staff Development Coordinator (SDC) said, she manages the orientation process and reviews a nursing checkoff list verbally to ensure staff are competent. The SDC said not everyone will have a hands-on nursing competencies and said she will verbalize what needs to be done. The SDC said she will sign off the competency packet before they work on the unit but she will not complete the hands on competency with each nurse, she will verbalize only. The SDC said she started working in the facility four months ago and said a lot of competencies were not done for a lot of clinical staff so she was playing catch up. During an interview on [DATE] at 10:12 A.M., with the Nursing Home Administrator (NHA), Director of Nurses (DON) and Regional Director of Clinical Services, the Regional Director of Clinical Services said staff competencies are based off the requirements outlined in the facility assessment and it is the expectation upon hire and annually that staff have training and competencies completed. The DON said all nurses in the facility must have clinical competencies completed upon hire and annually to assess and provide care. During an interview on [DATE] at 10:12 A.M., the NHA said it is her expectation that all clinical staff are trained and competent to provide the necessary care and services to residents within the facility. Resident #264 developed multiple pressure ulcers at the facility, specifically a sacral pressure ulcer that worsened in presentation of size and symptoms of infection which included gangrene and necrosis. The wound worsened at the facility despite being treated with antibiotics for multiple infections and eventually required hospitalization on [DATE] where the Resident underwent surgical debridement due to osteomyelitis of the coccygeal and ultimately died on [DATE] as a result of neglect. Resident #97 developed a Stage 4 pressure injury to the sacrum and development of osteomyelitis requiring antibiotics treatment, surgical debridement, and multiple hospitalization s. Resident #97 then developed two Stage 2 pressure injuries, one Deep Tissue Injury, and failed to arrange a wound clinic follow up for deteriorating wounds. Resident #103 was admitted with a sacral pressure ulcer wound that worsened in the facility. Despite documentation of a worsening wound and signs of infection in the wound, treatment and interventions in the place for the wound remained the same, eventually resulting in hospitalization from [DATE] through [DATE] for worsening wounds, treatment with intravenous (IV) antibiotics and multiple surgical debridements for osteomyelitis (A bone infection) and the need for ileostomy formation for fecal diversion away from the wound. Resident #103 was discharged back to the facility with Negative Pressure Wound Therapy (a medical technique used to accelerate wound healing by applying negative pressure to the wound site) for wound management. 45984

Based on interview and document review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to ensure an ongoing QAPI program was implemented, maintained and addressed concerns related to pressure ulcers and wounds in the facility. As a result of this failure, three Residents (#264, #97, #103) developed pressure injuries that worsened, became infected, required hospitalization , required intravenous antibiotics with surgical intervention and for one of the three Residents, resulted in death. Findings include: Review of the facility policy titled QAPI - Program Design and Scope, dated and revised [DATE], last reviewed [DATE], indicated the following: Policy: - The facility will have a QAPI program that is ongoing, comprehensive, and capable of addressing the full range of care and services it provides. - At a minimum, the QAPI program will: - Address all systems of care and management practices - Include clinical care, quality of life and resident choice - Utilize the best available evidence to define measure indicators of quality and facility goals that reflect the processes of care and facility operations that have been shown to be predictive of desired outcomes for residents - Reflect the complexities, unique care, and services that the facility provides. Procedure: - The facility will ensure QAPI programs address systems of care and management practices. Systems of care are the processes in place to achieve an expected clinical outcome. For example, the system for prevention of pressure ulcers also involves the system for ensuring adequate nutrition, as well was the systems for identification of changes in condition and infection prevention. Review of the facility policy titled Quality Assurance & Performance Improvement (QAPI) Plan for the Facility 2024 signed by the Facility Executive Director on [DATE] and the Medical Director on [DATE] indicated the following: - Purpose: The QAPI program is to utilize an ongoing, data driven, proactive approach to advance the quality if life and quality of care for all residents at our facility. QAPI principles will drive our facility decisions to promote excellence in all resident and staff-related areas. All facility associates will be encouraged to be involved in identifying opportunities for improvement, partake in QAPI teams, imbed QAPI activities in all core processes and providing ongoing feedback. - Governance and Leadership: The governing body is ultimately responsible for overseeing the QAPI Committee. The Executive Director has direct oversight responsibility for all functions of the QAPI committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. Review of the Facility's Facility Assessment Tool indicated that the last time the Wound Care Manual Policies were reviewed by the QAPI Committee was on [DATE]. Review of the facility's QAPI plan indicated monthly documentation titled Medical Director Oversight Committee (MDOC) Meeting Minutes completed by the Medical Director of the facility which included the following discussion points: - Dated and signed by the Medical Director and Executive Director [DATE]: - Based on the topics reviewed in QAPI, are there additional quality of care areas that should be reviewed? This was checked yes with the following documentation Assessment documentation, communication, timely intervention. - Are there any compliance or regulatory concerns? This was checked yes with the following documentation Documentation. - Are there any opportunities or changes needed to education programs for staff? This was checked yes with the following documentation orientation enhancement. - Are there any issues based on consultant reports (pharmacy, nutrition, wound), this was check off yes with the following documentation Dressings & compliance. - Dated and signed by the Medical Director and Executive Director on [DATE]: - Based on the topics reviewed in QAPI, are there additional quality of care areas that should be reviewed? This was checked yes with the following documentation Lab services. - Are there any opportunities or changes needed to education programs for staff? This was checked yes with the following documentation documentation. - Any concerns with Event Management Program (e.g. incident reports, falls, skin tears)? This was checked yes with the following documentation thoroughness of investigation and immediate implementation of new interventions. - Dated and signed by the Medical Director and Executive Director on [DATE]: - Are there any issues based on consultant reports (pharmacy, nutrition, wound)? This was checked yes with the following documentation Wounds - staging, documentation. - Any concerns with Event Management Program (e.g., incident reports, falls, skin tears)? This was checked yes with the following documentation need improved detail and investigation root cause. Further review of the facility's QAPI plan failed to indicate any documentation of a QAPI plan relating to the care and services of pressure wounds or skin injuries which included data-driven information, monitoring of pressure ulcer wounds or indicators of outcomes. On the morning of [DATE], the facility presented the surveyor with an audit of pressure ulcers for the facility. The audit revealed that there were four residents with nine in-house acquired pressure ulcers. During Resident #264, #97 and #103's stay in the facility, the physician did not evaluate the effectiveness of treatments ordered for a skin condition resulting in worsening pressure injuries, infection, hospitalization , surgical intervention and for one of the three residents, resulted in death. Resident #264 developed multiple pressure ulcers at the facility, specifically a sacral pressure ulcer that worsened in presentation of size and symptoms of infection which included gangrene and necrosis. The wound worsened at the facility despite being treated with antibiotics for multiple infections and eventually required hospitalization on [DATE] where the Resident underwent surgical debridement due to osteomyelitis of the coccygeal and ultimately died on [DATE] as a result of neglect. Resident #97 developed a Stage 4 pressure injury to the sacrum and development of osteomyelitis requiring antibiotics treatment, surgical debridement, and multiple hospitalization s. Resident #97 then developed two Stage 2 pressure injuries, one Deep Tissue Injury, and failed to arrange a wound clinic follow up for deteriorating wounds. Resident #103 was admitted with a sacral pressure ulcer wound that worsened in the facility. Despite documentation of a worsening wound and signs of infection in the wound, treatment and interventions in the place for the wound remained the same, eventually resulting in hospitalization from [DATE] through [DATE] for worsening wounds, treatment with intravenous (IV) antibiotics and multiple surgical debridements for osteomyelitis (A bone infection) and the need for ileostomy formation for fecal diversion away from the wound. Resident #103 was discharged back to the facility with Negative Pressure Wound Therapy (a medical technique used to accelerate wound healing by applying negative pressure to the wound site) for wound management. During an interview on [DATE] at 8:43 A.M., the Regional Director of Clinical Services said we have a QAPI process for the wounds in the facility and the wound nurses provide data for QAPI and it allows us to track what is going on in the facility. The Clinical Regional Nurse continued to say QAPI is the biggest tool for monitoring wound progress and treatment and that she will review QAPI discussions after the fact. During an interview on [DATE] at 10:45 A.M., the Director of Nursing said the governing body of the facility is involved with wound care in the facility and if there were any issues, we would identify them in QAPI. During an interview on [DATE] at 10:49 A.M., the Nursing Home Administrator (NHA) said she has noticed trends with wounds in the facility. During an interview on [DATE] at 11:43 A.M., with the NHA, the QAPI program was reviewed. The NHA said she looks for patterns and trends of what is going on in the facility for what to include in QAPI to improve the quality of the facility. The NHA said any plans that are put in place as a result of QAPI are monitored over time to see what is effective and if they are not improving, we discuss as a team and these results should be in the QAPI plan. When asked what has the facility been working on this part year for QAPI the NHA did not mention that wound care has been a part of QAPI this year. The NHA continued to say the facility's wound nurses have not been a part of QAPI. The surveyor and the NHA reviewed the attendance sheets for each month of QAPI and the wound care nurses were not in attendance. The surveyor showed the NHA the Medical Director Oversight Committee (MDOC) Meeting Minutes that was in the QAPI plan. When asked if there has been any follow up to the identified concerns, especially related to wounds in the facility, the NHA said no, and the Medical Director's concerns should have been addressed with follow up QAPI plans. The surveyor asked the NHA if there was any other documentation in the QAPI plan related to pressure ulcers or skin wounds and the NHA said there was not. Review of the QAPI plan indicated that the NHA did not follow up with the Medical Director's identified concerns including the identification or any improvement actitivies relating to wounds in the facility. Further review of the QAPI plan did not reveal any other information about wounds or pressure ulcers in the facility.

Based on observation, document review and interview, the facility failed to ensure the medical director was responsible for the implementation of resident care policies and the coordination of the medical care in the facility. In addition, the facility failed to ensure the appropriateness and quality of medical care and medically related care provided to residents which resulted in worsening pressure wounds for three residents resulting in hospitalization , osteomyelitis, and for one resident, death. Findings Include: Review of facility policy titled Medical Director, dated as reviewed [DATE], indicated the following: -Policy: The facility will have a designated medical director who is responsible for implementing care policies and coordinating medical care, and who is directly accountable for the management of the institution of which it is a distinct part. -The facility must designate a physician to serve as medical director. The medical director is responsible for (i) implementation of resident care policies; and (ii) the coordination of medical care in the facility. -Current professional standards of practice- Refers to approaches to care, procedures, techniques, etc., that are based on research and/or expert consensus and that are contained in current manuals, textbooks, or publications, or that are accepted, adopted, or promulgated by recognized professional organizations or national accrediting bodies. -Medical Director Responsibilities must include their participation in: b. Issues related to the coordination of medical care identified through the facility's Quality Assessment and Assurance (QAA) committee and other activities related to the coordination of care. d. Coordinating and planning for improvement of medical care in the facility. -In addition, the medical director responsibilities should include, but are not limited to: -a. Providing medical decision input and support to the executive director and governing body of the facility. -b. Ensuring the appropriateness and quality of medical care and medically related care. -f. Working with the facilities clinical team to provide surveillance and develop policies to prevent the potential infection of residents. -p. Any issues related to the facility performance improvement, regulatory compliance concerns, and any quality of care or safety issues should be recorded on the Medical Director Facility Oversight Committee Minutes. When requested, twice over the survey period, the facility was unable to provide a job description for the Medical Director position. Review of the facility's QAPI plan indicated monthly documentation titled Medical Director Oversight Committee (MDOC) Meeting Minutes completed by the Medical Director of the facility which included the following discussion points: - Dated and signed by the Medical Director and Executive Director [DATE]: - Based on the topics reviewed in QAPI, are there additional quality of care areas that should be reviewed? This was checked yes with the following documentation Assessment documentation, communication, timely intervention. - Are there any compliance or regulatory concerns? This was checked yes with the following documentation Documentation. - Are there any opportunities or changes needed to education programs for staff? This was checked yes with the following documentation orientation enhancement. - Are there any issues based on consultant reports (pharmacy, nutrition, wound), this was check off yes with the following documentation Dressings & compliance. - Dated and signed by the Medical Director and Executive Director on [DATE]: - Are there any issues based on consultant reports (pharmacy, nutrition, wound)? This was checked yes with the following documentation Wounds - staging, documentation. - Any concerns with Event Management Program (e.g., incident reports, falls, skin tears)? This was checked yes with the following documentation need improved detail and investigation root cause. During an interview on [DATE] at 10:49 A.M., the Nursing Home Administrator (NHA) said she has noticed trends with wounds in the facility. During an interview on [DATE] at 11:43 A.M., with the NHA, the QAPI program was Reviewed. The NHA said she looks for patterns and trends of what is going on in the facility for what to include in QAPI to improve the quality of the facility. The NHA said any plans that are put in place as a result of QAPI are monitored over time to see what is effective and if they are not improving, we discuss as a team. The NHA did not mention that wound care has been a part of QAPI this year. The NHA continued to say the facility's wound nurses have not been a part of QAPI. The surveyor showed the NHA the Medical Director Oversight Committee (MDOC) Meeting Minutes that was in the QAPI plan. When asked if there has been any follow up to the identified concerns, especially related to wounds in the facility, the NHA said no, and the Medical Director's concerns should have been addressed with follow up QAPI plans. The surveyor asked the NHA if there was any other documentation in the QAPI plan related to pressure ulcers or skin wounds and the NHA said there was not. The surveyor reviewed the QAPI plan and did not identify any information related to wounds including the identification of a problem or any improvement activities. Resident #264 developed multiple pressure ulcers at the facility, specifically a sacral pressure ulcer that worsened in presentation of size and symptoms of infection which included gangrene and necrosis. The wound worsened at the facility despite being treated with antibiotics for multiple infections and eventually required hospitalization on [DATE] where the Resident underwent surgical debridement due to osteomyelitis of the coccygeal and ultimately died on [DATE] as a result of neglect. Resident #97 developed a Stage 4 pressure injury to the sacrum and development of osteomyelitis requiring antibiotics treatment, surgical debridement, and multiple hospitalization s. Resident #97 then developed one Deep Tissue Injury, and failed to arrange a wound clinic follow up for deteriorating wounds. Resident #60, developted of a Stage 3 pressure injury to the lower back requiring antibiotic treatment and hospitalization . Resident #60 developed a Stage 2 pressure injury to the right buttock, Stage 1 pressure injury to the right lateral foot, Unstageable DTI to the right outer calf, Unstageable DTI to the right heel, and failed to arrange a wound clinic follow up as indicated by the Physician. Resident #103 was admitted with a sacral pressure ulcer wound that worsened in the facility. Despite documentation of a worsening wound and signs of infection in the wound, treatment and interventions in the place for the wound remained the same, eventually resulting in hospitalization from [DATE] through [DATE] for worsening wounds, treatment with intravenous (IV) antibiotics and multiple surgical debridements for osteomyelitis (A bone infection) and the need for ileostomy formation for fecal diversion away from the wound. Resident #103 was discharged back to the facility with Negative Pressure Wound Therapy (a medical technique used to accelerate wound healing by applying negative pressure to the wound site) for wound management. During an interview on [DATE] at 9:13 A.M., Unit Manager #1 and UM #2 said that at this time they are the only two who complete wound rounds. They said it is not very often that they ask the physician to observe wounds, and it is not often that the physician will visualize the wounds with the wound team. Unit Managers #1 and #2 further said it is not often that residents will be referred to the wound clinic and wounds are managed in house. Unit Managers #1 and #2 said that in general, they are not seeing wounds worsening or becoming infected in the facility. During an interview on [DATE] at 11:43 A.M. the Director of Nurses (DON) said she is not part of wound rounds, therefore can't say how often the Nurse Practitioner (NP) or Physician (who is the Medical Director) are looking at the wounds in the facility. She said both the NP and Physician are in the facility frequently but does know how often they are taking down dressings and observing wounds. The DON said the physician is not wound certified and does not believe that the NP is either. During an interview on [DATE] at 9:38 A.M., Physician #1 (who is also the Medical Director of the facility) said he is the Medical Director in the facility and is aware that the survey team has identified some concerns with wound care in the facility. He said that his expectation is that nurses who are competent in wound care perform wound rounds and make recommendations to him about what resident's needs are and what residents he needs to visualize the wounds of himself. He said he is not a wound expert, and he relies on the wound team to be assessing and implementing the correct orders for wound management. Physician #1 said that he does not believe he is always notified when the wound team changes a treatment order for a resident. During a follow up interview on [DATE] at 10:16 A.M., Physician #1 said, I am not a wound care expert and I really rely on the wound care team to utilize the best treatment option.

Based on record review and interviews, the facility failed to ensure that recommended specialist appointments were scheduled for two Residents (#60, and #103), out of a total sample of 30 residents. Specifically: 1. For Resident #60, the facility failed to ensure an outpatient appointment at the wound clinic was scheduled when requested by a Nurse Practitioner after the wound was documented as worsening and with signs of infection. 2. For Resident #103, the facility failed to ensure an outpatient appointment at the wound clinic was scheduled when requested by a Nurse Practitioner after the wound was documented as worsening and with signs of infection. Findings Include: Review of facility policy titled Use of Outside Consultants, dated as reviewed 6/7/24, indicated the following: When the facility does not employ qualified professional personnel to render a specific required service, the facility will make an arrangement for such services with an outside agency. 1. Resident #60 was admitted to the facility in October 2024 with diagnoses including multiple sclerosis, cellulitis of right lower limb, sepsis due to streptococcus group A, type one diabetes with foot ulcer, unspecified protein calorie malnutrition, muscle weakness, cognitive communication deficit, acute hematogenous osteomyelitis of right ankle and foot, raynaud's syndrome, spinal stenosis, and non-pressure chronic ulcer of right ankle. Review of Resident #60's Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #60 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, and is dependent on staff for activities of daily living tasks. Further review of the MDS indicated Resident #60 was at risk for developing pressure injuries and indicated the use of a pressure reducing device for chair and pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, applications of ointments/medications other than to feet, and applications to dressings of feet with or without topical medications. Review of the medical record failed to indicate that an appointment was scheduled for Resident #60 to be seen in the wound clinic. Review of the medical record further indicated that Resident #60 was hospitalized from 11/19/24 through 11/22/24 for an infected pressure wound of the lumbar area with increased pain, erythema, purulence, leukocytosis and elevated CRP. Review of Physician progress note dated 11/6/24, indicated: Resume clindamycin (an antibiotic for infection) for 10 days and get follow-up at the Wound Clinic. Review of the Nurse Practitioner progress note dated 11/7/24, indicated: Patient has a wound to lower mid back noted to have sloughy tissue surrounding tissue slightly pink no drainage noted. Patient has a scheduled appointment with wound clinic on Tuesday (11/12/24). Review of Physician progress notes dated 11/8/24, indicated: -Patient is back on Clindamycin until 16 November. Will follow-up on results from the Wound Clinic. He/she still has high CRP (an indicator of inflammation in the body). Wound is not improving with antibiotics yet. -Will see if there is been any report from wound clinic the patient has had labs done recently sodium is low at 130 this is patient's baseline CRP continues to be high at 61.5. CBC (complete blood count) within normal limits this is raises concern of residual infection the patient was taken off of clindamycin but went back on it in the setting of the CRP and concern of wound infection. He/she is scheduled to be on clindamycin until November 16. Despite the antibiotics his/her wound looks the same or slightly worse. Review of the physician progress note dated 11/11/24, indicated: Follow-up for diabetes and wound care. Wound care clinic follow-up with tomorrow. Continue with Clindamycin. Wound looks like it needs to be debrided today. We will make sure that he/she can get into wound care at some point this week. Review of the Nurse Practitioner progress note dated 11/12/24, indicated: Patient seen today in follow-up of several concerns, patient had a follow up appointment with orthopedic right ankle no new orders. On assessment patient appeared to be withdrawn reports discomfort to lower back area, has an appointment with the wound clinic on the 24th. Review of the social services note dated 11/14/24, indicated: Resident has multiple wounds that he/she is getting daily dressing for. He/she has a wound on his/her spine that is very concerning. A wound clinic appointment was made for him/her at the end of the month. It is recommended that he/she stay here until at least this appointment. He/she is concerned about the wounds and does not want to go home until they are healing or on the path to healing. Review of the physician progress noted dated 11/15/24, indicated: Back wound was changed to Santyl reevaluate the wound to see if it is debriding. At this point we will renew the Clindamycin. The wound looks a little bit worse he/she is getting Santyl he/she may not be able to wait until wound care which is on November 22. CRP still high around 60. will extend Clindamycin if gets worse he/she may need to go to the hospital before the wound care clinic which is scheduled for the 22nd. Review of the Nurse Practitioner progress note dated 11/19/24, indicated: Patient seen today in follow up of several concerns, on assessment patient appeared to be in distress, reports having generalized pain. Wound to lower midback area noted to have sloughy tissue has a wound appointment this Friday. Patient warm to touch noted to have a low grade fever. New order to send patient out to the hospital for further evaluation. Review of the medical record failed to indicate Resident #60 was seen by the wound clinic on 11/12/24. The surveyor requested all wound clinic visit notes during Resident #60's admission to the facility. The facility was unable to provide the surveyor with any documentation throughout the survey. During an interview on 11/21/24 at 9:14 A.M., Unit Manager #1 and Unit Manager #2 said that there were no recommendations for Resident #60 to go to the wound clinic prior to his/her rehospitalization on [DATE]. During an interview on 11/21/24 at 11:43 A.M., the Director of Nurses said if a recommendation is made to be seen in the wound clinic, she would expect that an appointment is made, however, the facility has trouble getting transportation to and from appointments at this time. During an interview on 11/22/24 at 9:38 A.M., Physician #1 said he is not a wound expert, and he relies on the wound team to be assessing and implementing the correct orders for wound management. During an interview on 11/25/24 at 12:25 P.M., Physician #1 said Resident #60's wounds were increasing and showing signs of infections and said he/she would have benefited from wound debridement at the wound clinic. During an interview on 11/25/24 at 8:01 A.M., Nurse Practitioner (NP) #1 said she did recommend having Resident #60 seen at the wound clinic but was not aware that it was never implemented. NP #1 said she would expect residents to see the wound clinic if it is recommended. NP #1 said Resident #60 had recommendations to see the wound clinic due to his/her wounds not improving. 49880 2. Resident #103 was admitted to the facility in August 2024 with diagnoses that include depression, diabetes, and pressure ulcer of the pressure region, unspecified. Review of Resident #103's most recent Minimum Data Set (MDS) Assessment, dated 11/12/24, indicated a Brief Interview for Mental Status score of 14 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated that the Resident has a pressure ulcer/injury over a bony prominence and is at risk for developing pressure ulcers. Further, the MDS indicated one stage 4 pressure ulcer that was present on admission or reentry to the facility. Review of a Nurse Practitioner Progress note dated, 9/12/24, indicated the following: 9/12/24: Patient seen today in follow-up of coccyx wounds, on assessment patient was in bed, wounds to coccyx area noted to have sloughy tissue scant amount of serosanguinous drainage and redness to surrounding area. Wounds appear to be getting worse, patient will be referred to wound clinic. Patient will continue with current medications and treatment plan. Review of the medical record failed to indicate that an appointment was scheduled for Resident #103 to be seen in the wound clinic. Review of the medical record further indicated that Resident #103 was hospitalized from 9/23/24 through 11/6/24 for an ongoing sacral wound that was worsening resulting in osteomyelitis and the need for ileostomy formation for fecal diversion. During an interview on 11/21/24 at 9:13 A.M., Unit Manager #1 and Unit Manager #2 said that there were no recommendations for Resident #103 to go to the wound clinic prior to his/her rehospitalization on [DATE]. During an interview on 11/21/24 at 11:43 A.M., the Director of Nurses said if a recommendation is made to be seen in the wound clinic, she would expect that an appointment is made, however, the facility has trouble getting transportation to and from appointments at this time. During an interview on 11/22/24 at 9:38 A.M., Physician #1 said he is not a wound expert, and he relies on the wound team to be assessing and implementing the correct orders for wound management. During an interview on 11/25/24 at 8:08 A.M., Nurse Practitioner #1 said that she did recommend having Resident #103 seen at the wound clinic, but was not aware that it was never implemented, or that the facility was having trouble with securing transportation to appointments. During an interview on 11/26/24 at 7:13 A.M., Nurse #2 said that the facility does not have a wound physician in house who sees residents with wounds.

Based on observation, interview and record review, the facility failed to ensure it completed a baseline care plan for one Resident (#60) out of 30 sampled residents. Specifically, the facility failed to complete a baseline care plan to address a surgical wound to the lower leg with a leg splint and failed to implement care plan interventions resulting in the development of a Stage 3 pressure injury to the lower back requiring antibiotic treatment and hospitalization , right buttock Stage 2 pressure injury, right lateral foot stage 1 pressure injury, right outer calf DTI (Deep Tissue Injury), and right heel DTI. The facility failed to respond to, and implement new interventions when Resident #60 developed new pressure injuries. Findings include: Resident #60 was admitted to the facility in October 2024 with diagnoses including multiple sclerosis, cellulitis of right lower limb, sepsis due to streptococcus group A, type one diabetes with foot ulcer, unspecified protein calorie malnutrition, muscle weakness, cognitive communication deficit, acute hematogenous osteomyelitis of right ankle and foot, raynaud's syndrome, spinal stenosis, and non-pressure chronic ulcer of right ankle. Review of Resident #60's Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #60 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, and is dependent on staff for activities of daily living tasks. Further review of the MDS indicated Resident #60 was at risk for developing pressure injuries and indicated the use of a pressure reducing device for chair and pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, applications of ointments/medications other than to feet, and applications to dressings of feet with or without topical medications. Review of Resident #60's Braden Scale for Predicting Pressure Injury Risk, dated 11/15/24, indicated a score of 16 indicating the Resident is at risk for developing pressure injuries. Review of Resident #60's Nursing Admission/Readmission Collection Tool dated 10/16/24, indicated Diabetic ulcer to RLE (right lower extremity), unable to visualize as dressing is in place and not to be removed until follow up appointment on October 22 with ortho (orthopedic). Limited/non-weight bearing - right. Review of the hospital discharge summary dated 10/16/24, indicated Resident #60 was admitted with group a bacteremia, encephalopathy, right diabetic foot ulcer complicated by cellulitis and acute lateral malleolus osteomyelitis. Discharge instructions included: -Weight bearing restrictions to the right lower extremity. -Right lower extremity in posterior slab splint, elevate right lower extremity above heart as much as possible. -Do not remove dressing before follow up visit. Follow up with orthopedic surgery. -Up in chair x 2hrs max during day w/waffle cushion on chair at all times. -Activity Recommendation OOB (out of bed) to chair with Prevalon Mat (cushion of air to help with transfers). -Equipment Recommendations: Prevalon Mat. Review of the discharge paperwork indicated the following skin conditions: Wounds: Traumatic Malleolus Right Lateral 6/19/24. Incision Leg Right, 10/7/24 Wound Description 4x4's Webril, Plaster Splint Ace (Webril leg splint is a type of medical bandage used to manage swelling, particularly to the lower leg or foot). Review of Resident #60's baseline care plan dated 10/20/24, indicated: -Encourage good nutrition and hydration in order to promote healthier skin. -Encourage offloading, and repositioning. -Enhanced barrier precautions -Follow facility protocols for treatment of injury. Review of Resident #60's baseline care plan was incomplete and failed to include goals or nursing interventions for wound management. Review of the facility document titled Wound Observation Tool dated 10/30/24, indicated that Resident #60 had five new identified skin areas including: - Right Buttock Pressure Stage 2 10/30/24. Measurement: Length 1.4cm. x 1.0cm. x 0.1cm. - Coccyx Pressure Stage 3 Wound Measurements: Length 1.0cm. x Width 1.0cm. x Depth 0.1 cm. - Right Lateral Foot Stage 1 Wound Measurements: Length 1.7cm. x Width 1.3cm. x Depth 0.0cm. - Right Calf Outer Pressure unstageable- DTI (Deep Tissue Injury). Measurements: Length 7.0cm. x Width 3.0cm. x Depth 0.0cm. - Right Heel Pressure unstageable- DTI (Deep Tissue Injury). Measurements: Length 7.0cm. x Width 3.0cm. x Depth 0.0cm. The Skin Check assessment included the following special equipment/preventive measures: Air mattress, offload as tolerated, turn/reposition, offloading heels. Review of Resident #60's care plan for skin breakdown failed to indicate the interventions recommended from the Skin Check assessment were initiated. On 11/18/24 at 8:43 A.M., the surveyor observed Resident #60 sitting up in bed. The Resident said he/she has lower back pain due to bedsores and said he/she developed a wound to his/her lower leg due to a splint that was not removed after surgery and additional wounds to his/her back. The Resident said he/she was scheduled to have wound debridement done but said he/she has not seen a wound doctor in the facility. There was no air mattress on Resident #60's bed. During an interview on 11/25/24 at 2:13 P.M., Nurse #6 said Resident #60 would have benefited from an air mattress on admission because he/she has been getting more wounds. On 11/25/24 at 2:47 P.M., Resident #60 was sitting up in bed. The Resident said he/she was just given a new mattress and said he/she still has pain to the coccyx area. During an interview on 11/21/24 at 9:23 A.M., Unit Manager #2 said the care plan should have been updated because the Resident was admitted with a wound and is at high risk of developing pressure areas. During an interview on 11/21/24 at 11:55 A.M. the Director of Nursing (DON) said that she would expect wound treatment orders and recommendations to be followed and said care plan interventions should have been implemented on admission. The DON said the Resident is high risk for skin break down and she would expect to see an air mattress order in place and to be on the care plan as well as cushioning, turning and repositioning, offloading of heels and use of the plaster splint should have been documented and assessed.

Based on observations and interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1. Review of the infection control program line listings, the facility failed to indicate the monitoring, tracking, and analyzing of infections in the facility. 2. The facility failed to ensure the use of Enhanced Barrier Precautions during a wound dressing treatment. Findings Include: Review of the facility policy titled Antibiotic Stewardship dated as reviewed 5/19/23, Indicated the following: -The program will be managed and overseen by the Infection Preventionist. 3. Action b. Assessment of residents suspected of having an infection. The facility will utilize the McGeer Criteria when considering initiation of antibiotics. 1. Review of the infection control program failed to indicate the monitoring, tracking, and analyzing of infections in the facility. The facility did not have any documentation of monthly line listings indicating the tracking of antibiotics and failed to provide documentation of signs and symptoms of infections related to antibiotic selection and continuations. During an interview on 11/25/24 at 11:16 A.M., the Infection Preventionist (IP) said she will review the use of antibiotics on admission and at the end of the month when she runs a report to see how many residents were treated with antibiotics. The IP then said she will compare the report with any cultures or labs that were done at the end of each month. The IP said staff will tell her if a resident has a fever or needs an X-ray but she does not track signs and symptoms of infections daily. Review of the Infection Control report printed by the Infection Preventionist dated 11/21/24 showed the use of antibiotics prescribed in the facility from 1/2/24 to 11/12/24 but failed to include active monitoring system and documentation of active infections and antibiotic use. The report contained past details of the prescribed antibiotics. The IP said she does not keep a monthly line listing of active signs and symptoms to track infections or antibiotic use because she will run the antibiotic report at the end of the month for reporting and will review the medical record to see if any labs or cultures were ordered. The IP said she will report infections during the quartely QAPI meeting but not monthly and said outbreaks are discussed monthly if needed. The IP said there have been no outbreaks in the facility. Review of the QAPI Program Data Collection form indicated: Data Analysis Frequency for Infection Prevention Surveillance Reports and Outcome Surveillance Reports are reviewed annually. The IP was unable to provide the survey team with line listings, monthly tracking of infections, or antibiotic usage within the facility for the month of November and said she would not have that data until she looks at the antibiotic report the end of the month because she does not track the data daily. During the survey, there were three identified wound infections within the facility with no active infection control monitoring or documentation. The IP was unaware of the wound infections requiring IV [intravenous] and oral antibiotic therapy for osteomyelitis. During an interview on 11/26/24 at 10:11 A.M. the Director of Nurses (DON) said she expects the facility to follow infection control guidelines for tracking and evaluating infections and said the infection preventionist should be aware of current infection in the facility. 49880 2. Review of facility policy titled Enhanced Barrier Precautions, dated as reviewed 6/3/24, indicated the following: -The facility should use Enhanced Barrier Precautions (EBP) as an additional Multi Drug Resistant Organism (MDRO)mitigation strategy for residents that meet the following criteria, during high- contact resident care activities. -EBP are indicated for residents with any of the following: wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. -Examples of high- contact resident care activities requiring gown and glove use include: wound care: any skin opening requiring a dressing. During an observation on 11/25/24 at 1:25 P.M., the surveyor entered a resident room to observe wound care. There was a sign on the doorway indicating Enhanced Barrier Precautions to be used. Nurse #1 was in the process of providing wound care to the resident. Nurse #1 had gloves on but was not utilizing a gown as indicated on the sign for EBP outside of the resident's room. During an interview on 11/25/24 at 1:27 P.M., Nurse #1 said that she should be wearing a gown for wound care but that she forgot to put it on. During an interview on 11/26/24 at 8:03 A.M., the Director of Nurses said that she would expect that staff wear a gown while performing a dressing change.

Based on observation and interview the facility failed to properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Review of the facility policy titled Safe Food Handling, dated as revised 4/26/23, indicated the following: - All food purchased, stored, and distributed is handled with accepted food-handling practices and per federal, state and local requirements. - Associates shall wash their hands before handling or consuming food including working with clean equipment and utensils, and: - After handling soiled equipment or utensils - During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks - Before donning gloves to initiate a task that involved working with food - After engaging in any other activities that contaminate the hands - All food is handled carefully to avoid contamination with potentially harmful debris The surveyor made the following observations on 11/22/24 during the breakfast tray line service in the kitchen: - At 7:28 A.M., a dietary aide was observed touching bread with her bare hands, wearing no disposable gloves while toasting the bread. - At 7:47 A.M., the same dietary aide removed her disposable gloves, left the station where she was toasting bread and went into the dry storage room to obtain new loaves of bread. She did not wash her hands or perform hand hygiene and put on a new set of gloves, contaminating the gloves. She then proceeded to grab the bread with the contaminated gloves and toast the bread. - At 7:54 A.M., the same dietary aide removed the gloves, left her station where she was toasting bread and went into the dry storage room to obtain new loaves of bread. She did not wash her hands or perform hand hygiene and put on a new set of gloves, contaminating the gloves. She then proceeded to grab the bread with the contaminated gloves and toast the bread. During an interview on 11/25/24 at 2:07 P.M., the Foodservice Director (FSD) said she expects dietary staff to be washing their hands before doing any task in the kitchen. The FSD continued to say staff should be washing their hands before putting on a new set of gloves, and when leaving their stations to change tasks. The FSD then said staff should not be touching ready to eat food with bare hands.

Based on observations, record review, policy review, and interview, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#70), out of a total sample of 30 residents. Specifically, for Resident #70, the facility failed to ensure nursing completed a PICC line dressing change as ordered by the physician. Findings Include: Review of facility policy titled 'Central Vascular Access Device (CVAD) Dressing Change' revised January 2004, indicated the following but not limited to: -The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. -perform sterile dressing changes: at least weekly -Upper arm circumference with PICC, and external catheter length measurements must still be completed as part of the initial assessment. Resident #70 was admitted to the facility in October 2024 with diagnoses that include acute osteomyelitis right ankle and foot and non-pressure chronic ulcer of right heel and mid foot. Review of Resident #70's Minimum Data Set, dated dated dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that the Resident is cognitively intact. The MDS further indicated that the Resident is on IV (intravenous) and antibiotic medications. The following observation was made by the surveyor: -On 11/19/24 at 8:33 A.M., the surveyor observed the Resident with a PICC line to the right arm. The dressing over the arm was dated 11/4/24. -On 11/19/24 at 12:34 P.M., the surveyor observed the Resident with a PICC line to the right arm. The dressing over the arm was dated 11/4/24. The Resident said the nurses look at it but did not recall anyone taking off the whole thing indicating to the dressing. Review of Resident #70's physician's orders indicated the following: -Change PICC line transparent dressing weekly every Sun Measure upper arm circumference (10cm above antecubital). - Measure external catheter length. Notify MD if length has changed since last measurement AND as needed for concern of line movement or infection. - Measure upper arm circumference (10cm above antecubital. Measure external catheter length. If length has changed since last measurement; if concern of line movement, infection, hold antibiotic and notify MD, dated 10/29/24. Review of the November 2024 Medication Administration Record indicated the following: -The PICC line dressing was changed on 11/3/24 and documented as NA for arm circumference and external catheter length. -The PICC line dressing change was signed as other/see nurses note on 11/10/24. -The PICC line dressing was documented as changed on 11/17/24. Review of Resident #70's Progress notes indicated the following: -An Orders- Administration Note dated 11/10/24 indicating Change PICC line transparent dressing weekly every Sun Measure upper arm circumference (10cm above antecubital). Measure external catheter length. Notify MD if length has changed since last measurement. at activities -A skilled note dated 11/17/24 indicated the following but not limited to: 'PICC patent, dressing intact'. Review of the progress notes failed to indicate that the PICC line dressing was changed on 11/17/24. Review of the active care plan indicated the following: -Peripherally Inserted Central Catheter (PICC)/ Potential for catheter related bloodstream infection, phlebitis, site infection, deep vein thrombosis, catheter occlusion, and catheter migration, date Initiated 11/14/24, with interventions that include: -Measure upper arm circumference as ordered. -Compare insertion site and precious measurements, notify prescriber with changes. -Measure external catheter length on admission, weekly with each dressing change and as needed. Review of the medical record failed to indicate that arm circumference or external length had been measured until 11/20/24. During an interview on 11/22/24 at 1:51 P.M., Nurse #1 said that PICC line dressings should be changed every seven days. During an interview on 11/25/24 at 8:01 A.M., the Director of Nurses (DON) said that PICC line dressing changes are weekly. She said that she would expect that every time the nurses are using the PICC line that they are assessing the line and insertion site. She would expect the dressing would also be changed as needed if it was soiled or lifting off.

Based on record review and interviews, the facility failed to develop and implement person-centered care plans for two Residents (#42, and #83) out of a sample of 30 Residents. Specifically, 1. For Resident #42, the facility failed to implement an Activities of Daily Living (ADL) care plan. 2. For Resident #83 the facility failed to develop a person-centered behavior and history of substance abuse care plan. Findings include: A review of the facility policy titled Area of Focus: Care Planning-Baseline, Comprehensive, and Routine Updates reviewed 1/4/24 indicated the following: -The facility is required to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs. -The comprehensive care plan must include a problem/focus statement, measurable goals, and interventions. A review of the facility policy titled 'Behavioral Health Services' reviewed 9/6/24 indicated the following: -The facility will provide behavioral health care and services that create an environment that promotes emotional and psychosocial well-being, meet each resident's needs and include individualized approaches to care. Procedure: -Complete a social services assessment upon admission/readmission, quarterly and as needed with change in condition. -Initiate behavior monitoring, behavior management care plan and Kardex as indicated by assessment findings. The Social Worker is primarily responsible for initiation of the behavior management care plan. 1. Resident #42 was admitted to the facility in April 2017 with diagnoses including Dementia and depression. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating severe impairment. Further review of the MDS indicated the following: -The ability to transfer to and from a bed to a chair (or wheelchair))-dependent-helper does all of the effort, resident does none of the effort to complete the activity. A review of Resident #42's Activities Daily Living (ADL) care plan initiated 4/24/19 indicated the following interventions: -Resident utilizes wheelchair and requires staff assist for locomotion. -Resident requires mechanical lift (Hoyer) with two assist for transfers. A review Resident #42's transfer tasks from 5/20/24-5/27/24 indicated that staff signed off they completed transfer tasks as follows: - Transfer-Self Performance-How the resident moves between surfaces including to and from bed, chair, wheelchair, standing position (excludes to/from bath/toilet). - Transfer-Support provided- How the resident moves between surfaces including to and from bed, chair, wheelchair, standing position (excludes to/from bath/toilet). -5/20/24-Day shift-4,2-4-Total dependence (Full staff performance), 2-One-person physical assist, Evening shift-3,2-3-Extensive assistance (Resident involved in activity, staff provide weight bearing support), 2-One-person physical assist. -5/21/24-Evening shift-4,2-4-Total dependence (Full staff performance), 2-One-person physical assist. -5/26/24-Day shift-2,2-2-Limited assistance (Resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) 2-One-person physical assist. During an interview and record review on 11/22/24 at 6:15 A.M., Certified Nurse's Assistant (CNA) #5 said all staff are expected to follow the care plan, he said all residents on mechanical lifts, Hoyers, for transfers should be transferred by two staff at all times. CNA #5 said if the Resident is not transferred by two staff, the transfer could be dangerous, he said the Resident could get injured, get a skin tear, fall, or get stuck in the equipment during the transfer. CNA #5 said Resident #42 should always be transferred by two staff at all times. CNA #5 did not have any comment after reviewing the May 2024 transfer record indicating he signed off on 5/21/24 evening shift that he transferred Resident #42 alone. CNA #5 did not have any comment when the surveyor asked if he transferred Resident #42 alone on 5/21/24. During an interview and record review on 11/22/24 at 7:46 A.M., CNA #7 said care plans should always be followed, she said residents who should be transferred with a Hoyer lift should be transferred by two staff at all times. CNA #7 said if the residents are transferred by one staff only, they could get hurt, get skin tears, fall, fracture and could possibly die. After reviewing the May 2024 transfer record with the surveyor, CNA #7 had no comment on why she documented that she transferred Resident #42 alone on 5/20/24 day shift. CNA #7 did not have any comment when the surveyor asked if she transferred Resident #42 alone on 5/20/24 day shift. During a telephone interview on 11/22/24 at 9:12 A.M., CNA #9 said all care plans should be followed, she said all residents on Hoyer transfers should be transferred by two staff at all times. CNA #9 was informed by the surveyor that on 5/20/24 evening shift, she signed off the transfer task that she transferred Resident #42 alone. CNA #9 did not have any comment when the surveyor asked if she transferred Resident # 42 alone on 5/20/24 evening shift. CNA #9 said Resident #42 should not be transferred by one staff. During an interview and record review on 11/22/24 at 8:09 A.M., CNA #8 said care plans should be followed at all times, she said residents requiring a two-person transfer should always be transferred by two staff. She said if one staff attempts to complete the transfer, the resident could fall and get injured. CNA #8 and the surveyor reviewed the May 2024 transfer record indicating she transferred Resident #42 alone on 5/26/24 day shift. CNA #8 did not have any comment when the surveyor asked if she transferred Resident #42 alone on 5/26/24 day shift. During an interview and record review on 11/22/24 at 10:15 A.M., Unit Manager #2 said she expects all the staff on the unit to follow care plans. Unit Manager #2 said residents who require a two person transfer with a Hoyer lift should always be transferred by two staff. She said if staff transfer the resident alone, the resident could get stuck in the wheelchair, the Hoyer lift could tip, the Resident could get tangled in the wheelchair and get injured. Unit Manager #2 said Resident #42 should be transferred by two staff at al times. During an interview on 11/25/24 at 6:27 A.M., Nurse #8 said he expects staff to follow all care plans, he said residents who require a Hoyer to transfer should be transferred by two staff at all times. Nurse #8 said if staff transfer the resident alone, the resident could get injured, the resident could fall and acquire skin tears. Nurse #8 said Resident #42 should be transferred by two staff at all times. During an interview and record review on 11/25/24 at 9:08 A.M., The Director of Rehabilitation said Resident #42 should be transferred with a Hoyer lift and two staff should always assist. During an interview on 11/25/24 at 9:58 A.M., the Director of Nurses (DON) said all care plans should be followed as written. She said she expects all residents who are transferred by a Hoyer lift to have two staff assisting during transfers at all times. The DON said she was not aware that staff were documenting that they were transferring Resident #42 alone. The DON said if staff transfer the residents on Hoyer transfers alone, the residents could have potential for injuries which include fractures, and skin tears. The DON said Resident #42 should always be transferred by two staff at all times. 2. Resident #83 was admitted to the facility in August 2021 with diagnoses including major depressive disorder, hallucinations and psychotic disorder. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating severe cognitive impairment. A review of a medication management behavioral health note dated 9/10/24 indicated the following: -Chief complaint- Requested to be seen by staff for anxiety. -History of present illness- hallucinations and paranoid delusions. Substance Use/Addiction history-Resident consumed alcohol in his/her early life, history of alcohol use disorder, history reviewed (no changes). A review of the behavior care plan dated 5/4/23 indicated the following: - Resident has noted behaviors including accusing of others, expressing frustration/anger towards others, disruptive sounds, and wandering causing disruption to others and the environment requiring staff intervention. [sic] A review of the mood and behavior care plan dated 2/7/23 indicated the following: -At risk for change in mood and behavior due to dementia, (resident exhibits confusion, anxiety and paranoia). [sic] During an interview and record review on 11/21/24 at 1:13 P.M., Social Worker #1 and the Surveyor reviewed Resident #83's care plan. Social Worker #1 said that all of the Resident's behaviors were not included in the behavior care plan. She said a hallucinations and a history of alcohol abuse care plan should be developed. The Social Worker said the care plan that included paranoia as a behavior did not personalize the Resident's paranoid delusions. Social Worker #1 said all residents' behavior care plans should be person centered.

Based on observation, record review, and interview, the facility failed to provide adequate supervision, implement care plans and update falls care plans as needed resulting in falls with injury for 1 sampled Resident (#9) out of a total of 22 sampled Residents. Findings include: Review of the facility's Incident and Reportable Event Management Policy, revised 8/16/22, indicated: *Policy: The facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. *Event management includes but is not limited to the following types of events: falls, unwitnessed or witnessed *Procedure: The licensed nurse should perform a quick initial investigation to determine the most likely cause of the event. The licensed nurse should implement an appropriate immediate intervention, based on the conclusions of the initial investigation. The licensed nurse should update the resident care plan and communicate the intervention to the staff caring for the resident. Resident #9 was admitted to the facility in March 2021 with diagnoses including dementia and muscle weakness. Review of his/her most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated he/she is moderately cognitively impaired and requires assistance with toileting, transfers and dressing, and supervision with ambulation. On 10/4/22, at 7:54 A.M., the surveyor observed Resident #9 asleep in bed. Resident #9 had a cast on his/her right hand. Review of Resident #9's care plans indicated: The Resident has an Activities of Daily Living (ADL) self care performance deficit due to decreased ability to initiate and sequence steps to perform ADL tasks: 7/20/21. Interventions: Mobility: Resident ambulates with supervision and at times needs handheld assist of 1 due to fatigue, weakness, cognitive deficits (revised 5/11/22). Dressing: The Resident is dependent on staff to dress. Toilet Use: The Resident is dependent on staff for toileting. Transfer: The Resident is able to transfer bed to chair with supervision. Resident is at risk for falls, 3/27/21; revised 8/1/22. Interventions: Call light within reach, complete fall risk assessment. Keep pathway to bathroom free of clutter and obstacles (8/19/21) Keep walker within reach as much as possible. Offer reminders if noted to be ambulating without his/her walker. Review of Resident #9's falls incident reports indicated the following: 3/20/22: at 6:20 P.M., staff found Resident #9 on the floor on of his/her room. The fall investigation form section Recommendations/Actions taken indicated: non-skid strips next to both sides of the bed and non-skid socks to be worn by Resident #9 while in bed. 4/6/22: at 8:30 P.M. staff found Resident #9 on the floor of his/her room and he/she had sustained skin tears. Resident #9 said he/she had sat on the floor to change his/her pants. The form indicated Recommendations/Actions taken was to encourage Resident #9 to wear Geri sleeves; an intervention that would not address Resident #9 potential for further falls. There were no updates to Resident #9's fall care plan. 5/8/22: at 3:35 P.M. staff found Resident #9 laying in bed with blood on his/her face. The fall investigation concluded that Resident #9 had an unwitnessed fall in his/her bathroom and he/she was sent to the ER and returned with steri strips to his/her left eye. The Recommendations/Actions taken indicated for staff to ensure the removal of wet floor signs from Resident #9's bathroom. Resident #9's existing care plans indicated interventions that Resident #9 required assistance with toileting and for there to be clear pathways without obstacles to his/her bathroom. 5/17/22: at 10:45 P.M. staff heard Resident #9 yelling for help and he/she was found on floor of room. Resident #9 had sustained a laceration to his/her upper lip and was sent to the hospital where he/she received 8 sutures. Resident #9 reported to staff that he/she was getting up to go to the bathroom. Two days later on 5/19/22, Resident #9 had an X-ray to his/her right ankle after swelling was noted and results indicated a healing distal fibular shaft fracture. There were no updates to his/her fall care plan. 7/30/22: at 4:30 P.M., Resident #9 reported pain to his/her right hand and nursing noted bruising and swelling. On 8/1/22, an X-ray was conducted at the facility and the findings indicated an acute metacarpal fracture with malalignment. Resident #9 reported to staff that he/she fell in the bathroom. Resident #9's care plans were updated to have rehab assess and evaluate him/her and for non-skid strips to be placed to the sink and commode area. 8/23/22: at 8:00 A.M., Resident #9 was found by staff laying on the floor next to his/her bed with a laceration to the right side of his/her forehead. Resident #9 was sent to the ER and required 4 sutures. There were no updates to his/her fall care plan. 9/15/22: at 11:45 A.M., The staff heard a loud bang and Resident #9 was found on floor in his/her room. Recommendations/Actions taken indicated for pharmacy to perform a medication review and for staff to complete orthostatic blood pressures 2 times a day for 4 days. 9/16/22: at 1:55 P.M., staff heard a bang and found Resident #9 on the floor in front of his/her closet. Recommendations/Actions taken indicated for labs to be ordered. There were no updates to Resident #9's fall care plan. On 10/5/22, at 12:40 P.M. the surveyor observed Resident #9 standing in front of his/her window in his/her room. Resident #9's walker was approximately 4 feet away from him/her. There were no staff in the area to supervise or assist Resident #9 as he/she turned and held on to furniture as he/she put himself/herself back in bed. During an interview on 10/5/22, at 12:43 P.M., CNA #4 said that she was assigned to care for Resident #9. She said that Resident #9 was not at risk for falls. On 10/5/22, at 1:50 P.M., the surveyor observed Resident #9 ambulating independently down the hallway. There were no staff in the area providing supervision. Then, Resident #9 approached the nurses station and spoke with CNA #4. Resident #9 then turned around and while CNA #4 continued to stay at the nurses station, Resident #9 ambulated independently back to his/her room without staff supervision.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's order for [MEDICATION NAME] (long acting injectable antipsychotic) was for 125 milligrams (mg), the Facility failed to ensure the resident was free from significant medication errors, when he/she was administered [MEDICATION NAME] 500 mg, in error. Resident #1 was transferred to the Hospital Emergency Department and admitted with a [DIAGNOSES REDACTED]. Findings include: Review of the Facility's Policy titled, Administration of Medications, dated 5/6/20, indicated, all medications would be administered safely and appropriately per physician order, the Facility would ensure residents were free from significant medication errors, defined medication errors as preparation or administration of medications which was not in accordance with accepted professional standards manufacturer's specifications regarding the preparation and administration of medications, and defined significant medication errors as one which caused the resident discomfort or jeopardized his or her health or safety. Review of the Facility's Policy titled, Intramuscular Injection, dated 8/21/20, which referred to the Lippincott Procedure, titled, Intramuscular Injection, dated 8/21/20, indicated staff would avoid distractions and interruptions when preparing and administering medications to prevent medication errors, and staff would verify administration of the proper dose of medication. Review of Resident #1's medical record indicated he/she was admitted to the Facility in November 2020, with [DIAGNOSES REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of the pharmacy instructions affixed to Resident #1's [MEDICATION NAME] multidose vial packaging indicated [MEDICATION NAME] 100 mg per ml, inject 1.25 ml IM one time a day every 14 days. Review of actual vial contents indicated it was labeled as [MEDICATION NAME] (1 mg per ml) and that the vial contained a total of 5 milliliters (which converted to 500 mg) in multidose vial. Review of the Facility's Investigation, undated, indicated that on 11/26/20, Nurse #1 administered 5 ml (500 mg) of [MEDICATION NAME] to Resident #1, in error. The Facility's Investigation indicated Resident #1 was transferred to the Hospital for evaluation. Review of Resident #1's Hospital Discharge Summary, dated 11/28/20, indicated Resident #1 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. During interview on 12/21/20 at 3:00 P.M., Nurse #1 said that on 11/26/20 at 5:00 P.M., he was preparing Resident #1's [MEDICATION NAME] injection, and was repeatedly distracted by another resident. Nurse #1 said he needed to use two syringes because of the volume of medication in the vial, drew up the entire 5 ml vial, and after he administered both syringes to Resident #1, he recognized that he had accidentally administered 500 mg instead of the prescribed 125 mg. During interview on 12/21/20 at 1:04 P.M., the Director of Nurses said Resident #1's MAR indicated [REDACTED].

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), who was dependent on staff for transfers and required the assistance of two with a mechanical lift, the Facility failed to ensure his/her safety was maintained during a mechanical lift transfer and that he/she was transferred using the appropriate mechanical lift. Resident #1 was transferred using a sit to stand lift that required him/her to perform some weight bearing, instead of a mechanical lift that required him/her to perform no weight bearing during the transfer. After the transfer, Resident #1 experienced a change in condition, exhibited signs and symptoms of pain, he/she was transferred to the Hospital Emergency Department for evaluation and diagnosed with [REDACTED]. Findings include: The Facility's Policy titled, Mechanical Lift Use, undated, indicated staff would review the resident's care plan for any special needs of the resident, and would follow the manufacturer guidelines with respect for use of the mechanical lift, and the resident would safely transfer between areas without falls or injury. A Hoyer Lift transfer is performed using a full body sling attached to the boom of a mechanical lift, and does not require the person being transferred to bear any weight at all. The Instruction Guide for the Sabina II Lift, dated 4/17/2012, indicated: - The resident must be able to bear weight - Staff would place the resident's feet in the middle of the foot rest with the lower legs parallel to the lower leg support - Before using the Sabina Lift, staff would adjust the height and depth of the lower leg support as needed for comfortable support below the kneecap Resident #1 was admitted to the Facility in March of 2018, with [DIAGNOSES REDACTED]. The Physical Therapy Evaluation and Plan of Treatment, dated 6/21/19 through 7/4/19, indicated Resident #1's transfer status was dependent with use of a Hoyer. The Quarterly Minimum Data Set (MDS) assessment, dated 7/31/19, indicated Resident #1 was dependent on two or more staff for all transfers. The Activities of Daily Living Care Plan, dated 11/21/18, with last updated target date of 11/12/19, indicated Resident #1 was dependent on two staff members for transfer using a mechanical lift. The Care Plan indicated staff to specify which mechanical lift Resident #1 required. However review of the Care Plan indicated the specific type of mechanical lift staff were to utilize when transferring Resident #1 was not indicated. Furthermore, there was no documentation to support that after Physical Therapy recommended use of the Hoyer Lift that staff updated Resident #1's Care Plan to reflect the Physical Therapy recommendations. A Nurse Progress Note, dated 9/10/19, indicated Resident #1 was assessed as having increased respirations, an irregular and rapid heart rate, and his/her skin color was pale. A Nurse Progress Note, dated 9/10/19, indicated Resident #1 was expressing pain when touched on his/her lower abdominal area. A Nurse Progress Note, dated 9/10/19, indicated Resident #1 was transferred to the Hospital Emergency Department for evaluation. The Hospital's Radiology Cat Scan (CT) Report, dated 9/11/19, indicated Resident #1 was diagnosed with [REDACTED]. The Facility's Investigation Report, undated, indicated that on 9/10/19 during the Sabina mechanical lift transfer with staff, Resident #1 knelt on the knee rest and lifted his/her feet off the foot plate. The Report indicated staff assisted Resident #1 to lower his/her legs to complete the transfer. The Report indicated that later that day, Resident #1 was assessed with [REDACTED].#1's injuries may have been the result of Resident #1 kneeling on the knee rest of the Sabina mechanical lift during the transfer on the morning of 9/10/19. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 12:51 P.M. on 10/16/19. CNA #1 said she had known Resident #1 to require transfers using a Hoyer lift. CNA #1 said that on 9/10/19 she provided morning care for Resident #1, and said she got CNA #2 to assist her with transferring Resident #1 from the bed to his/her wheelchair using the Sabina mechanical lift. CNA #1 said when she and CNA #2 raised the Sabina mechanical lift to what should have been a standing position for Resident #1, he/she knelt on the knee rest and raised his/her feet off the foot plate, and said she realized she and CNA #2 needed assistance to complete the transfer. CNA #1 said she called to Nurse #1 to assist her and CNA #2 with the transfer. CNA #1 said Nurse #1 and CNA #2 moved Resident #1's knees from the knee rest by pushing his/her lower legs down while he/she was suspended up in the sling of the Sabina mechanical lift, and then completed transferring him/her to the reclining wheelchair. CNA #1 said once the transfer was completed, Resident #1 was breathing heavy, as though he/she had exerted him/herself. CNA #1 said she had only used the Sabina mechanical lift to transfer Resident #1 one other time, and said she had previously used the Hoyer lift to transfer Resident #1. CNA #1 said she did not know why staff were using the Sabina mechanical lift to transfer Resident #1. The Surveyor interviewed CNA #2 at 2:55 P.M. on 10/15/19. CNA #2 said she was familiar with Resident #1, and said his/her transfer ability would change from day to day, and said some days Resident #1 was able to stand up, but some days he/she was unable to follow directions and required a Hoyer transfer. CNA #2 said on the morning of 9/10/19, she assisted CNA #1 transfer Resident #1 using the Sabina mechanical lift. CNA #2 said Resident #1 was known to put his/her knees up on the knee rest and lift his/her feet off the foot rest during transfers with the Sabina mechanical lift, and said Resident #1 had previously been transferred using the Hoyer lift. CNA #2 said only physical therapy was allowed to determine residents' transfer status. The Surveyor interviewed Nurse #1 at 10:43 A.M. on 10/16/19. Nurse #1 said that on the morning of 9/10/19, she was called to Resident #1's room by CNA #1 and CNA #2 to assist with transferring Resident #1 to his/her reclining wheelchair using the Sabina mechanical lift. Nurse #1 said when she went to Resident #1's room, he/she was already up in the lift, and was kneeling on the knee rest with his/her feet lifted off the foot plate. Nurse #1 said Resident #1 did not put his/her feet down for the entire transfer, and said CNA #1 and CNA #2 attempted to reposition Resident #1's legs by pushing down on his/her lower legs, but he/she did not stand on the foot plate. The Surveyor interviewed the Director of Rehabilitation Services (Director of Rehab) at 10:28 A.M. on 10/18/19. The Director of Rehab said Resident #1 was known to be unable to follow directions due to cognitive decline. The Director of Rehab said Resident #1 had not been assessed by Therapy for use of the Sabina mechanical lift. The Surveyor interviewed the Director of Nurses at 10:15 A.M. on 10/15/19 and multiple times throughout the survey. The Director of Nurses said she would expect staff to follow Physical Therapy's recommendation for use of the Hoyer Lift for Resident #1's transfers. The Surveyor interviewed the Medical Director at 12:45 P.M. on 10/15/19. The Medical Director said the Facility determined that when Resident #1 knelt on the knee rest of the Sabina lift and his/her legs were lowered by staff, the twisting and pressure associated with the transfer was likely the cause of his/her fractures.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), who was dependent for transfers, required two person assist with a mechanical lift, the Facility failed to ensure his/her plan of care related to activities of daily living specific to transfers indicated the type of mechanical lift he/she required for safe transfer. Although Physical Therapy recommendations indicated that Resident #1 should be transferred using a Hoyer lift, staff utilized a Sabina lift which was not appropriate for him/her, and as a result Resident #1 sustained multiple fractures. Findings include: The Facility's Policy titled, Mechanical Lift Use, undated, indicated staff would follow the manufacturer guidelines with respect for use of the mechanical lift, and the resident would safely transfer between areas without falls or injury. A Hoyer Lift transfer is performed using a full body sling attached to the boom of a mechanical lift, and does not require the person being transferred to bear any weight at all. The Instruction Guide for the Sabina II Lift, dated 4/17/2012, indicated: - The resident must be able to bear weight - Staff would place the resident's feet in the middle of the foot rest with the lower legs parallel to the lower leg support - Before using the Sabina Lift, staff would adjust the height and depth of the lower leg support as needed for comfortable support below the kneecap Resident #1 was admitted to the Facility in March of 2018, with [DIAGNOSES REDACTED]. The Physical Therapy Evaluation and Plan of Treatment, dated 6/21/19 through 7/4/19, indicated Resident #1's transfer status was dependent with use of a Hoyer. The Activities of Daily Living Care Plan, dated 11/21/18, with last updated target date of 11/12/19, indicated Resident #1 was dependent on two staff members for transfer using a mechanical lift. The Care Plan indicated staff to specify which mechanical lift Resident #1 required. However review of the Care Plan indicated the specific type of mechanical lift staff were to utilize when transferring Resident #1 was not indicated. Furthermore, there was no documentation to support that after Physical Therapy recommended use of the Hoyer Lift that staff updated Resident #1's Care Plan to reflect the Physical Therapy recommendations. A Nurse Progress Note, dated 9/10/19, indicated Resident #1 was assessed as having increased respirations, an irregular and rapid heart rate, and his/her skin color was pale. A Nurse Progress Note, dated 9/10/19, indicated Resident #1 was expressing pain when touched on his/her lower abdominal area. A Nurse Progress Note, dated 9/10/19, indicated Resident #1 was transferred to the Hospital Emergency Department for evaluation. The Facility's Investigation Report, undated, indicated that on 9/10/19 during the Sabina mechanical lift transfer with staff, Resident #1 knelt on the knee rest and lifted his/her feet off the foot plate. The Report indicated staff assisted Resident #1 to lower his/her legs to complete the transfer. The Report indicated that later that day, Resident #1 was assessed with [REDACTED]. The Hospital's Radiology Cat Scan (CT) Report, dated 9/11/19, indicated Resident #1 was diagnosed with [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 12:51 P.M. on 10/16/19. CNA #1 said she had known Resident #1 to require transfers using a Hoyer lift. CNA #1 said that on 9/10/19 she provided morning care for Resident #1, and said she got CNA #2 to assist her with transferring Resident #1 from the bed to his/her wheelchair using the Sabina mechanical lift. The Surveyor interviewed CNA #2 at 2:55 P.M. on 10/15/19. CNA #2 said she was familiar with Resident #1, and said his/her transfer ability would change from day to day. CNA #2 said on the morning of 9/10/19, she assisted CNA #1 transfer Resident #1 using the Sabina mechanical lift. CNA #2 said Resident #1 was known to put his/her knees up on the knee rest and lift his/her feet off the foot rest during transfers with the Sabina mechanical lift, and said Resident #1 had previously been transferred using the Hoyer lift. CNA #2 said only physical therapy was allowed to determine residents' transfer status. The Surveyor interviewed the Medical Director at 12:45 P.M. on 10/15/19. The Medical Director said the Facility determined that when Resident #1 knelt on the knee rest of the Sabina lift and his/her legs were lowered by staff, the twisting and pressure associated with the transfer was likely the cause of his/her fractures.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Nurse #1 and Nurse #2 placed Resident #1 in the Broda chair in a safe area in his/her room. Resident #1's plan of care indicated his/her [DIAGNOSES REDACTED]. On 3/28/15, Nurse #1 and Nurse #2 positioned Resident #1 in the Broda chair next to the baseboard heater in his/her room to watch television and Resident #1 was found by certified nursing assistant (CNA) #4 with the left hand dangling off the side of the chair and resting on the heater. Resident #1 sustained a burn to his/her left thumb and left hand. Findings include: The Face Sheet indicated the staff admitted Resident #1 to the Facility in August 2014 and Resident #1 had a history of [REDACTED]. The Quarterly Minimum Data Set (MDS) Assessment, completed on 1/28/15, indicated Resident #1's [DIAGNOSES REDACTED]. The MDS Assessment indicated Resident #1 had minimal cognitive impairment and usually understood others. The MDS Assessment indicated two staff were required for transfer activities and positioning Resident #1. The Physician Order, dated 3/18/15, included: Resident #1 to rest left upper extremity on a pillow at all times. The Surveyor interviewed the Rehabilitation Director at 12:00 P.M. on 5/12/15. The Rehabilitation Director said the rehabilitation staff trialed several different types of chairs with Resident #1 to improve his/her positioning when out of bed. The Rehabilitation Director said although Resident#1 had sporadic movement and was able to shift his/her position in the Broda chair, the Broda chair afforded Resident #1 the safest and most comfortable seating system. The Surveyor interviewed Unit Manager #1 at 11:05 A.M. on 5/12/15. The Surveyor interviewed Nurse #2 at 11:45 A.M. on 5/12/15. The Surveyor interviewed Nurse #3 at 10:00 A.M. on 5/12/15. The Surveyor interviewed Nurse #4 at 3:30 P.M. on 5/12/15. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:15 P.M. on 5/12/15. The Surveyor interviewed CNA #2 at 12:20 P.M. on 5/12/15. The Surveyor interviewed CNA #3 at 2:00 P.M. on 5/12/15. The Surveyor interviewed CNA #4 at 3:05 PM. on 5/12/15. Unit Manager #1, Nurse #2, Nurse #3, Nurse #4, CNA #1, CNA #2, and CNA #3 said Resident #1 moved in the Broda chair, used his/her right arm to move the pillow, frequently scooted down in the Broda chair, and required frequent monitoring and positioning. Unit Manager #1, Nurse #2, Nurse #3, Nurse #4, CNA #1, CNA #2 CNA #3, and CNA #4 said sometimes they observed the pillow under Resident #1's left arm on the floor and Resident #1 leaned toward his/her left side with the paralyzed arm hanging over the Broda chair. Unit Manager #1, Nurse #2, Nurse #3, Nurse #4, CNA #1, CNA #2 CNA #3, and CNA #4 said the staff monitored Resident #1 in the hallway or in the Day Room to assist him/her with frequent positioning and to keep him/her safe. Unit Manager #1 said Resident #1 attended the activity in the Day Room after lunch. CNA #3 said on 3/28/15, she was assigned to provide personal care to Resident #1 between 6:00 A.M. and 2:00 P.M. CNA #3 said she provided incontinence care to Resident #1 prior to lunch and after lunch. CNA #3 said she went to lunch break between 1:00 P.M. and 1:15 P.M. and Resident #1 was in the Day Room. CNA #3 said Resident #1 was always in the Day Room in the afternoon at an activity and the staff notified her if Resident #1 required assistance. CNA #3 said the nurse did not tell her Resident #1 was in his/her room, therefore, she did not observe Resident #1 after she returned to the nursing unit or prior to finishing her shift. The Surveyor interviewed Nurse #1 at 11:30 A.M. on 5/12/15. Nurse #1 said she was a per diem nurse at the Facility and was not familiar with Resident #1. Nurse #1 said she was not aware Resident #1 moved in the Broda chair and required frequent positioning and monitoring. Nurse #1 said after lunch, she transferred Resident #1 to his/her room and changed the colostomy bag. Nurse #1 said afterward, she and Nurse #2 positioned Resident #1 in the Broda chair. Nurse #1 said Resident #1 asked if he/she could watch television in his/her room. Nurse #1 said she asked Nurse #2 if Resident #1 was allowed to stay in his/her room and Nurse #2 said yes. CNA #1 said on 3/28/15, between 1:00 P.M. and 2:00 P.M., she and the nurses positioned Resident #1 in the Broda chair. CNA #1 said the nurse placed Resident #1's Broda chair at an angle next to the side of the bed, near the foot of the bed, which was near the baseboard heating unit near the floor. CNA #1 said the nurse placed a pillow under Resident #1's left arm and she left the room. Nurse #1 and Nurse #2 said the baseboard heater was on Resident #1's left side and the Broda chair was not too close toward the baseboard heater. Nurse #2 said Resident #1 was not able to independently move the Broda chair. Nurse #2 said the CNAs were responsible for monitoring the residents after lunch. Nurse #2 said she did not notify the CNAs that Resident #1 was in his/her room and did not tell Nurse #1 to notify the CNAs. Nurse #1 said at 2:30 P.M., she spoke with Resident #1's Roommate. Nurse #1 said Resident #1 sat in the Broda chair with his/her left arm on a pillow and voiced no concerns. CNA #4 said on 3/28/15, at 3:15 P.M., she was surprised to see Resident #1 in the Broda chair in his/her room, which was next to the baseboard heating unit near the window. CNA #4 said the room temperature was hot and the thermostat was set at 80 degrees Fahrenheit. CNA #4 said Resident #1 told her his/her hand was stinging. CNA #4 said she observed Resident #1's left arm dangling on the side of the Broda chair and his/her fingers rested on the baseboard heater. CNA #4 said she immediately removed Resident #1's left hand from the baseboard heater and notified the Nurse #4. Nurse #4 said on 3/28/15, she immediately assessed Resident #1's left hand. The Non-Pressure Skin Condition Record, dated 3/28/15, indicated Resident #1 had a 2.5 centimeter (cm) by 2 cm burn on the left thumb, a 2 cm by 1.5 cm burn on the first left finger, and a 1.3 cm by 1 cm burn on the left third finger. Nurse #4 said the above areas were intact blisters. Nurse #4 said the blisters on the first and third fingers on the left hand were on Resident #1's knuckles. The physician progress notes [REDACTED].#1 had a weak extremity with a burn from the heater in his/her room. The Physician Note indicated there was decreased [DIAGNOSES REDACTED] and the left thumb had a large blister. The Physician Order, dated 3/28/15, included: apply Silvadene (cream to treat burns) to burn/blister areas of left hand/digits followed by dry clean dressing twice a day. The Surveyor interviewed the Director of Nurses (DON) at 7:20 A.M. on 5/12/15. The DON she investigated the incident. The DON said the staff were not aware Resident #1's Roommate sometimes turned the temperature up in the room. The DON said placing a resident next to a heating unit was not a safe practice.

Based on observations, staff interviews, and record review, the facility failed to prevent the fall for 1 resident (Resident #8) in a total sample of 24 residents and failed to ensure that the resident environment remained as free of accident hazards as possible. Findings include: 1. For Resident #8, the facility failed to ensure adequate interventions and supervision to prevent the resident's fall from bed on 6/23/14 at 10:50 A.M.. Review of the resident's clinical record on 7/1/14, indicated that the resident was admitted from another facility in 7/2013 with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 4/16/14, indicated that the resident was cognitively intact and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS indicated that the resident required 2 staff members for bed mobility, transfers, toileting, personal hygiene, and bathing. The MDS further indicated that the resident was incontinent of bladder and bowel. The resident's plan of care for Activities of Daily Living (ADLs), last updated 4/2014 indicated that the resident required assistance with all ADLs. There was no indication on the plan of care regarding the number of staff that the resident required to perform these tasks. The resident's Fall Assessment, last updated 4/11/14, indicated the resident was at a high risk for falls. The plan of care for the prevention of falls, reviewed in 4/2014. indicated that the resident was at high risk for falls. The plan of care indicated that a PT (physical therapy) and/or OT (Occupational Therapy) referral could be made as needed. There was no indication on the resident's plan of care regarding the number of staff required to assist the resident with positioning and toileting. Review of the incident report, dated 6/23/14, indicated that the resident fell out of bed after the resident lifted his/her left leg up and over his/her right hip. Documentation on the resident's monthly flow report, dated 6/23/14 from 7:00 A.M. to 3:00 P.M., indicated that the resident required two people for bed mobility. Review of the resident's Certified Nurse Aide's (CNA) care card on 7/2/14 at 7:55 A.M. indicated that the resident required extensive assist with bathing, bed mobility, and toileting. The care card indicated that the resident used the Sabina lift (a mechanical lift used when a resident can stand and assist staff with the transfer). There was no indication on the care card how many staff members were required to assist the resident for the tasks listed. During interview on 7/2/14 at 7:55 A.M. with Unit Manager #1, she said the resident required 1 to 2 staff members for positioning, toileting, and bathing depending upon the need of the resident at the time of the task. Unit Manager #1 said CNA #1 was assigned to provide care to the resident daily. During an interview with CNA #1 on 7/2/14 at 10:15 A.M., she said she provided care to Resident #8 on a daily basis. CNA #1 said she always had another CNA with her when she provided care that required the resident to turn side to side although the resident was able to assist in turning himself/herself. CNA #1 said the resident was a large person. CNA #2 was interviewed on 7/2/14 at 9:55 A.M. CNA #2 said that in early June 2014 when she was providing care to the resident, the resident almost fell out of bed when turning the resident to the right side. CNA #2 said the resident was able to lift his/her left leg up and over to the side by himself/herself but the momentum of the resident's leg almost caused the resident to fall out of bed. She asked the charge nurse to refer the resident to Physical Therapy (PT) for an evaluation pertaining to turning the resident in bed. Review of the clinical record indicated that a referral was made to PT on 6/9/14 regarding bed mobility, transfers, trunk control, balance and coordination. During an interview with the Physical Therapist on 7/2/14 at 3:05 PM, she said she performed a screen to determine if the resident required therapy. The Physical Therapist said she was able to turn the resident side to side by herself while she stood with the resident in bed rolled toward her body. She said this position may prevent the resident from falling out of bed. She said the resident required extensive assistance of one staff member due the resident's increased weight since admission. The Physical Therapist said she did not educate the staff using the technique she used. During an interview with CNA #3 on 7/2/14 at 9:00 A.M., she said she provided personal care to the resident alone on 6/23/14 at approximately 10:40 A.M.. CNA #3 said the resident really required 2 people to provide care because of his/her increase in weight. CNA #3 said after the resident turned to his/her right side, she asked the resident to lift his/her left leg over his/her body so she could wash the resident's buttocks. CNA #3 said she was standing on the resident's right side not on the left which was the resident's affected side. She said when the resident lifted his/her left leg over his/her body, the momentum of the left leg caused the resident's lower body to be pulled off the bed toward the floor. CNA #3 said the resident landed on the floor on his/her knees. CNA #3 said she immediately called for help. During an interview with Resident #8 on 7/3/14 at 8:45 A.M., the resident described the fall and said when she turned on her right side and lifted his/her left leg up off the bed and over his/her body, he/she fell out of bed. The Resident said the left leg dragged him/her out of bed. The Resident said CNA #3 was standing on the left side of the bed when he/she fell . Review of the nurse's notes, dated 6/23/14, indicated that the physician and family were notified of the resident's fall; the physician ordered an X-ray of the resident's left ankle and knee; the X-rays were reported as negative for a fracture, and Tylenol was administered for pain with good effect. Review of the nurse's note on 6/24/14 indicated that resident's left foot became swollen and bruised; the physician was notified, and the resident was transferred to the hospital for repeat X-rays. The nurse's note indicated that the resident sustained [REDACTED]. Unit Manager #1 said the resident now required two staff members at all times for turning side to side and had a scoop mattress placed on his/her bed to prevent the resident from falling out of bed. 2. On 7/3/14 at 4:00 P.M., the Surveyor observed the soiled Utility room on the C Wing. There were no staff in the vicinity and a key was observed in the door. The Surveyor entered the room and observed an unlocked cabinet under the sink. A pocketbook containing prescription medication was stored in full view and was easily accessible to anyone entering the unlocked room. Shortly thereafter the Surveyor spoke to an aide passing by and the aide said the key is broken but is left in the door so staff can access the room. On 7/3/14 at 4:10 P.M., the Surveyor observed the locked clean Utility room on the A Wing. The key to the room was hanging at eye length on a chain next to the door, making the room accessible to residents residing in the facility. In addition, the soiled Utility room on the A wing was left unlocked. On 7/3/14 at 4:15 P.M., the Surveyor spoke to the Nursing Supervisor and informed her of the above observations. She observed the clean Utility room on the C Wing with the Surveyor and said she was unaware the key was being left in the door. She observed the pocketbook with prescription medicine in it and said staff should not be storing their personal belongings in this room. She immediately removed the key from the door and informed staff nearby that they cannot store their personal belongings in the Clean Utility room. A nursing staff person then entered the room and removed the pocketbook, indicating it was hers. The Nursing Supervisor also observed the key hanging on a chain next to the Clean Utility room on the A Wing. She said she would speak to staff and have it placed in an area that was not accessible to residents. In addition, she said the soiled Utility room should be locked and that she would speak to staff.

Based on record review and staff interviews, the facility failed for 1 resident (#2) out of 6 applicable residents, in a total sample of 22 residents to adequately monitor and implement effective interventions to avoid weight loss. Resident #2 was not weighed for a six week period. In that period of time the resident experienced an unplanned significant weight loss of 30 pounds (lbs), which was 20% of her/his body weight. Findings include: Resident #2 was admitted to the facility 2/2013 with [DIAGNOSES REDACTED]. Review of the admission physician orders, dated 2/15/13, indicated that the resident's diet was ordered as a regular house diet. Review of the initial Minimum Data (MDS) Assessment, dated 2/22/13, indicated the resident's cognition was intact and the resident required extensive assist for bathing, grooming, and dressing. The resident was able to feed himself/herself after the tray was set up. He/she was totally dependent with transfers. The resident's weight was not coded for any weight loss and his/her weight was listed as 146 pounds. The resident was also coded as having frequent, severe pain. The resident's plan of care resident did not include nutritional interventions, as there was no evidence at the time of admission of any weight and/or nutritional concerns. During the resident's stay in the facility she/he was transferred and admitted to the hospital on [DATE] for a fecal impaction and returned to the facility on [DATE]. She/he was also treated with antibiotics for an elevated temperature and urinary tract infection in both 3/2013 and 4/2013. Review of the facility's Weight Monitoring Policy, dated 3/1/13, indicated the following: * Weights are to be obtained within 24 hours of admission/readmission and recorded in SofCare2 (the facility electronic health record). * Reweighs should occur in the same shift but no more than 24 hours after the first weighing. * Weekly weights are obtained for the following residents: New admissions weekly for 4 weeks-more frequent weights for readmissions will be determined by the RAR (resident at risk) committee or unless otherwise specified by a physician. Review of the RAR Meeting policy, dated March 2013, indicated the following: This facility conducts a weekly resident at risk meeting to review residents who have been identified nutritional and/or hydration problems/concerns or who have an identified risk factor that may lead to nutrition/hydration issues. Review of the RAR meeting minutes indicated that the resident was reviewed only once, on 3/8/13, and not again until 5/2/13, despite identified risks factors including the resident's recent hospitalization for fecal impaction and treatment of [REDACTED]. Review of the resident's weight documentation indicated the following: *2/19/13, 146 lbs (taken 4 days after admission, not within 24 hours as policy indicated) *3/11/13, 150 lbs (taken 6 days after readmission, not within 24 hours as policy indicated) * Week of 3/18/13, no documented weight * Week of 3/25/13, no documented weight * Week of 4/1/13, no documented weight * Week of 4/8/13, no documented weight * Week of 4/15/13, no documented weight * 4/22/13, 120 lbs, which indicated a 30 pound weight loss or 20 % of her/his body weight. (this weight was obtained 6 weeks from the last weight, not weekly as the policy indicated) * 4/29/13, 123 lbs (reweigh to validate weight loss, taken 7 days after initial reported weight loss, not within 24 hours as policy indicated) * 5/10/13, 128 lbs (this weight was obtained 11 days, from the previous weight, not weekly as the policy indicated, and was prompted by surveyor questioning) Review of the Initial Nutrition Assessment, dated 4/28/13, indicated that the resident's weight was 146 lbs and there were no nutritional concerns. Dietitian note's are as follows: *3/14/13- Intake 75%, resident weight was stable at 150 lbs, that the resident was on antibiotics for a urinary tract infection, and that the dietitian would "follow on unit" (no further notes until 4/22/13) *4/22/13 - Intake 50-100 %, some decrease intake related to previous pain issues, resident agreed to Ensure plus weight 120 lbs, severe loss, will request another weight to validate and refer to RAR *4/29/13 - Weight validated at 123 lbs. Has been started on Ensure plus 120 milliliters (ml) 3 times a day. Will follow in RAR. The resident's initial care plan, dated 2/28/13, did not contain a nutritional care plan. A nutritional care plan was not developed until 5/2/13. (10 days after the significant weight loss was identified). Interventions included: *House Regular Diet. *Monitor meal intake. *Monitor weight; refer to RAR. *Ensure plus 120 ml 3 times a day Review of physician's orders [REDACTED]. (3 days after the identified significant weight loss). The resident's weight has increased from 120 lbs to 128 lbs since this intervention was put into place. During interview on 5/9/13 at 2:30 P.M., Nurse #2 said that all new admissions should be weighed weekly for at least 4 weeks. She continued to say she wasn't sure why the resident had not been weighed weekly, but that the facility was really focusing on the resident's pain management issues. Once they realized that the resident had lost weight, they started the resident on Ensure supplements. During interview on 5/15/13 at 2:00 P.M., the Director of Nurses (DON) said that the resident's weights were not monitored as per facility policy of obtaining weekly weights for new and readmitted residents. She continued to say that she wasn't sure why the resident was not followed in the RAR meetings in light of her risk factors (new admission, recent hospitalization , urinary tract infection, bowel issues and pain issues). She confirmed that the weights and reweighs were not done within the time frames listed in the weight monitoring policy. She also confirmed that the resident has gained weight with the implementation of the Ensure supplement. The DON said that there has been a change in dietitian and that the facility is in the process of reviewing the current practices of weight monitoring.

Based on observation, staff interview, and record review, the facility failed to prevent from developing the pressure sore under the left gluteal fold for 1 resident (Resident #3) of 3 applicable residents from a total sample of 22 residents. Finding include: Review of Resident #3's clinical record on 5/13/13 indicated that the resident was admitted to the facility in 3/2010 with [DIAGNOSES REDACTED]. Review of the resident's Norton Plus Assessment for the risk of possible skin breakdown, dated 4/10/13, indicated that the resident was at moderate risk for skin breakdown. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 4/17/13, indicated that the resident required two staff members for bed mobility, toileting, and personal hygiene. The MDS indicated that the resident was always incontinent of bowel and occasionally incontinent of urine. Review of the resident's CNA (certified nurse aide) care card (undated) indicated that the resident wore incontinence briefs for the purpose of containment for either urine and/or feces. Review of the facility's policy for skin assessments, revised on 10/7/10, indicated that a weekly skin assessment (full body) was to be completed each week by the licensed nurse. The skin should be also checked daily. The policy indicated that once a lesion was found, an in-depth assessment was to be performed and recorded on the Pressure Ulcer (Sore) Status Record. In addition, each resident's pressure sore description was to be listed on the Weekly Pressure Ulcer Tracking Report. Review of the nurse's note, dated 5/8/13 at 4:04 P.M., indicated that "a popped blister" was noted on 11:00 P.M. to 7:00 A.M. shift under the left gluteal fold and the wound nurse was notified. Review of the physician orders, dated 5/8/13, indicated that there was no new physician order [REDACTED]. Review of the nurse's notes from 5/9/13 through 5/12/13 did not document that there was any open area on the resident's left gluteal fold. Review of the Weekly Skin Assessment, completed on 5/11/13, indicated that the resident's skin was intact. Review of the facility Weekly Pressure Ulcer Report did not identify any open areas for Resident #3. On 5/13/13 at 11:50 A.M., the Surveyor with Unit Manager #1 observed a 1 centimeter (cm) by 1 cm round reddened and scabbed pressure sore under the resident's left gluteal fold. There was no drainage or odor present. The pressure sore was difficult to visualize without the assistance of another person who pulled the skin away because the pressure sore was under the gluteal fold. During an interview with Unit Manager #1 on 5/13/13 at 11:55 A.M., she said that on 5/13/13 she notified the physician/NP (nurse practitioner) to obtain a physician order [REDACTED]. During an interview with the Director of Nurses (DON) on 5/14/13 at 11:05 A.M., she said that the nursing staff failed to implement the facility's policy on 5/8/13 when the resident's left gluteal fold pressure sore was found because a physician order [REDACTED].