Every finding on record at Littlefork Care Center

Based on interview and document review, the facility failed to develop and implement a comprehensive antibiotic stewardship program with established protocols and monitoring to help reduce unnecessary antibiotic use and reduce potential drug resistance for 1 of 1 resident (R6) reviewed for antibiotic use. The lack of a program had potential to affect all 37 residents residing in the facility. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 had no cognitive impairment and required maximal assistance with dressing, grooming, and was dependent with toileting. R6 had an indwelling foley catheter and was occasionally incontinent of bowel. Diagnoses included congestive heart failure, kidney disease, retention of urine and unspecified hydronephrosis. The monthly Infection Surveillance Report for October 2025, identified R6 was prescribed ceftriaxone (an antibiotic) one time per day for two days. Review of R6's medical record lacked evidence of any established criteria (i.e. McGeer) being used to determine the presence of infection before an antibiotic was initiated. R6's medical record also lacked urine culture results to ensure the antibiotic ordered for R6's infection was appropriate and would be effective. During the recertification survey, Infection Surveillance Reports were printed for November and December 2025. Each report contained the month's infection control data. These identified the following: October 2025: An Infection Surveillance Report with October 2025 infections was organized with six columns which collected the following data: Resident name and room number, Case Details, Symptoms, Lab Results, Treatment Details, and Outcome. A total of five residents were listed on the form, with a total of all five infections listed as treated with antibiotics. The remaining two infections listed were facility employee infections. None of the five resident infection listed lab results and the urinary tract infections (UTI) did not identify a urinalysis or culture to ensure the antibiotics ordered were effective. November 2025: An Infection Surveillance Report with November 2025 infections was organized with six columns which collected the following data: Resident name and room number, Case Details, Symptoms, Lab Results, Treatment Details, and Outcome. A total of two residents were listed on the form, with a total of one infection listed as treated with antibiotics. The other resident was identified with potential symptoms of a urinary tract infection (UTI) including dysuria (painful urination). The form lacked identification of treatment details, lab results and identified the UTI infection as resolved eight days after the symptoms were identified. The form did not identify the antibiotic treatment ordered. There was no evidence documented or provided within the infection control program to demonstrate the infections' antibiotic use was screened for appropriateness prior to starting the medications, any documented infection cultures, nor any evidence to demonstrate the prescribed antibiotics were monitored to ensure effectiveness and there had been no adverse effects from the medication course. December 2025: An Infection Surveillance Report with December 2025 infections was organized with six columns which collected the following data: Resident name and room number, Case Details, Symptoms, Lab Results, Treatment Details, and Outcome. A total of three residents were listed on the form. One resident demonstrated a suspected skin infection with symptoms of blistering and was treated with antibiotic. No organism was listed. A resolved outcome was identified as of 12/4/25. One resident demonstrated other for infection. No symptoms or labs were identified and was treated with antibiotic. No organism was listed. An outcome of chronic was identified as of 12/4/25. On resident demonstrated a UTI with symptoms of nausea and vomiting. An organism was identified with antibiotic treatment ordered. However, there was no evidence of a culture to determine if the antibiotic treatment was appropriate or any established criteria (i.e. McGeer) being used to determine the presence of infection before the antibiotic was initiated.There was no evidence documented or provided within the infection control program to demonstrate the infections' antibiotic use was screened for appropriateness prior to starting the medications, any documented infection cultures, nor any evidence to demonstrate the prescribed antibiotics were monitored to ensure effectiveness and there had been no adverse effects from the medication course. During joint interview the director of nursing (DON) and the infection preventionist (IP)-D on 12/10/25, at 10:50 a.m. IP-D stated she had just started in the position last week and was learning how to track and trend resident and staff illness and infections. There was a period of time the facility did not have an acting IP nurse prior to her starting. The staff registered nurse would notify the IP nurse if a resident had an infection or she would learn about resident illness and infections during the facility's morning stand up meetings. If a resident had an antibiotic ordered, it would be listed on the infection control dashboard, and she could track it there as well. The IP nurse also attended the interdisciplinary team meetings where they discussed resident changes. There had not been good follow up with infections and antibiotic use. The facility did not have a process or procedures in place for antibiotic stewardship. IP-D stated had seen some McGeer forms in her office, but there was nothing currently being used by the facility to assist them in determining the presence of infection before calling the physician for an antibiotic. IP-D stated a urine culture had not been obtained to follow up with the antibiotic ordered for R6 and it should have been followed up on to ensure the antibiotic was effective in treating R6's infection. The facility's policy Antibiotic Stewardship Program with review date 1/21/25, identified the facility would establish an antibiotic stewardship team (ASP) accountable for antibiotic stewardship. The team would consist of the IP nurse, DON, administrator, medical director, pharmacy consult and other team members the team chose. The team would implement antibiotic use protocol, and criteria, including a system to monitor and track antibiotic use.

Based on interview and document review, the facility failed to follow through on a grievance regarding staffing levels to complete baths for 4 of 4 (R14, R15, R21, R32) residents who voiced concerns during resident council. Findings include:R14's annual MDS dated [DATE], identified R14 was cognitively aware and was independent with activities of daily living. The ability to bathe was not assessed.R15' quarterly MDS dated [DATE], identified R15 was cognitively aware and was dependent on staff for toileting and required substantial/maximal assistance with bathing.R21's quarterly MDS dated [DATE], identified R21 was cognitively aware and required set up for personal hygiene and was dependent on staff for toileting. However, bathing was not assessed.R32's quarterly MDS dated [DATE], identified R32 was cognitively aware and was independent with activities of daily living. The ability to bathe was not assessed.During resident council on 12/9/25 at 1:14 p.m., R15, R21 and R32 all stated they were supposed to get more than one bath a week. R32 stated that never happens. They might get one bath a week, but R21 stated he rarely would get that. R15, R21 and R32 all stated staffing was the issue for residents' baths not being done. R21 stated there just isn't enough people. R15 stated she was supposed to get a bath the morning of 12/9/25, but that hasn't happened yet. Evening staff will not do a bath. Review of the resident council meeting minutes identified the following: 3/24/25, Nursing: Residents would like a consistent bath schedule and to notified of any changes in t ere bath time or day. Bathing continues to be an issue, and staff are working on resolving the issue.7/15/25, Nursing: Bathing has improved with the new assignment sheets.8/19/25, Nursing: Bathing still improving with the new assignment sheets. Residents are concerned about call times and how many staff it takes to help with a lift. Discussed how sometimes a second member of staff is needed for cares and to utilize the Hoyer lifts and that may take a few minutes to get them there to help if they are helping another resident.9/30/25, Nursing: Bathing still improving with the new assignment sheets. Still having long call times. Will address with DON and administration.10/28/25, Nursing: Still having long call times. Will address with DON and administration.11/24/25, Call light concerns were discussed. Residents are encouraged to inform staff of call light wait times right away, so they can be audited. Discussed staff coming into resident's rooms with a negative attitude, discuss with staff that a positive approach when entering a resident's room sets the tone for the cares/visit being done. A new bath schedule is being implemented. Discussed assignment sheets for daily cares for residents.The untitled bath schedule undated, identified the following: R14 was scheduled for a bath on Saturday mornings R15 was scheduled for a bath on Tuesday mornings and Saturday evenings. R21 was scheduled for a bath on Wednesday mornings and Saturday evenings. R32 was scheduled for a bath on Sunday evenings.During a private interview on 12/10/25 at 2:09 p.m., R32 stated he took baths, not showers. Stated he did get a bath on a Friday, 12/5/25, evening because he had an outing on Saturday morning. I insisted. A lot of the time, R32 will ask staff for a bath, and he would be told we'll see and the staff never came back. Before the 12/5/25 bath, it had been approximately 3 weeks since his last bath. They have to wash my hair and my back, but I do the rest. During an interview on 12/10/25 at 2:59 p.m., the social services designee (SSD) stated baths and call light times had been an ongoing issue during resident council. SSD documented the concern in the minutes, then staff discuss it during the interdisciplinary team (IDT)meetings. The SSD did not assist any of the residents with formal grievance because it's more as a group. The SSD stated she did conduct an audit of the call wait times that did not show a significant concern with wait times. The SSD stated a bath schedule was created, however, an audit to ensure residents were receiving baths on their scheduled day was not conducted. During an interview on 12/10/25 at 3:03 p.m., the administrator stated staff had created a daily assignment sheet that was started November 2025 but had not been audited to determine how effective it was. A grievance policy was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure pneumococcal immunizations were offered, addressed and/or provided in accordance with Centers for Disease Control (CDC) guidelines for 3 of 5 residents (R11, R23, R37) reviewed for immunizations.Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified several tables with corresponding recommendations when to receive various versions (i.e., PPSV23, PCV13, PCV20) of the pneumococcal vaccine. The graph labeled, Adults 19-[AGE] years old with chronic health conditions ., identified persons who received only a PPSV23 had an option to either get a PCV15 or PCV20 a year after the last PPSV23 dose. The conditions listed including alcoholism and cigarette smoking. Further, the graph labeled, Adults [at or older than] [AGE] years old, outlined persons with a complete series of pneumococcal vaccination (i.e., PCV13 at any age, PPSV23 at or above [AGE] years old) should have shared clinical decision-making between the resident and healthcare provider to determine if PCV20 was appropriate.R11's significant change Minimum Data Set (MDS) dated [DATE], identified an admission date of 10/30/25, and date of birth [DATE]. R11 had intact cognition and was independent with most activities of daily living (ADLs). Diagnoses included metabolic encephalopathy, and hypertension. R11's medical record was reviewed and lacked any immunization records or evidence R11 had been offered, educated on, or provided the CDC recommended pneumococcal immunization(s) since her admission to the nursing home several months prior. R23's discharge MDS dated [DATE], identified an admission date of 11/25/25, and date of birth [DATE]. R23 had intact cognition and required moderate to maximal assistance with most of his ADLs. Diagnoses included cirrhosis of the liver with ascites, hepatic encephalopathy, thrombocytopenia, and pleural effusion. R23's medical record was reviewed and lacked any immunization records or evidence R11 had been offered, educated on, or provided the CDC recommended pneumococcal immunization(s) since his admission to the nursing home a month prior. R37's admission MDS dated [DATE], identified an admission date of 12/2/25, and date of birth [DATE]. R37 had moderate impaired cognition and supervision to moderate assistance with most ADLs and was independent with mobility. Diagnoses included hypertension, peripheral vascular disease and polycythemia. R37's medical record was reviewed and lacked any immunization records or evidence R37 had been offered, educated on, or provided the CDC recommended pneumococcal immunization(s) since his admission to the nursing home a month prior.A joint interview was conducted with the director of nursing (DON) and the infection preventionist (IP)-D on 12/10/25, at 10:50 a.m. The IP nurse stated she had just started her position last week. There had been a period of time where the facility did not have an IP nurse prior to her starting. She had just received a list of resident consent for vaccinations to go over and was just starting to pull their immunization records and planned to go around and talk with each of the residents. They were working on getting all the residents up to date now that she has started in the IP position. The facility's policy Resident Immunizations with review date 1/21/25, identified the Adult Immunization Schedule prepared by the Centers of Disease Control (CDC) would be utilized to ensure residents were offered and encouraged to accept the appropriate vaccinations. An immunization history would be taken on admission which would include checking the Minnesota Immunization Information Connection (MIIC) website. Any immunizations that were not current, or unknown vaccination histories would be shared with the attending physician and appropriate orders obtained. The resident's immunization history would be documented and maintained in the resident's medical record. Vaccination Information Statements would be provided to the resident and/or representative prior to administration of the vaccination. Education would be provided and any questions answered prior to administration of the vaccination. The determination to vaccinate or not would be documented in the medical record.

Based on observation, interview and document review, the facility failed to immediately report allegations of abuse to the state agency for 1 of 1 resident (R30) reviewed for abuse, who had an altercation with R3 Findings include:R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had a severe cognitive impairment and diagnoses that included Alzheimer's disease.R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had a severe cognitive impairment and diagnoses that included Alzheimer's disease. R30's nursing progress note identified the following on 12/5/25: At 6:35 p.m., R30 grabbed R3 by the clothing protector and was jerking the clothing protector toward himself at 6:20 p.m. It did take several staff to remove R30 from the area and to get the clothing protector off R3. R30 did swing at staff and was yelling. R30 was in dining room in wheelchair dozing just prior to this incident. At 6:40 p.m., Did attempt to notify director of nursing (DON) at 6:31 p.m. and left a voicemail. Attempted to notify administrator at and left a voicemail at 6:32 p.m. At 7:24 p.m., Return phone call from DON at 7:07 p.m.On 12/10/25 at 10:42 a.m., the DON stated a report was not filed with the state agency (SA). During a telephone interview on 12/10/25 at 11:27 a.m., registered nurse (RN)-B stated she was down the hall from the dining room with the med cart. All residents were done with the supper meal and were relaxing in their chairs in the dining room. They looked like they were sleeping. RN-B heard someone yell and started walking toward the dining room. There, nursing assistant (NA)-A was pulling the NAs were pulling R30 away from R3. RN-B wasn't right there and didn't see all of it but knew R30 had a hold of R3's clothing protector. R30 yelled God damn it and R30 let go. RN-B director NA-A to take R30 away from the area and assessed R3's neck and saw no marks. R3 was breathing like R3 was worked up. R3 was upset but had no idea what happened to him. Afterwards, R30 sat with the nursing assistants while they completed report. RN-B attempted to call the DON to report the incident and R30 fell asleep in his wheelchair and was no longer upset. When RN-B didn't reach the DON, RN-B attempted to contact the administrator and left a voicemail. Later, RN-B spoke with the DON and reported the incident. RN-B stated the DON stated it was a reportable event and would contact the administrator.During an interview on 12/10/25 at 12:11 p.m., the DON stated she returned a call to the facility on Friday evening regarding the incident between R30 and R3. The nurse reported R30 grabbed R3's clothing protector and R3 looked afraid. The DON attempted to call the administrator and left a message but couldn't contact the administrator. The DON did not have the ability to file a report with the SA. Staff did discuss the incident during the Monday morning meeting but did not report the incident.During an interview on 12/10/25 at 12:16 p.m., the administrator stated she was told about the incident on Monday or Tuesday. The administrator stated she was told R30 grabbed R3's clothing protector but it was not described as an aggressive assault. Because there was no harm, the staff separated R30 and R3 immediately and there was no danger in the situation, the incident was not a reportable event. However, the administrator stated the incident should have been reported immediately to the SA and staff were expected to notify the DON, the social service designee, and/or the administrator immediately.The facility policy Maltreatment Reporting Guidelines revised 11/26/24, identified the facility would report any allegations of maltreatment of a vulnerable adult (VA) residing in our care center to the appropriate authorities, as required by abuse reporting for the Federal Regulations and maltreatment reporting for the Minnesota State Statutes. A report must be filed immediately, but not later than 2 hours after the allegation is made if the incident involves abuse, neglect, or financial exploitation that results in serious bodily injury, including injuries of unknown source and misappropriation of VA property.

Based on observation, interview and document review, the facility failed to comprehensively assess potentially abusive behaviors and identify interventions to prevent abuse for 1 of 1 resident (R30) reviewed for abuse and involved R3. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had a severe cognitive impairment and diagnoses that included Alzheimer's disease. R3's nursing progress note dated 12/5/25 at 6:46 p.m., identified a physical altercation with another patient at 6:20 p.m. R3 had his clothing protector pulled on repeatedly by another patient. R3 did appear to be alarmed while incident was happening as staff witnessed facial expression and fast paced breathing. R3 did not appear to have any marks left from clothing protector being pulled. R3 did not retaliate. R3 appeared to be calm at this time. Clothing protector removed. Other patient removed from vicinity. At 6:50 p.m., Did attempt to notify director of nursing (DON) at 6:31 p.m. and left a voicemail and administrator at 6:32 p.m. and left a voicemail about incident. See prior alert note. At 7:25 p.m., return phone call from DON at 7:07 p.m. However, the notes failed to identify interventions implemented to ensure R3 and other residents' safety.R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had a severe cognitive impairment and diagnoses that included Alzheimer's disease.R30's nursing progress notes identified the following:12/5/25, at 6:35 p.m., R30 grabbed R3 by the clothing protector and was jerking the clothing protector toward himself at 6:20 p.m. It did take several staff to remove R30 from the area and to get the clothing protector off R3. R30 did swing at staff and was yelling. R30 was in dining room in wheelchair dozing just prior to this incident. At 6:40 p.m., Did attempt to notify DON at 6:31 p.m. and left a voicemail. Attempted to notify administrator at and left a voicemail at 6:32 p.m. At 7:24 p.m., Return phone call from DON at 7:07 p.m. However, the note failed to identify interventions implemented to ensure residents' safety.During an observation on 12/8/25 at 5:40 p.m., R30 was sitting in his wheelchair at the dining room table eating his supper meal. Nursing assistant (NA)-D was seated to R30's left and another male resident was seated to R30's right. R30 was within arm's reach of the male resident. During an interview on 12/9/25 at 3:30 p.m., NA-C stated R30 was combative with staff, especially during transfers. NA-C had never seen R30 become combative with other residents. He doesn't do that. During an interview on 12/9/25 at 3:52 p.m., licensed practical nurse (LPN)-C stated she was not at the facility when the incident happened between R3 and R30 but heard about it. LPN-C stated R30 had R3's clothing protector around R3's neck and was choking him. LPN-C stated she really didn't know what interventions were put into place because she wasn't there. During an observation on 12/9/25 at 3:55 p.m., R30 sat in his wheelchair in the hallway next to the medication cart. R30 sat quietly watching the other residents and staff with a blank stare. Other residents were in the area. At 4:32 p.m., a visitor with a dog stopped amongst the group to visit and allow the residents to pet the dog. R30 sat quietly and watched closely but did not move.During an interview on 12/10/25 at 10:00 a.m., LPN-A stated she did not work at the facility when the incident between R3 and R30 happened and didn't know what had occurred. During an interview on 12/10/25 at 10:01 a.m., registered nurse (RN)-A stated she read R3's and R30's progress notes on Monday morning and it was discussed briefly during the Monday morning meeting. R30 grabbed a hold of R3's clothing progress and was pulling on it. Staff intervened and removed R30 from the area. RN-A believed staff brought R30 behind the nursing desk and sat 1:1 with R30 until R30 was calmer. RN-B stated no investigation was done to determine what motivated the incident to happen. RN-B had not seen R30 become aggressive unless cares were being done. RN-B stated it was a good question what interventions were implemented to ensure residents' safety. I guess staff should try to ensure R30 was not in reach of other residents. However, RN-B stated staff had not been doing that. During a telephone interview on 12/10/25 at 11:27 a.m., registered nurse (RN)-B stated she was down the hall from the dining room with the med cart. All residents were done with the supper meal and were relaxing in their chairs in the dining room. They looked like they were sleeping. RN-B heard someone yell and started walking toward the dining room. There, nursing assistant (NA)-A was pulling the NAs were pulling R30 away from R3. RN-B wasn't right there and didn't see all of it but knew R30 had a hold of R3's clothing protector. R30 yelled God damn it and R30 let go. RN-B directed NA-A to take R30 away from the area and assessed R3's neck and saw no marks. R3 was breathing like R3 was worked up. R3 was upset but had no idea what happened to him. Afterwards, R30 sat with the nursing assistants while they completed report. RN-B attempted to call the DON to report the incident and R30 fell asleep in his wheelchair and was no longer upset. When RN-B didn't reach the DON, RN-B attempted to contact the administrator and left a voicemail. Later, RN-B spoke with the DON and reported the incident. RN-B stated the DON stated it was a reportable event and would contact the administrator. However, RN-B stated the DON did not provide further direction. When RN-B worked the next evening, RN-B kept eyes on R30 and made sure clothing protectors were off immediately after the meal. RN-B told the next shift staff needed to be more cautious and attempt to keep R30 out of reach of the other residents. However, R30 needed a lot of help eating so RN-B kept R30 with her and away from the other residents.During an interview on 12/10/25 at 12:11 p.m., the DON stated she returned a call to the facility on Friday evening regarding the incident between R30 and R3. The incident was discussed during the morning meeting on Monday, but no investigation/assessment was done nor were interventions implemented to ensure residents' safety. During an interview on 12/10/25 at 12:16 p.m., the administrator stated she was told about the incident on Monday or Tuesday. The administrator stated she was told R30 grabbed R3's clothing protector but it was not described as an aggressive assault. Because there was no harm, the staff separated R30 and R3 immediately and there was no danger in the situation. The incident was discussed during the Monday morning meeting, but no further investigation was conducted. The facility policy Maltreatment Prohibition revised 11/26/24, identified residents served in in the facility were provided a safe environment through prevention of abuse, neglect, and financial exploitation. Each of the following are integral components of this process. ScreeningTraining PreventionIdentification and Examples have been provided in the following policies: Maltreatment Definitions can assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property.Examples of Reportable Maltreatment can assist staff in identifying reportable abuse, neglect, exploitation of residents, and misappropriation of resident property. Investigation Protection Reporting/response

Based on interview and document review, the facility failed to conduct a thorough investigation of possible abuse for 1 of 2 resident (R30) reviewed for abuse who had an altercation with another resident (R3). Findings include:R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had a severe cognitive impairment and diagnoses that included Alzheimer's disease.R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had a severe cognitive impairment and diagnoses that included Alzheimer's disease. R30's nursing progress note dated 12/5/25 identified the following: At 6:35 p.m., R30 grabbed R3 by the clothing protector and was jerking the clothing protector toward himself at 6:20 p.m. It did take several staff to remove R30 from the area and to get the clothing protector off R3. R30 did swing at staff and was yelling. R30 was in dining room in wheelchair dozing just prior to this incident. At 6:40 p.m., Did attempt to notify director of nursing (DON) at 6:31 p.m. and left a voicemail. Attempted to notify administrator at and left a voicemail at 6:32 p.m. At 7:24 p.m., Return phone call from DON at 7:07 p.m.On 12/10/25 at 10:42 a.m., the DON stated there was no investigation file regarding R30's 12/5/25 incident. During a telephone interview on 12/10/25 at 11:27 a.m., registered nurse (RN)-B stated she was down the hall from the dining room with the med cart. All residents were done with the supper meal and were relaxing in their chairs in the dining room. They looked like they were sleeping. RN-B heard someone yell and started walking toward the dining room. There, nursing assistant (NA)-A was pulling the NAs were pulling R30 away from R3. RN-B wasn't right there and didn't see all of it but knew R30 had a hold of R3's clothing protector. R30 yelled God damn it and R30 let go. RN-B director NA-A to take R30 away from the area and assessed R3's neck and saw no marks. R3 was breathing like R3 was worked up. R3 was upset but had no idea what happened to him. Afterwards, R30 sat with the nursing assistants while they completed report. RN-B attempted to call the DON to report the incident and R30 fell asleep in his wheelchair and was no longer upset. When RN-B didn't reach the DON, RN-B attempted to contact the administrator and left a voicemail. Later, RN-B spoke with the DON and reported the incident. RN-B stated the DON stated it was a reportable event and would contact the administrator.During an interview on 12/10/25 at 12:11 p.m., the DON stated staff did discuss the incident during the Monday morning meeting but did not investigate the incident. During an interview on 12/10/25 at 12:16 p.m., the administrator stated she was told about the incident on Monday or Tuesday. The administrator stated she was told R30 grabbed R3's clothing protector but it was not described as an aggressive assault. Because there was no harm, the staff separated R30 and R3 immediately and there was no danger in the situation, the incident was not further investigated. The administrator stated staff were expected to investigate all allegations of abuse.The facility policy Maltreatment Reporting and Investigation revised 11/26/24, identified the facility would investigate all incidents and allegations of maltreatment to determine the root cause of the event and to determine if the incident needs to be reported to the appropriate authorities.

Based on observation, interview and document review, the facility failed to provide timely assistance with toileting for 2 of 3 residents (R3, R30) reviewed for toileting. Findings include:R3R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and required maximal assistance with transfers and bed mobility.R3'a Urinary Incontinence and Indwelling Catheter Care Area assessment dated [DATE], identified R3 was always incontinent of bladder. He was often resistive to assistance with toileting tasks, had been noted on a couple occasions to have refused assistance to the toilet and urinated in the dining room. R3 had a yeasty rash in his groin, nystatin powder was being applied per standing house orders. R3 refused to let writer assess area. No other skin issues have been observed/reported.R3's care plan dated 10/20/25, identified R3 was incontinent of bowel and bladder and directed staff to check R3 every 2-3 hours to assist with toileting as needed.During a continuous observation on 12/9/25 at 9:51 a.m., R3 is sitting in his wheelchair in the small tv area off the dining room. At 11:59 AM nursing assistant (NA)-C wheeled R3 to the dining table for his dinner meal. R3 was not offered and/or toileted. At 1:06 pm R3 has finished eating his dinner meal and continues to sit in his wheelchair in the dining room. R3 had not been offered toileting. At 1:25 p.m., NA-B and NA-C assisted R3 to his room and transferred R3 into his bed via a full body mechanical lift. R3's incontinence brief was changed. R3 had a small amount of urine in his incontinence brief. During an interview on 12/9/25 at 1:30 p.m., NA-C stated R3 was supposed to be toileted every 2-3 hours and should have been check and changed between 11:30 a.m. to 12:00 p.m.During an interview on 12/9/25 at 1:35 p.m., registered nurse (RN)-A stated R3 was care planned to be toileted every 2-3 hours. R3 should have been laid down by 12:30 p.m., but that was in the middle of the dinner meal so prior to dinner would have been best in theory. During an interview on 12/10/25 at 12:00 p.m., the director of nursing (DON) stated staff were expected to ensure residents were toileted according to their care plans timely.R30R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had a severe cognitive impairment and diagnoses that included Alzheimer's disease, dementia, and type 2 diabetes.R30's care plan revised 10/30/25, identified R30 had urinary incontinence due to Alzheimer's disease, dementia and impair mobility. Staff were directed to check/change R30 every 2 hours and as needed.During a continuous observation on 12/10/25 at 6:58 a.m., R30 was lying in bed on his back. R30 was awake and moving his shoulders and legs by pushing his feet against the walls until his head was hanging off the head of the bed. R30's bed was in a low position with a fall mat lying on the floor. At 8:20 a.m., R30 continued to lie in bed on his back. R30 had rested his head on his pillow. Blankets covered R30 to his mid-chest. At 8:32 a.m., R30's call light turned on. R30 was again moving in bed with his head hanging off the side just below R30's grab bar. Licensed practical nurse (LPN)-A walked past R30's room door but did not look into R30's room. At 8:33 a.m., LPN-A walked past R30's room back to the nursing station but did not look in. R30 moved his head back to his pillow and the call light turned off. At 8:52 a.m., R30 continued to lie in bed on his back and his call light had turned on. At 8:59 a.m., R30's call light turned off. No staff have checked on R30. At 9:01 a.m., R30's call light turned on. LPN-A and NA-B entered the room next to R30's but did not check on R30. At 9:06 a.m., R30's call light turned off. R30 had not been repositioned. At 9:17 a.m., R30 was pushed against the wall with his feet and R30's head and right shoulder were hanging off the side of the bed so R30 was looking out into the hallway with his upside-down head. LPN-A and NA-B walked past R30's open room At 9:20 a.m., R30 continued to have his head hanging down off the side of his bed. R30's forehead was bright red in color. R30 lifted his head momentarily then lets it drop. At 9:22 a.m., RN-A entered R30's room and asked R30 what he was doing. RN-A asked for assistance to get R30 up for the day. At 9:29 a.m., RN-A and NA-B assisted R30 to the bathroom to assist with morning cares. During an interview on 12/10/25 at 9:55 a.m., NA-B stated R30 should be checked and changed every 2 hours, but staff waited when R30 was sleeping hard to lessen the likelihood of behaviors. If R30 was moving and adjusting in bed, that's when staff would get him up. NA-B stated she was the only nursing assistant on the hall that morning and did not know R30's call light had sounded. During an interview on 12/10/25 at 10:01 a.m., RN-A stated R30 should have been checked/changed when he started moving that morning.During an interview on 12/10/25 at 11:59 a.m., the DON stated staff were to follow the resident care plans for toileting. The facility policy Urinary Incontinence Program reviewed 4/6/15, identified Each resident who is incontinent will be identified, assessed, and provided appropriate care and services to achieve or maintain their greatest level of continence. Each resident will receive the appropriate care and services to prevent incontinence related complications to the extent possible.

Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning for 2 of 3 residents (R3, R30) reviewed for pressure ulcers. R3R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had a severe cognitive impairment and required maximal assistance with transfers and bed mobility. R3 was at risk for pressure injury/ulcer but did not have a current pressure injury/ulcer. R3's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 7/30/25, identified R3 had a Braden score of 16, indicating he was at mild risk for pressure ulcer/injury. R30 was always incontinent of bowel/bladder, usually resistive to allowing staff to perform peri cares and other hygiene tasks. R30 was able make changes in his position frequently and independently as he chose. R30 was ambulatory but gait was unsteady, a referral to physical therapy was made. R30 was using a wheelchair to move around the facility, had a pressure reducing mattress on his bed and a pressure reducing cushion in his wheelchair. R3's skin was checked daily with cares and weekly on bath days. R3 had a yeasty rash in his groin, nystatin powder is being applied per standing house orders. R3 refused to let writer assess area. No other skin issues have been observed/reported.R3's care plan dated 10/20/25, identified R3 had an ADL self-care performance deficit related to Alzheimer's and Dementia. Staff were directed R3 was totally dependent by 2 staff to move between surfaces. R3 required a full body mechanical lift and R3 was to be turned and repositioned every 2-3 hours to help prevent skin breakdownDuring a continuous observation on 12/9/25 at 9:51 a.m., R3 is sitting in his wheelchair in the small tv area off the dining room. At 11:59 AM nursing assistant (NA)-C wheeled R3 to the dining table for his dinner meal. R3 was not repositioned. At 1:06 pm R3 has finished eating his dinner meal and continues to sit in his wheelchair in the dining room. R3 has not been repositioned, and repositioning had not been offered.At 1:25 p.m., NA-B and NA-C assisted R3 to his room and transferred R3 into his bed via a full body mechanical lift.During an interview on 12/9/25 at 1:30 p.m., NA-C stated R3 was supposed to be repositioned every 2-3 hours and should have been laid down between 11:30 a.m. to 12:00 p.m. R3's skin was intact. During an interview on 12/9/25 at 1:35 p.m., registered nurse (RN)-A stated R3 was care planned to be repositioned every 2-3 hours to prevent pressure ulcers. All residents were at risk for pressure ulcers, but R3 had risk factors such as incontinence and the inability to reposition himself. R3 should have been laid down by 12:30 p.m., but that was in the middle of the dinner meal so prior to dinner would have been best in theory. During an interview on 12/10/25 at 12:00 p.m., the director of nursing (DON) stated staff were expected to ensure residents were repositioned according to their care plans timely to prevent pressure injury/ulcers. R30R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had a severe cognitive impairment and diagnoses that included Alzheimer's disease, dementia, and type 2 diabetes. R30 was at risk for pressure injury/ulcer but had no current pressure injury/ulcer.R30's care plan revised 10/30/25, identified R30 required substantial assistance to turn and reposition in bed every 2 hours and as necessary.During a continuous observation on 12/10/25 at 6:58 a.m., R30 was lying in bed on his back. R30 was awake and moving his shoulders and legs by pushing his feet against the walls until his head was hanging off the head of the bed. R30's bed was in a low position with a fall mat lying on the floor.At 8:20 a.m., R30 continued to lie in bed on his back. R30 had rested his head on his pillow. Blankets covered R30 to his mid-chest.At 8:32 a.m., R30's call light turned on. R30 was again wiggling across his bed, creating friction without relieving pressure to his buttocks and his head hanging off the side just below R30's grab bar. Licensed practical nurse (LPN)-A walked past R30's room door but did not look into R30's room. At 8:33 a.m., LPN-A walked past R30's room back to the nursing station but did not look in. R30 moved his head back to his pillow and the call light turned off. At 8:52 a.m., R30 continued to lie in bed on his back and his call light had turned on. At 8:59 a.m., R30's call light turned off. No staff have checked on R30. At 9:01 a.m., R30's call light turned on. LPN-A and NA-B entered the room next to R30's but did not check on R30. At 9:06 a.m., R30's call light turned off. R30 had not been repositioned. At 9:17 a.m., R30 had wiggled in his bed, creating friction and without relieving pressure to his buttocks. R30's head and right shoulder were hanging off the side of the bed so R30 was looking out into the hallway with his upside-down head. LPN-A and NA-B walked past R30's open room At 9:20 a.m., R30 continued to have his head hanging down off the side of his bed. R30's forehead was bright red in color. R30 lifted his head momentarily then lets it drop. At 9:22 a.m., RN-A entered R30's room and asked R30 what he was doing. RN-A asked for assistance to get R30 up for the day. At 9:29 a.m., RN-A and NA-B assisted R30 to the bathroom to assist with morning cares. During an interview on 12/10/25 at 9:55 a.m., NA-B stated R30 should be turned and repositioned every 2 hours, but staff waited when R30 was sleeping hard to lessen the likelihood of behaviors. If R30 was moving and adjusting in bed, that's when staff would get him up. NA-B stated she was the only nursing assistant on the hall that morning and did not know R30's call light had sounded. During an interview on 12/10/25 at 10:01 a.m., RN-A stated R30 should have been at least turned/checked when he started moving that morning.During an interview on 12/10/25 at 11:59 a.m., the DON stated staff were the follow the resident care plans for turning/repositioning to prevent pressure injury/ulcer. The facility policy Skin Integrity revised 5/21/25, identified nursing staff will monitor resident's skin integrity and address issues promptly while providing care and services consistent with professional standards of practice. C. Residents at risk for skin breakdown will have preventative measures implemented such as repositioning plan and pressure redistribution devices.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement interventions to prevent weight loss for 1 of 1 resident (R30) reviewed for nutrition. Findings include:R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had a severe cognitive impairment and had diagnoses that included Alzheimer's disease, dementia and type 2 diabetes.R30's care plan revised 10/30/25, identified R30 had an ADL self-care performance deficit related to Alzheimer's disease, dementia and right/left knee pain. The care plan directed R30 was independent in eating. The care plan also identified R30 had a potential for weight loss related to his disease process. Staff were directed to monitor meal and snack intake, offer a bedtime snack per R30's routine: cottage cheese, yogurt, granola bar or cheese and crackers. R30 had a regular diet with regular texture and thin consistency. R30 was to be weighed weekly on bath days.R30's Mini Nutritional assessment dated [DATE], identified R30 had a potential for malnutrition but failed to identify care planned interventions.R30's medical record identified the following weights: 10/27/25, 157.2 pounds (lbs.) 11/4/25, 155.6 lbs. A loss of 1.6 lbs. 11/27/25, R30 weighed 143.0 lbs. A loss of 12.6 lbs.During an observation on 12/10/25 at 10:18 a.m., R30 was sitting at the dining table with his breakfast in front of him. All the other residents had finished breakfast and R30 is the only resident eating in the dining room. Licensed practical nurse (LPN)-A was standing behind R30 at the medication cart but did not monitor R30 or encourage R30 to eat. R30's fork was lying across his plate with a bite of eggs, but R30 did not attempt to eat. R30 did drink his orange juice and drank approximately 75% of his milk. At 10:20 a.m., the director of nursing (DON0 approached R30 and asked R30 if he was done eating. The DON removed R30's breakfast but did not attempt to assist R30 with eating.During an interview on 12/10/25 at 10:23 a.m., LPN-A stated R30 did ok with eating earlier in the day. If staff set R30 up, R30 did ok on his own. Later in the day, especially evenings, R30 might get confused and might need more help then. More guidance and encouragement. LPN-A stated she was unaware R30 had lost weight since admission.During an interview on 12/10/25 at 10:57 a.m., registered nurse (RN)-A stated, when a resident was admitted , the dietary manager reviewed all the resident's information with the registered dietician. Then, the dietary manager pulled a weekly report and reviewed any resident with a significant weight loss and will order supplements, if needed. Staff tried not the jump the gun with supplements because supplements were very filling. When R30 was admitted , his family identified R30 would need assistance with eating. Staff were directed to keep an eye on R30 in the dining room overall and, if staff were seeing food left on R30's plate, to monitor his weight for loss or coughing, to report it. Upon review of R30's weights, RN-A stated R30 had an almost 15 lbs. weight loss in 2 months. RN-A stated she entered R30's 11/27/25 weight and did not recognize R30's weight loss. Normally, RN-A would request R30 be reweighed and initiate a contacted the provider to request supplements. RN-A stated staff were expected to monitor R30's intake and encourage him to eat before removing his meal.During an interview on 12/10/25 at 11:07 a.m., the dietary manager (DM) stated a report was printed every Tuesday that identified all residents who had weight loss in the past week. The residents were discussed at the morning high risk meetings and all the information was emailed to the registered dietician. R30 was admitted to the facility on [DATE] and DM was unaware R30 had a significant weight loss. I must have totally missed that. R30 was not weighed weekly and R30 should have been reweighed when the weight was entered to ensure it was correct. Additionally, the DM expected nursing to monitor weights as well and report concerns as they arise.During a telephone interview on 12/10/25 at 11:37 a.m., the registered dietician (RD) stated all new admits were assessed. The RD stated she did notice R30's weight was done and had asked R30 be reweighed, but had not received the reweigh yet. The RD stated she expected staff to obtain weights as ordered because it ensured weight losses or gains were monitored and addressed timely.During an interview on 12/10/25 at 11:59 a.m., the DON stated R30 should have been helped with eating to ensure he was receiving the calories needed. R30 should be weighed weekly to monitor for weight loss and nursing were expected to recognize weigh changes and obtain a reweigh to ensure accuracy, then alert the DM for assessment if needed. During an interview on 12/10/25 at 12:16 p.m., the administrator stated she expected staff to weigh residents as ordered to monitor for weight loss and/or gain and to report to the DM as needed. The facility policy Weight Monitoring Program revised 1/18/21, identified the facility would monitor weights of individuals receiving services (IRS) to prevent unintended weight loss and medically significant weight gain. Actions for the prevention of weight loss and medically significant weight gain:a. Residents will be weighed weekly, as needed, or as ordered by physician/attending practitioner.b. Weight data will be assessed, tracked, and entered into electronic health record (EHR) weekly (unless otherwise indicated by a physician's order - i.e. hospice care).c. Interdisciplinary team (IDT) will discuss the resident with at risk weight loss, significant weight loss, or medically significant weight gain weekly. Documentation will include determined interventions.

Based on observation, interview and document review, the facility failed to ensure as needed (PRN) medications were administered as prescribed for 1 of 1 resident (R12) observed to have lower extremity edema and weight gain. In addition, the facility failed to ensure medications were given per manufacturer instructions for 1 of 1 resident (R20) observed to receive insulin administration from a insulin flex pen during observations of medication pass in the facility. Findings include:R12R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R12 had intact cognition, and required moderate to maximal assistance with dressing and grooming. Diagnoses included acute on chronic congestive heart failure (CHF), diabetes, kidney disease and persistent atrial fibrillation. R12's Physician Progress Notes dated 10/2/25, identified R12 was seen by his primary provider on 10/2/25, during nursing home rounds. The provider identified R12 was recently admitted to the nursing home for congestive heart failure with pulmonary edema. R12 required diuresis, which had to be carefully done. R12 had 2+ pitting edema in his lower extremities. The plan was to add an extra 40 mg of furosemide if R12 were to accumulate more than three pounds in a week's period. The provider would consider adding another medication if the additional PRN furosemide was not helpful. R12's Order Summary Report signed 11/26/25, identified R12's medication and treatment orders which included: furosemide (a diuretic) 40 milligrams (mg) as needed (PRN) for edema related to acute on chronic CHF. If weight increased by more than 3 pounds per week, give extra 40 mg of furosemide. Daily weight before breakfast. Report signs of fluid retention to charge nurse. Symptoms include weight gain of 3 pounds in 24 hours and accompanied by increased shortness of breath, increased swelling of extremities, abdominal fullness/bloating, increased weakness, cough, dizzy, lightheaded, diarrhea or vomiting. Also report loss or gain of 5 pounds in one week. R12's medical record was reviewed and identified the following weights:11/3/25 weight 194 and 11/4/25, weight 198, a four-pound weight gain in a 24-hour period. PRN furosemide was not administered as ordered.11/9/25 weight 190.4 and 11/11/25, weight 193.5, a three-pound weight gain in a 48-hour period. PRN furosemide was not administered as ordered.11/17/25 weight 189 and 11/18/25, weight 192, a three-pound weight gain in a 24-hour period. PRN furosemide was not administered as ordered.11/30/25 weight 189 and 12/1/25 weight 192, a three-pound weight gain in a 24-hour period. PRN furosemide was not administered as ordered.12/6/25 weight 190.6 and 12/7/25 weight 193.4, a three-pound weight gain in a 24-hour period. PRN furosemide was not administered as ordered, even though R12's weight remained 193 pounds on 12/8/25, and 193.8 pounds 12/9/25.On 12/10/25, at 7:33 a.m. R12 was observed seated in a chair in his room fully dressed. R12's feet had pedal edema and feet appeared shaped like rounded balls. Licensed practical nurse (LPN)-B stated the nurses reminded R12 to elevate his feet and he was pretty good about elevating his feet after breakfast. During interview on 12/10/25, at 7:35 a.m. LPN-B stated she looked back on R12's weights at least a couple of days and if his weight increased, she would give the additional furosemide. There was no real explanation of what a week is, if it was 7 days back or Sunday to Sunday. R12 is weighed daily and the nurses just looked back at the previous couple of days weights. There was an additional order under R12's daily weight order to notify the physician if R12 had a three-pound weight gain in a 24-hour period or 5 pounds in one week, but that order was to notify the physician and was not related to the as needed furosemide order. When interviewed on 12/10/25, at 10:50 a.m. the director of nursing (DON) stated it was the facility's practice to prime all insulin flex pens by dialing up two units after attaching the needle and wasting it before dialing up the resident's ordered insulin dose. It was important to do so to ensure an accurate dose was given to the resident as ordered. All the nurses were trained on that and aware of the facility's practice to prime the insulin needle. The DON had already educated LPN-A on the importance of priming insulin needles. An untitled, undated Novolog flex-pen users manual identified a procedure to administer the insulin while using the pen. The instructions identified, . to avoid injecting air and to ensure proper dosing, then directed to attach the needle to the flex-pen, turn the dose selector to two units and depress the push-button to remove any collected air in pen and/or needle.The facility policy Insulin Pens with review date 10/2025, insulin injection was done by use of an insulin pen or with syringe and vial of insulin. Staff were directed to wash hands, check for correct insulin product, check expiration date, clean top of pen with an alcohol pad and attach needle on to pen. Staff were directed to perform air shot (checking the flow) before injection by dialing dose selector to two units. Hold pen with needle pointing up. Press the push button all the way in. Dose selector would return to zero and staff should see drops of insulin at the end of the needle. Then with the dose selector starting at zero, turn the selector to the dose of insulin ordered and give the injection. R20R20's most recent Order Summary Report signed 10/16/25, identified R20 had current physician orders for Lantus (a long acting insulin for diabetes) inject 18 units subcutaneously (SQ) in the morning for diabetes. On 12/10/25, at 7:10 a.m. licensed practical nurse (LPN)-A prepared medications for R20 at a mobile cart in the hallway. LPN--A stated she was going to draw up R20's scheduled Lantus insulin dose. LPN-A removed a Lantus flex-pen from the cart and attached a new, sterile needle to the end of the flex-pen, after cleaning the tip with an alcohol wipe, then reviewed R20's medication administration record (MAR) and turned the dial of the pen (used to inject the desired insulin dose) to 18 units. LPN-A did not prime the needle with any insulin to ensure an accurate dose would be delivered. LPN-A turned away from the medication cart and started to approach R20 to administer the medication. LPN-A was stopped by the surveyor and questioned on priming the needle attached to the flex-pen. LPN-A stated she did not prime the insulin needle because she only primed the flex pens that had two dots before the numbers and R20's flex pen did not have those dots so she would not have to prime the needle for that type of pen. LPN-A stated besides, priming the needle caused it to leak all over. LPN-A administered the Lantus insulin to R20's abdomen SQ after wiping the skin area with an alcohol wipe and returned to the medication cart, removed the needle and returned the flex pen to the medication cart, stating no-on ever primed the insulin needles. During medication pass observation on 12/10/25, at 7:33 a.m. LPN-B was observed passing medications to residents. LPN-B stated when she administered insulin to residents, she always primed the insulin needles by dialing the flex pen to 2 units and wasting it. After wasting the 2 units to ensure there was no trapped air or bubbles, she dialed the flex pen to the resident's ordered insulin dose and administered the medication as ordered. It was important to dial up 2 units first to ensure any trapped air was pushed out and to ensure the correct dose of insulin was administered. When interviewed by telephone on 12/10/25, at 10:04 a.m. the consultant pharmacist (CP)-C stated it was the usual practice to prime all insulin pens with two units of insulin. It was important to do so to ensure the insulin pen was working properly and also to ensure residents were getting the correct dose. If nurses did not prime the insulin pen first, there was a potential the resident would not get the correct ordered dose of insulin. When interviewed on 12/10/25, at 10:50 a.m. the director of nursing (DON) stated it was the facility's practice to prime all insulin flex pens by dialing up two units after attaching the needle and wasting it before dialing up the resident's ordered insulin dose. It was important to do so to ensure an accurate dose was given to the resident as ordered. All the nurses were trained on that and aware of the facility's practice to prime the insulin needle. The DON had already educated LPN-A on the importance of priming insulin needles. An untitled, undated Novolog flex-pen users manual identified a procedure to administer the insulin while using the pen. The instructions identified, . to avoid injecting air and to ensure proper dosing, then directed to attach the needle to the flex-pen, turn the dose selector to two units and depress the push-button to remove any collected air in pen and/or needle.The facility policy Insulin Pens with review date 10/2025, insulin injection was done by use of an insulin pen or with syringe and vial of insulin. Staff were directed to wash hands, check for correct insulin product, check expiration date, clean top of pen with an alcohol pad and attach needle on to pen. Staff were directed to perform air shot (checking the flow) before injection by dialing dose selector to two units. Hold pen with needle pointing up. Press the push button all the way in. Dose selector would return to zero and staff should see drops of insulin at the end of the needle. Then with the dose selector starting at zero, turn the selector to the dose of insulin ordered and give the injection.

Based on observation, interview and document review, the facility failed to ensure staff consistently implemented enhanced barrier precautions (EBP) in accordance with the Centers for Disease Control (CDC) guidelines to reduce the risk of infection spread for 2 of 2 residents (R6, R5) in the sample that were on EBP. In addition, the facility failed to establish a system to identify, investigate and control infections to prevent the spread of infection. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 had no cognitive impairment and required maximal assistance with dressing, grooming, and was dependent with toileting. R6 had an indwelling foley catheter and was occasionally incontinent of bowel. Diagnoses included congestive heart failure, kidney disease, retention of urine and unspecified hydronephrosis. R6's care plan with revision date 2/14/25, identified R6 was on enhanced barrier precautions (EBP) due the presence of a urinary catheter and a goal to not acquire a multidrug-resistant organism related to her catheter. Staff were directed to use EBP with R6. On 12/8/25, at 1:16 p.m. R6's room door had a sign on her room door that identified R6 had Enhanced Barrier Precautions and directed staff to wear gloves and a gown for the following high-risk activities: Dressing Bathing/showering Transferring Changing linens Providing hygiene Changing briefs or assisting with toileting Device care or use Wound care On 12/9/25, at 9:27 a.m. nursing assistant (NA)-B was observed to enter R6's room to answer the call light. R6 requested assistance to the bathroom. NA-B used alcohol based hand gel (ADHR) on her hands and applied disposable gloves. NA-B assisted R6 to stand up with her walker and ambulate to the bathroom. Once inside the bathroom, NA-B pulled down R6's pants and assisted her to sit on the toilet. NA-B removed her gloves, used ABHR on her hands and partially closed the bathroom door to allow for privacy. When R5 indicated she was finished, NA-B put on gloves and assisted R6 to stand. NA-B wiped R6's peri area with a disposable wipe, pulled up her brief and assisted R6 to ambulate back to the recliner in her room. NA-B removed her gloves and applied ABHR to her hands. During interview on 12/9/25, at 9:40 p.m. NA-B stated she did not wear a disposable gown when assisting R6 to the bathroom. She only needed to wear a gown if she was working directly with R6's catheter. NA-B stated it was very confusing, but they did not gown for residents who had a catheter unless they were directly working with the catheter. During interview on 12/9/25, at 9:50 a.m. licensed practical nurse (LPN)-A stated staff were supposed to wear a gown with EBP whenever they would be doing any high contact activity that may come into contact with body fluids. LPN-A stated she was not sure if staff would need to wear a gown to take R6 to the bathroom. But for residents with EBP staff would wear a gown to provide care, so yes, they did need to wear a gown when taking R6 to the bathroom. R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 was cognitively aware and had diagnoses that included stage 4 pressure ulcer of the right buttock, anxiety, and spinal stenosis. R5 was at risk for pressure injury/ulcer and had 1 unhealed stage 4 pressure ulcer. R5's care plan revised 10/28/25, identified R5 had a documented stage 4 pressure ulcer. Staff were directed to: Educate R5/R5's representative about proper skin care to prevent skin breakdown, Educate R5/R5's representative on importance of keeping skin clean and moisturized, Encourage R5 to frequently shift weight, and Monitor ulcer for sign of progression or declination. The care plan failed to direct staff to follow Enhanced Barrier Precautions. During an observation on 12/09/25 at 8:23 a.m., R5 had a sign on her room door that stated Enhanced Barrier Precautions and directed staff to wear gloves and a gown for the following high-risk activities: Dressing Bathing/showering Transferring Changing linens Providing hygiene Changing briefs or assisting with toileting Device care or use Wound care During an observation on 12/10/25 at 7:02 a.m., nursing assistant (NA)-B was wearing gloves but no gown and was making R5's bed. Linens were touching NA-B's uniform. During an interview on 12/10/25 at 7:26 a.m., NA-A stated they used to say when R5 had a catheter to wear a gown, but that's gone and now they say staff still had to wear a gown when you touch R5 because R5 had a wound. I don't touch the wound though. Staff did not wear a gown while touching R5's bed linens because staff were not touching R5. A joint interview was conducted with the infection preventionist (IP)-D and the director of nursing (DON) on 12/10/25, at 10:50 a.m. The IP-D stated EBP was initiated with any residents with catheters, wounds, infections, any resident with an open area or invasive device. The facility had not been performing any audits on staff performance on EBP's recently, but all staff had infection control training through the facility's Educare online training. The DON stated when a resident was placed on EBP because of an indwelling catheter, staff were expected to gown and glove when assisting with personal care, toileting and when they worked directly with the catheter. The DON thought staff had some training done in the spring for infection control, but she could see they needed to do some more training with staff. During an interview on 12/10/25 at 12:00 p.m. DON stated she expected staff to follow CDC guidelines regarding enhanced barrier precautions to prevent the spread of potential disease. The facility's policy Enhanced Barrier Precautions with review date 8/20/24, identified EBP was used to prevent the spread of multidrug-resistant organisms. EBP would be used for residents with chronic swounds and/or indwelling medical devices. EBP was to be employed when staff performed high-contact resident care activities such as dressing, bathing, changing linen, transferring, hygiene care, toileting, peri care, emptying catheter bag, wound care, indwelling medical device care and therapy treatment.

Based on interview and document review, the facility failed to ensure the Coronavirus Disease (COVID-19) vaccination was offered and/or provided to reduce the risk of severe illness to 3 of 5 residents (R11, R23. R37) reviewed for immunizations.Findings include:R11's significant change Minimum Data Set (MDS) dated [DATE], identified an admission date of 10/30/25, and date of birth [DATE]. R11 had intact cognition and was independent with most activities of daily living (ADLs). Diagnoses included metabolic encephalopathy, and hypertension. R11's medical record was reviewed and lacked any immunization records or evidence R11 had been offered, educated on, or provided the CDC recommended COVID-19 immunization(s) since her admission to the nursing home several months prior. R23's discharge MDS dated [DATE], identified an admission date of 11/25/25, and date of birth [DATE]. R23 had intact cognition and required moderate to maximal assistance with most of his ADLs. Diagnoses included cirrhosis of the liver with ascites, hepatic encephalopathy, thrombocytopenia, and pleural effusion. R23's medical record was reviewed and lacked any immunization records or evidence R11 had been offered, educated on, or provided the CDC recommended COVID-19 immunization(s) since his admission to the nursing home a month prior. R37's admission MDS dated [DATE], identified an admission date of 12/2/25, and date of birth [DATE]. R37 had moderate impaired cognition and supervision to moderate assistance with most ADLs and was independent with mobility. Diagnoses included hypertension, peripheral vascular disease and polycythemia. R37's medical record was reviewed and lacked any immunization records or evidence R37 had been offered, educated on, or provided the CDC recommended COVID-19 immunization(s) since his admission to the nursing home a month prior.A joint interview was conducted with the director of nursing (DON) and the infection preventionist (IP)-D on 12/10/25, at 10:50 a.m. The IP nurse stated she had just started her position last week. There had been a period of time where the facility did not have an IP nurse prior to her starting. She had just received a list of resident consent for vaccinations to go over and was just starting to pull their immunization records and planned to go around and talk with each of the residents. They were working on getting all the residents up to date now that she has started in the IP position. The facility's policy Resident Immunizations with review date 1/21/25, identified the Adult Immunization Schedule prepared by the Centers of Disease Control (CDC) would be utilized to ensure residents were offered and encouraged to accept the appropriate vaccinations. An immunization history would be taken on admission which would include checking the Minnesota Immunization Information Connection (MIIC) website. Any immunizations that were not current, or unknown vaccination histories would be shared with the attending physician and appropriate orders obtained. The resident's immunization history would be documented and maintained in the resident's medical record. Vaccination Information Statements would be provided to the resident and/or representative prior to administration of the vaccination. Education would be provided and any questions answered prior to administration of the vaccination. The determination to vaccinate or not would be documented in the medical record.

Based on interview and document review the facility failed to ensure timely reporting of an allegation of resident to resident abuse to the state agency (SA) for 2 of 2 residents (R1, R2) reviewed for abuse.Findings include:R1's admission Record indicated he admitted to the facility 1/10/25, with diagnosis that included neurocognitive disorder with [NAME] bodies, dementia with mood disturbance, agitation and psychotic disturbance.R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he displayed physical, verbal and other behaviors 1-3 days during the assessment period. The MDS indicated R1 ambulated independently.R1's care plan dated 5/22/25, identified a risk for harm to self or others. The care plan directed staff to approach R1 from the side when upset, hold hands gently when attempting to re-direct, and if he posed a potential threat to self or others, approach calmly and speak directly to him. The care plan further directed nursing to contact law enforcement to send to the emergency department (ED) when aggressive and not directable.R1's Progress Notes indicated the following:7/22/25, At approximately 2:30 p.m., R1 was standing at the nurses station and had a friendly conversation with R2. R1 walked away, then turned back around and Grabbed onto R2's walker. R2 asked him to let go and R1 yelled at her and pushed R2 backwards. Before staff could interfere, R1 struck R2 in the chest. Staff assisted R2 to keep from falling and R1 continued to reach around and grabbed and punched at R2. R1 connected with R2's chest and shoulder at least three times. R2's admission Record indicated she admitted to the facility 3/14/24. Diagnosis included cerebral infarction (stroke), hyperlipidemia and hypertension.R2's quarterly MDS dated [DATE] indicated her short term memory was okay. The MDS indicated R2 displayed verbal and physical behaviors 1-3 days during the assessment period and indicated she ambulated independently.R2's Care Plan dated 4/9/25, identified a potential to be verbally aggressive related to poor impulse control and directed staff to guide away from source of distress. A facility incident report dated 7/22/25, indicated At approximately 2:30 p.m., R2 was standing at the nurses station. R1 was also standing there having a snack. R1 walked away, then turned back around and grabbed R2's walker. R2 very kindly asked him to let go and his behavior changed instantly. R1 yelled at R2 and pushed her back. Before staff could intervene, R1 struck R2 in the chest. Staff stepped between the two residents but R1 continued reaching around the staff and grabbed and punched at R2. The report indicated R2 sustained injury to her right shoulder and reported pain rated 7/10 to her right shoulder and neck. R2 also had a lump on the front of her right bicep.During interview on 8/8/25 at 12:45 p.m., the social service designee (SD) stated she had completed a report right away after the incident occurred but said she had not reported to the correct agency.During interview on 8/6/25 at 10:10 a.m., the administrator stated the incident had not been reported to the SA timely and said after the corporate consultant identified it had not been reported, she reported the incident to the SA.Facility policy Maltreatment Reporting Guidelines dated undated indicated if suspected maltreatment occurred, report to the SA immediately, but not later than 2 hours after the allegation is made if the incident involves abuse, neglect, or financial exploitation that results in serious bodily injury, including injuries of unknown source and misappropriation of VA property.

Based on interview and document review the facility failed to provide notice of intent to discharge for 1 of 1 residents (R1) who was sent to the hospital and discharged from the facility.Findings include:R1's admission Record indicated he admitted to the facility 1/10/25, with diagnosis that included neurocognitive disorder with [NAME] bodies, dementia with mood disturbance, agitation and psychotic disturbance.R1's quarterly Minimum Data Set, dated [DATE], identified severe cognitive impairment and indicated he displayed physical, verbal and other behaviors 1-3 days during the assessment period. R1's care plan dated 5/22/25, identified a risk for harm to self or others. The care plan directed staff to approach R1 from the side when upset, hold hands gently when attempting to re-direct, and if he posed a potential threat to self or others, approach calmly and speak directly to him. The care plan further directed nursing to contact law enforcement to send to the emergency department (ED) when aggressive and not directable.R1's Progress Notes indicated the following:7/22/25, At approximately 2:30 p.m., R1 was standing at the nurse's station and had a friendly conversation with R2. R1 walked away, then turned back around and Grabbed onto R2's walker. R2 asked him to let go and R1 yelled at her and pushed R2 backwards. Before staff could interfere, R1 struck R2 in the chest. Staff assisted R2 to keep from falling and R1 continued to reach around, grabbing and punching at R2. R1 connected with R2's chest and shoulder at least three times. R1 was taken to the emergency department.7/24/25, Facility staff received a phone call that R1 would be returning to the facility. Direction from facility administrator was to notify hospital not to accept R1 for re-admission.7/25/25, R1 had been officially discharged from the facility and is being placed in a behavioral health unit.A facility incident report dated 7/22/25, indicated At approximately 2:30 p.m., R2 was standing at the nurses station. R1 was also standing there having a snack. R1 walked away, then turned back around and grabbed R2's walker. R2 very kindly asked him to let go and his behavior changed instantly. R1 yelled at R2 and pushed her back. Before staff could intervene, R1 struck R2 in the chest. Staff stepped between the two residents but R1 continued reaching around the staff and grabbed and punched at R2. The incident report indicated R1 was sent to the emergency department for placement elsewhere.During interview on 8/6/25 at 10:10 a.m., the administrator stated R1 was in a behavioral health unit and said the facility had discharged him due to his aggression. The administrator said when the hospital called and wanted to send him back to the hospital the facility did not take him back and said they did not have the resources to give him what he needed. The administrator stated they had discussed a memory care unit with R1's family but said she did not know what the families plan for R1 was. A facility discharge policy was requested but not received.

Based on observation, interview and document review, the facility failed to implement transmission-based precautions (TBP) for respiratory symptoms until confirmatory respiratory test results were obtained for 6 of 38 residents (R34, R31, R11,R22, R36, R32), failed to initiate droplet precautions for 1 of 6 residents (R31) known to test positive for influenza A, failed to implement strategies to mitigate the risk of an influenza outbreak, including initiating active surveillance of residents for signs and symptoms of influenza A, isolation of residents presenting with symptoms of influenza A, and post signage at the facility entrances to notify visitors of active illness in the facility. This resulted in a system wide failure in infection control procedures to prevent the spread of illness within the facility when 8 of 38 residents (R31, R11 , R36, R32, R38, R7, R35, R3) contracted influenza A. This resulted in an immediate jeopardy (IJ) which placed all 38 residents at a high likelihood for serious illness and/or death by contracting a communicable disease, including but not limited to influenza A. In addition, the facility failed to track and trend all resident actual/potential infection on the monthly tracking form to effectively identify symptoms and reduce the spread of infection with a potential to affect all 38 residents residing in the facility. The IJ began on 2/13/25, when R34 exhibited symptoms of respiratory illness, was not isolated or placed on TBP when symptoms were exhibited, and subsequently tested positive for influenza A on 2/14/25, and failed to implement interventions to reduce the spread of influenza A which resulted in eight other residents contracting influenza A. The director of nursing (DON) was notified of the IJ on 2/24/25, at 9:27 p.m. The IJ was removed on 2/26/24, at 10:26 a.m. when the facility implemented actions to reduce/prevent the spread of illness. However, noncompliance remained at the lower scope and severity, F widespread, which indicated no actual harm with potential for more than minimal harm that was not IJ. Findings include: INFLUENZA A OUTBREAK: The Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities from the Centers of Disease Control (CDC) dated 9/17/24, identified influenza can be introduced into a long-term care facility by newly admitted residents, healthcare personnel, and visitors. Spread of influenza can occur between and among residents, healthcare personnel and visitors. Residents of long-term care facilities can experience severe and fatal illness during influenza outbreaks. If one laboratory-confirmed influenza positive case was identified along with other cases of acute respiratory illness in a unit of a long-term care facility, an influenza outbreak might be occurring. Active surveillance for additional cases should be implemented as soon as possible once one case of laboratory-confirmed influenza is identified in a facility. When 2 cases of laboratory-confirmed influenza were identified within 72 hours of each other in residents on the same unit, outbreak control measures should be implemented as soon as possible. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility. The CDC guidance for Flu and People [AGE] years and Older dated 9/5/24, identified people [AGE] years and older are at higher risk of developing serious flu complications compared with young, healthy adults. This increased risk is due in part to changes in immune defenses with increasing age. While flu seasons vary in severity, during most seasons, people [AGE] years and older bear the greatest burden of severe flu disease. In recent years, for example, it ' s estimated that between 70 percent and 85 percent of seasonal flu-related deaths have occurred in people [AGE] years and older, and between 50 percent and 70 percent of seasonal flu-related hospitalization s have occurred among people in this age group. On 2/24/25, at 11:30 a.m. surveyors entered the facility to conduct an annual recertification survey. No signs were posted to alert visitors an influenza outbreak was occurring in the facility. During the entrance conference 2/24/25, at 12:26 p.m. with the DON, the DON failed to identify there were any residents ill with respiratory illness or the facility may be experiencing an influenza outbreak. R34: R34's significant change Minimum Data Set (MDS) dated [DATE], identified R34 was [AGE] years of age and had moderately impaired cognition. R34 required maximum assistance with most activities of daily living (ADLs). R34 was vaccinated for influenza on 10/11/24. Diagnoses included Alzheimer's disease, acute kidney failure and encephalopathy. R34's progress notes identified on 2/12/25, R34 had developed a hoarse voice and dry cough and on 2/13/25, R31 had developed a low-grade temperature. A positive influenza test was identified on 2/14/25. Droplet precautions were put into place on 2/14/25. R34's medical record failed to identify transmission-based precautions were implemented when R34 first presented with respiratory symptoms to prevent the spread of influenza A to other residents and staff. R31: R31's quarterly MDS dated [DATE], identified R31 was [AGE] years of age and had intact cognition. R31 required partial assistance with dressing and was dependent with toileting and bathing. R31 was vaccinated for influenza on 10/10/24. Diagnoses included congestive heart failure, and diabetes. R31's progress note on 2/23/25, identified R31 complained of not feeling well with body aches and wheezes noted in both lung fields. R31 was sent to the emergency room to be evaluated and returned on 2/24/25, at 2:20 a.m. with a positive influenza A test result. R31's medical record failed to identify droplet precautions were implemented when R34 returned from the hospital positive for influenza A, to prevent the spread of influenza A to other residents and staff. On 2/24/25, at 3:20 p.m. prior to the surveyor entering the room for screening nursing assistant (NA)-A stated R31 was on enhanced barrier precautions because R31 had a catheter in place. Staff were required to wear gown and gloves when providing close contact care. The personal protective equipment (PPE) was not required to visit with resident if not in close contact with resident. The surveyor proceeded to enter the room to complete the screening process for the survey. On 2/24/25, at 4:46 p.m. trained medication aide (TMA)-A was observed removing the enhanced barrier precaution sign on R31's door and placing a droplet precaution sign on the door. During interview on 2/24/25, at 4:46 p.m. TMA-A stated R31 only had enhanced barrier precautions sign on his door, which directed staff to gown and glove when providing personal care and did not require staff to mask. TMA-A had just put a new droplet precaution sign on R31's door that directed all persons to gown, glove, and mask prior to entering the room. TMA-A stated all the staff working that day were aware R31 had tested positive for influenza A since his return from the emergency room at 2:30 a.m., as it was reported during shift report that morning. The precautions sign had just not been changed. (the droplet precautions were placed 13 1/2 hours later) When interviewed on 2/24/25, at 4:59 p.m. the infection preventionist registered nurse (RN)-A stated R31's precautions should have been changed from enhanced barrier precautions to droplet precautions as soon as he returned from the emergency department. R11: R11's admission MDS dated [DATE], identified R11 was [AGE] years of age and had severe cognitive impairment. R11 required moderate assistance with dressing, bathing, and toileting. R11 was vaccinated for influenza prior to his admission to the facility. Diagnoses included malignant neoplasm of the rectal sigmoid junction and thrombocytopenia. R11's progress note(s) identified on 2/24/25, R11 had required administration of acetaminophen 650 milligrams at 7:54 a.m. for a temperature of 101.4. On 2/24/25, at 1:13 p.m. a family member (FM)-A was observed sitting on R11's bed, in very close contact with R11, who was seated in his recliner in his room. FM-A stated R11 had a temperature that morning and had fallen getting out of bed as he was so weak. The facility had tested him for respiratory illness and were waiting on the results. FM-A was not wearing any PPE and there was no evidence transmission-based precautions were not implemented with close contact with R11. During observation on 2/24/25, at 1:20 p.m. two unidentified nursing assistants (NA) were seen entering R11's room to assist his roommate R14 to bed. R11 was seated in his recliner in the room, next to the fully open privacy curtain. The NAs drew the privacy curtain halfway across the room and assisted R14 to bed using a mechanical lift. The NAs re-opened the privacy curtain, used alcohol-based hand rub on their hands after completing the task and exited the room. Neither NA's put on personal protective equipment. There was no signage or PPE cart outside of R11's room to alert staff to the need for PPE when entering the room to prevent potential transmission to others. On 2/24/25, at 6:18 p.m. NA-C and NA-D were observed assisting R11 to the bathroom. NA-C, wearing mask and gloves, was kneeling in front of R11 who was seated on the toilet. NA-D was outside of the bathroom making the bed up. NA-D did not have gown or mask on. NA-D stated she remembered someone mentioning something about wearing a mask but had forgotten. NA-D exited the room to read the precaution sign posted on R11's room door. The sign indicated R11 was on droplet precautions, and everyone must wear a mask and clean hands on entering and leaving the room. If contact with secretions were likely staff were directed to use gown, gloves and eye cover as well. NA-D stated she now realized she needed to wear a gown and mask. NA-D put on a gown and surgical mask and brought NA-C an isolation gown to put on. R11's progress note on 2/24/25, at 6:31 p.m. identified R11 tested positive for influenza A and was placed on droplet precautions. Appropriate signage and a PPE cart were placed outside of his door. R22: R22's admission MDS dated [DATE], identified R22 was [AGE] years of age and had severe cognitive impairment. R22 required supervision with ADL's. R22 had not been vaccinated for influenza virus. Diagnoses included neurocognitive disorder with Lewy bodies, and heart disease. During observation on 2/24/25, between 1:00 p.m., to 5:30 p.m. R22 was lethargic, lying halfway on his bed with both feet on the floor. R22 did not wake to eat lunch. At 2:00 PM. TMA-A and another unidentified staff member were attempting to arouse R22 to drink water. Neither staff were wearing any PPE. There were no isolation precautions or PPE cart noted in the room. R22's progress note(s) identified the following: - 2/24/25, at 11:09 a.m. a respiratory panel was completed for cough, headache and body aches. - 2/24/25, at 2:02 p.m. identified R22 had been wandering throughout the shift, into other resident rooms and was difficult to redirect. - 2/24/25, at 7:20 p.m. identified R22 had not been feeling well that day and had complained of ear pain, neck pain and headache R22 had a temperature of 100.4 and oxygen saturation was 92%. A respiratory panel had been completed with results pending. R22 was sent to the emergency room for further evaluation. - 2/25/25, at 3:21 a.m. identified R22 had returned from the emergency room . R22's respiratory panel was negative, however, R22 continued to complain of neck pain, refused to eat his meals and remained in bed. R22's medical record failed to identify transmission-based precautions were implemented when R22 first presented with respiratory symptoms on 2/24/25, to prevent the spread of potential respiratory infections to other residents and staff. R36: R36's admission MDS 12/11/24, identified R36 was [AGE] years of age and had intact cognition. R36 was independent with his ADLs. R36 had been vaccinated for the influenza prior to his admission to the facility. Diagnoses included chronic obstructive pulmonary disease, irritable bowel syndrome, and abnormal weight loss. During interview on 2/24/25, at 2:51 p.m. R36 stated he was not feeling well and had not eaten much in two weeks. R36 reported he had fallen that morning because he was so weak. There were no isolation precautions, signage or PPE cart noted in the room. On 2/24/25, at 3:28 p.m. R36 was observed dressed in coat, hat and gloves, ambulating down the hallway. R36 stated he was going outside to smoke a cigarette. R36 stopped at the nurse's station and visited with the nurse for several minutes, before obtaining a cigarette and going outside to smoke. R36's progress note dated 2/24/25, at 7:42 p.m., identified R36 had tested positive for influenza A and was placed on droplet precautions. R32: R32's quarterly MDS dated [DATE], identified R32 was [AGE] years of age and had intact cognition. R32 was independent with ADL's. R32 had refused the influenza vaccine. Diagnosis included chronic obstructive pulmonary disease. R32's progress note(s) identified the following: - 2/23/25, R32 complained of chest congestion and had a temperature of 101.2. - 2/24/25, R32 was positive for influenza A and placed on droplet precautions. R32's medical record failed to identify transmission-based precautions were implemented when R34 first presented with respiratory symptoms on 2/23/25, to prevent the spread of influenza A to other residents and staff. During observations on 2/24/25, there continued to be no signs posted on the facility entrances to inform visitors and staff of influenza in the building. When interviewed on 2/24/25, at 6:10 p.m. RN-A stated when residents exhibit a cough or elevated temperature the facility encouraged the resident to stay in their room. If the resident needed to come out of their room, they were encouraged to wear a surgical mask and did not implement transmission-based precautions. The facility did not implement droplet precautions unless the resident had a positive test result for influenza. During interview on 2/24/25, at 6:29 p.m. the director of nursing (DON) stated R34 was the facility's first case of confirmed influenza. R34 tested positive for influenza A on 2/13/25 and was placed on droplet precautions on 2/14/25 and not when R34 first developed symptoms. When residents did not feel well, the facility tried to limit exposure to the ill resident until they had confirmed test results. R31 tested positive for influenza A during his visit to the emergency room and should have been isolated and placed on precautions on his return. The DON indicated she thought six other residents had some symptoms of respiratory illness and had been tested . The residents were not on transmission- based precautions but were asked to stay in their rooms as much as they could. Staff and visitors were not required to wear PPE to enter the resident rooms and some of the symptomatic residents did share their room with a roommate. The DON stated residents who exhibited any symptoms of respiratory illness should be placed in transmission based-precautions, a respiratory test completed and then placed in droplet precautions with a confirmed test however, the documentation did not reflect that. When interviewed on 2/24/25, at 7:33 p.m. the DON stated the facility was now implementing droplet precautions with all residents who exhibited symptoms of acute illness and not waiting for lab results before implementing the precautions. However, the facility was not doing any active surveillance for monitoring for influenza A and only obtained vital signs including temperatures weekly unless they report symptoms of illness or the facility staff notice something was off. Further, the facility had not done anything different with roommates of residents with influenza A such as isolating them or offering room changes. The DON felt when they did that during the COVID pandemic and felt it did not work and spread the illness further. During an interview on 2/26/25 at 3:41 p.m., RN-A stated she was responsible for the facility Infection Prevention and Control Program. RN-A started her role at the facility in November 2024 and worked as the facility's wound nurse as well. Staff would document any signs/symptoms of possible infections in the resident electronic medical record (EMR) and staff had the ability to initiate transmission-based precautions but had not done so until RN-A arrived to work on 2/24/25. Any resident with any sign or symptoms of infection should have been documented on the surveillance log to prevent the spread of illness. Further, the facility had not started active surveillance of residents to identify symptoms early. The facility identified via email R38 ,R7, R35 and R3 had subsequently positive influenza A tests: R38's admission MDS dated [DATE], identified R38 was [AGE] years old and had diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis and hemiplegia (weakness of one side of the body) following a stroke and hypertension. R7's quarterly MDS dated [DATE], identified R7 was [AGE] years old and had diagnoses that included chronic obstructive pulmonary disease (COPD) (a lung condition caused by damage to the airways and alveoli), asthma and hypertension. R35's quarterly MDS dated [DATE], identified R7 was [AGE] years old and diagnoses that included hypertension and type 2 diabetes. R3's quarterly MDS dated [DATE], identified R3 was [AGE] years old and had diagnoses that included atrial fibrillation (irregular heartbeat), heart failure and chronic kidney disease. The facility Influenza A and B or Lung MDRO policy dated 9/11/17, identified in addition to standard precautions, staff were to implement droplet precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the individual coughing, sneezing, talking or by the performance of procedures such as suctioning. If the resident's cognition and physical ability was such that they were consistently able to cover their cough and place the tissue in a trash bag, they could come out of their room and have company without wearing a mask. The resident must be able to follow instructions and do proper hand hygiene. Place resident in a private room. if private room was not available and cohorting was not achievable, staff were directed to use curtain in room and maintain at least three feet of space between infected resident and other residents or visitors. In addition to standard precautions, staff were to wear a mask when working within three feet of the resident. The facility Resident Influenza policy dated 5/1/24, identified influenza was a highly contagious infection of the respiratory tract caused by a virus and transmitted by air-borne droplet infections. Typical influenza illness was characterized by abrupt onset of fever/chills, myalgia, sore throat and non-productive cough. Staff were instructed to report to the charge nurse or infection prevention any suspicion of residents exhibiting influenza symptoms. Employees with a fever of 100.4 or higher should not come to work. use proper handwashing techniques, use appropriate PPE when caring for residents with symptoms of influenza. any resident with influenza symptoms or fever over 100.4 must eat in their room. Keep resident away from activities or therapies if contagious and discourage visitors. All cases of influenza would be entered on the facility infection control logs. The IJ that began on 2/13/25, was removed on 2/26/25, at 10:26 a.m., when it could be verified through observation, interview and document review the facility implemented droplet precautions for all residents that tested positive for influenza A, implemented a system for ongoing active surveillance of residents for symptoms of influenza A, implemented transmission -based precautions for all symptomatic residents until confirmatory test resulted and the facility reviewed and revised their influenza policy to reflect current CDC guidelines. 40943 ONGOING INFECTION CONTROL SURVEILLANCE: The faciltiy provided an Infection Surveillance Report for each month that included resident name, case details, symptoms, lab results, treatment details and outcome. The facility Infection Surveillance Report dated January 2025, was reviewed and failed to include R13's influenza A exposure and symptoms. R13 R13's annual Minimum Data Set (MDS) dated [DATE], identified R13 had a severe cognitive impairment and diagnoses that included congestive heart failure (CHF), hypertension and type 2 diabetes. R13's nursing progress note dated 1/6/25, identified R13 was exposed to influenza A from roommate. R13 was also experiencing respiratory symptoms so R13 was swabbed for a respiratory panel which has been sent to the lab. Results pending. The facility Infection Surveillance Report dated February 2025, failed to include R34's respiratory signs and influenza A positive status, R34 R34's significant change MDS dated [DATE], identified R34 had a severe cognitive impairment and diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension and dementia. R34's nursing progress notes identified: - 2/12/25 at 4:29 p.m., R34 from a nap this afternoon with a hoarse voice and dry cough. No fever noted or any other symptoms at this time. - 2/13/25 at 2:13 p.m., R24 continued to have a hoarse voice today and dry cough. She also had a low grade temp this morning. Resp Panel swab completed at 4:00 p.m - 2/13/25 at 2:14 p.m., R18 was sleepy today. Was running a low grade temp this morning. R34 received scheduled Tylenol. She was complaining of pain in her right shoulder and right hip. Pain meds were effective. R34 has not eaten well today but has been drinking fluids when given to her. R34 was propelling herself around in her wheelchair more. PT works with R34 daily. - 2/13/25 at 8:33 p.m., R34 wanted to go to bed soon after supper, she appeared tired, not as talkative as usual when asked she denied any pain, no coughing noted this shift, awaiting results of resp panel. Currently R34 asleep in bed respirations easy and regular at 18. R34 was able to get place to place by wheeling wheelchair and appeared to tolerate well. - 2/14/25 at 6:51 a.m., R34 tested positive for influenza A. Isolation precautions set up on R34's door. R34 was experiencing a low grade temp, cough, and hoarse voice. A skilled nurse is monitoring signs and symptoms. Plan of care ongoing. During an interview on 2/26/25 at 3:41 p.m., RN-A stated every day RN-A was scheduled to work, RN-A read through either the 24 hour or 72 hour report. For example, if RN-A did not work the weekend, RN-A would review the 72 hour report on Monday mornings. When RN-A was not working, there was no designated staff member to complete resident illness surveillance. Any resident with any sign or symptoms of infection should have been documented on the surveillance log to prevent the spread of illness. During an interview on 2/27/25 at 4:18 p.m., the DON stated all signs/symptoms of illness were expected to be documented and entered on the surveillance log to prevent the potential spread of illness. The facility policy Infection Surveillance revised 2/25/25, identified the facility would conduct ongoing surveillance for Healthcare-Associated Infections (Thais) and epidemiologically significant infections that have substantial impact on potential resident outcome.

Based on interview and document review, the facility failed to ensure use of an as-needed psychotropic medication was limited to a 14-day period and/or re-evaluated by the provider to ensure ongoing need and efficacy of the medications for 2 of 5 residents (R18,R22) reviewed for unnecessary medication use. In addition, the facility failed to complete comprehensive assessment and ongoing monitoring of behaviors for an administered antipsychotic medication to ensure efficacy of the medication for 1 of 5 residents (R11) reviewed for unnecessary medication use. Findings include: R18: R18's significant change Minimum Data Set (MDS) dated [DATE], identified R18 had a severe cognitive impairment and diagnoses that included Alzheimer's disease and dementia. R18 did not exhibit behaviors during the assessment period. R18's undated care plan, identified R18 used anti-anxiety medications (lorazepam) related to recent changes in health status. Interventions included: - Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. - Make referrals for me as needed - Monitor me for safety. I am taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations - Monitor/record occurrence of for target behavior symptom, inappropriate response to verbal communication, violence/aggression towards staff/daughter and document per facility protocol. - My non-pharmacological interventions include: 1: 1, Distraction/redirection, family visits. - Observe for changes in my behavior and update provider R18's physician order dated 1/16/25, identified lorazepam tablet 0.5 milligram (MG). Give one tablet by mouth every two hours as needed for anxiety or agitation. R18's electronic medication administration record (EMAR) dated January 2025, identified R18 received lorazepam on 1/29/25. R18's EMAR dated February 2025, Jan EMAR identified R18 received lorazepam on 2/11/25 and 2/21/25. R18's medical record failed to identify if a a face-to-face provider evaluation for continued use of a as needed (PRN) psychotropic medication was completed. R18's nursing progress notes identified the following: - 1/16/25 at 2:27 p.m., R18 was slightly declining for the past 48 hours. Concerns were discussed with family. Orders were obtained from the medical director (MD) to ensure R18 remained comfortable and had no anxiety/anxiousness. Lorazepam 0.5mg every 2 hours as needed and morphine sulfate 20mg/milliliter (mL), give 0.125mL every 2 hours as needed for severe pain/discomfort, and oxygen to maintain sats above 90% or for comfort. These medications should only be utilized if/when R18 was no longer safe to obtain oral pain medications. - 1/29/25 at 6:10 p.m., R18 was in the dining room sitting at her daughter's table and started yelling help me help me, I want to lay down. When approached, R18 started yelling that she needed to go to bed. Staff took R18 to her room and got her into her bed. R18 was not in her bed 10 minutes, and R18 began yelling that she wanted to get up. Staff got her up and then R18 started to say she wanted to lay down again. Staff would tell her that she needed to stay up for a while and that they could not keep laying her down and getting her back up. Staff was administered 0.5mg Ativan at 6:01 p.m. for anxiety. R18 was saying that her legs hurt, she did get her pain medication as scheduled at 5:50 p.m. R18 was sitting in the dining room and kept asking staff to lay her back down. - 2/11/25 at 3:58 p.m., R18 was lying in bed and started hollering help me, help me!! When staff arrived, R18 was flailing her arms and legs around and starting to dry heave. Staff was unable to get R18 to calm down, staff administered 0.5mg Ativan at 3:46 p.m., a warm blanket and sat by her bedside until R18 calmed down and fell asleep. - 2/21/25 at 12:46 a.m., R18 was yelling out non-stop. R18 insisted that she was laying on top of a car and the guys have to get her off. Staff spent 1:1, changed her brief, gave fluids and offered a snack. Staff was unable to redirect/reorient her. She declined snack, took in fluids but continued to yell out. R18 was anxious and teary, very agitated. As needed lorazepam 0.5 mg was given. Staff continued to reassure R18 that everything was okay. During an interview on 2/27/25 at 12:55 p.m., registered nurse (RN)-F stated she recently learned an as needed antipsychotic should be re-evaluated with a face-to-face provider visit every two weeks. I just learned that yesterday. RN-F stated R18's medical record lacked information identifying a face-to-face provider evaluation was completed. During a phone interview on 2/27/25 at 3:29 p.m., R18's physician (DR)-A stated he was unaware of the requirement to perform a face-to-face re-evaluation of antipsychotic PRN medications every 14 days and nursing did not inform him. 41575 R11: R11's admission MDS dated [DATE], identified R11 had severe cognitive impairment and required moderate assistance with dressing, bathing, and toileting. R11 was identified to have wandering one to three times during the assessment period and did not exhibit physical or verbal behaviors toward others. R11's diagnoses included malignant neoplasm of the rectal sigmoid junction and thrombocytopenia. R11's care plan with revision date 12/24/24, identified R11 was at risk for elopement and wandering. Interventions included to provide a wander guard and structured activities such as toileting, walking, and reorientation strategies such as signs, pictures, and memory boxes. Use of psychotropic medications related to behavior management was also identified. Staff were instructed to administer medications as ordered, monitor for side effects, discuss with physician regarding ongoing need and indicated R11 was on a behavior management program, however, lacked documentation of what behaviors were exhibited and/or what the behavior management program entailed. The care plan further identified R11 at risk for insomnia with interventions to administer medications as ordered, maintain a consistent routine to retire and wake up and discourage daytime naps. R11's Order Summary Report dated 2/17/25, identified an order for quetiapine 25 mg one tablet at bedtime related to dementia with other behavioral disturbances with order date 11/26/24, gabapentin 250 mg/5ml give 1 ml three times per day related to dementia with other behavioral disturbances with order date 1/22/25, and escitalopram 2.5 mg every morning related to dementia with other behavioral disturbances with order date 12/18/24. Staff were directed to monitor for side effects related to the psychotropic medications. Target behaviors with order date 11/29/24, listed depression with non-pharmalogical approaches of one to one, distraction, calm approach and offer food/drink every shift. Staff were to record if behaviors had been observed or not observed. R11's Order Summary Report dated 2/26/25, identified R11's gabapentin was increased from 1 ml three times per day to 1.5 ml three times per day with start date 2/24/25. The medical record lacked an assessment to support the increase in gabapentin. R11's MAR for February 2025, identified the medication quetiapine, gabapentin and escitalopram was administered every day 2/1/24 through 2/26/25, as ordered. Target behaviors were not monitored on the February 2025, MAR. On 2/25/25, at 11:20 a.m. R11 was observed standing with walker in his room doorway, fully dressed in preparation to go to the dining area for lunch. When staff attempted to redirect R11 back into room, R11 stated no he did not want to eat in his room. R11 was assisted to put on a face mask and assisted to the dining area. R11 remained seated alone at the dining room table, removing his mask only to eat and then returned to his room. On 2/26/25, at 11:36 a.m. R11 was observed seated in a recliner in his room. R11 was seated quietly in his room. There was no television in room and/or magazines visible nearby. R11 watched as staff and residents passed by the room and occasionally would holler out a greeting and/or smile and wave. A joint interview was conducted on 2/27/25, at 9:13 a.m. with nursing assistant (NA)-A and NA-H. NA-A stated she was not aware R11 had any behaviors. R11 could sometimes act a little grumpy or anxious but liked to joke around and would soon come out of it. R11 was a nice man but would at times get anxious if he had nothing to do. R11 always seemed to need something to do but once you found something to occupy him, he was fine. NA-H stated R11 was very nice and liked to read the paper in the dining area and people watch. R11 enjoyed visiting with others and staff frequently sat down with him to visit and he would laugh and joke with them. Never resistive or combative with cares or others. R11's progress notes, dated 1/28/25 to 2/24/25, were reviewed. A progress note dated 2/18/25, identified R11's mood was pleasant with no unwanted behaviors witnessed and R11 slept through the night. No behavioral incidents were recorded in the 28-day period reviewed. R11's medical record lacked evidence what symptoms or specific behaviors were being tracked or monitored to ensure the efficacy of the ordered quetiapine and gabapentin and support the use of the medications. During interview on 2/27/25, at 9:33 a.m. registered nurse (RN)-B stated R11 had dementia and experienced a lot of anxiety, but she never witnessed aggressive behaviors. The gabapentin was increased on 2/24/25, for R11's own comfort to see if they could make him feel better. R11 would wander and get very anxious and make comments that he did not know why he was here or what he should be doing. R11 seemed more comfortable now and less episodes of those behaviors happening. RN-B did not do rounds with the mental health provider NP-F and so was not sure what was discussed when NP-F increased R11's medication. R11's anxiety was not on the care plan, and it should have been. It would be important to list the type of behavior R11 exhibited and the interventions so staff could utilize them before medication to decrease R11's symptoms of loneliness and depression. During telephone interview on 2/27/25, at 12:54 p.m. the consultant pharmacist (CP)-E stated R11 received quetiapine at bedtime for dementia and that was not an appropriate diagnosis for the medication unless there was evidence the behaviors could harm self or others. There were usually targeted behaviors and non pharmalogical interventions in the care plan related to the use of antipsychotic medications and she had noticed R11's care plan did not address behaviors. CP-E had also noted NP-F had increased R11's gabapentin in January and there was no rationale for the increase in R11's medical record. CP-E reviewed all the progress notes for behaviors as well and could not find rationale for the medication increase documented. During interview on 2/27/25, at 2:12 p.m. the DON stated she would expect anxiety and related behaviors to have been documented on R11's plan of care. She knew R11 had a lot of anxiety, and she would have expected some behavioral incidents to have been documented in his progress notes to justify the initiation and two increased doses of gabapentin ordered and/or whether the medication was successful or not. Dementia alone was not enough of a reason to prescribe quetiapine or gabapentin, and the DON needed to speak with the provider regarding the issue. During telephone interview on 2/27/25, at 3:29 a.m. with R22's primary physician (DR)-A stated he was not sure who had first prescribed quetiapine for R11, however, he thought he had done the admission orders. The diagnoses just popped up on the chart and he picked the most appropriate diagnosis. DR-A was not aware of all the regulations and the issues had not been brought up to him when he conducted rounds at the facility. R11 was seen by a mental health provider NP-F and she would be more aware of all the regulations surrounding those type of medications. On 2/27/25, at 4:01 p.m. NP-F was called with a request for a return call; however, none was received. The facility policy Psychotropic Medications dated 8/20/24, identified the facility would have the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, behavioral interventions and psychopharmacological medications could be utilized to meet the needs of the individual resident. Primary providers would order psychotropic medication only for the treatment of specific medical and/or psychiatric conditions or when the medication meets the needs of the resident to alleviate significant distress for the resident not met by non-pharmacological approaches. The provider would document rationale and diagnosis for use and identify Target Behavior symptoms for the reason the medication was being utilized. PRN psychotropic medications ordered would be limited to 14 days. The prescribing practitioner would evaluate and document the medications necessity, benefits, and improvement (expressions, indications of distress). If the physician deemed it appropriate to extend beyond the 14-day limit, supporting rationale must be documented. The facility staff would monitor and document for the presence of target behaviors daily, charting by exception (i.e., charting only when the behaviors are present), noting any adverse effects, review usage of the medications with the physician and the IDT on a quarterly basis to determine the continued presence of target behaviors and/or presence of any adverse effects, implement non-pharmacological interventions for target behavior(s), document results, and add to care plan, and utilize PRN psychotropic medication, following provider order, if non-pharmacological intervention(s) are unsuccessful.

Based on observation, interview, and document review, the facility failed to ensure the care plan was updated timely to to prevent falls for 1 of 1 residents (R19) reviewed for falls. Findings include: R18's significant change Minimum Data Set (MDS) dated [DATE], identified R18 had a severe cognitive impairment and diagnoses that included Alzheimer's disease, dementia and osteoporosis. R18 had a fall without injury and a fall with injury. R18 did not use an alarm or any physical or electronic device that monitored R18's movement and alerted staff when movement was detected. R18's care plan revised 2/6/25, identified R18 was at risk for all related to confusion. Interventions included: - Assist R18 as needed with mobility and transfers - Be sure R18's call light was within reach and encourage R18 to use it for assistance as needed. - Bed in lowest position - Ensure that R18 was wearing appropriate footwear shoes when up ambulating or mobilizing in wheelchair and gripper socks when in bed. - R18 did not remember that R18 needed assistance with transfer or ambulation, anticipate needs. - R18 had a Bed sensor on R18's wall. - R18 had an easy touch call light under sheet, under R18's hip on R18's bed. - R18 needed a safe environment with floors free from spills and/or clutter; personal items within reach, gripper strips on floor in front of bed, recliner, and toilet - Keep R18 wheelchair next to R18 during meals and activities - R18 fall risk would be assessed every quarter and with change in condition R18's Incident Forms identified the following: - 11/7/24 at 8:45 a.m., identified R18 was heard yelling out for help, she was found lying on the floor in the hallway off the dining room. R18 was laying on the floor, laying on her right side. R18 stated she was walking to eat, and her knees just gave out and she fell to her knees and then fell to her right side. R18 would have been in bed three hours prior to fall. At 7:30 a.m., staff walked resident out to the dining room for breakfast. R18 was evaluated in the emergency room . Fall interventions included: physician reviewed medications, continue with present care plan, staff to offer to assist back to room when done with meals. However, the care plan was not revised to reflect this updated intervention. - 11/15/24 at 3:00 p.m., R18 was found lying on the floor. Fall interventions included toilet every two hours and follow care plan. However, the care plan was not revised to reflect this. - 11/22/24 at 1:15 a.m., identified R18 was found lying on the floor. Fall intervention included a flat sensor placed under sheet under hip. However, the care plan was not revised to reflect this until 12/3/24. - 11/22/24 at 11:40 p.m., identified R18 was found lying on her left side next to her bed. Fall interventions included to place flat sensor under sheet under hip on bed. Referred to maintenance t to order. However, the care plan was not revised to reflect this until 12/3/24. During an interivew on 2/27/25 at 1:09 p.m., RN-E stated R18 was at risk for falls and R18's care plan was not revised to reflect toileting every two hours and/or for staff to assist R18 back to her room after meals. During an interview on 2/27/25 at 3:38 p.m., the director of nursing (DON) stated staff were expected to revise resident care plans with identified fall interventions and were expected to follow the care plans to attempt to prevent further falls. The facility policy Person Centered Care Planning revised 12/18/23, identified the facility would will develop a comprehensive person-centered care plan with the resident and/or family representative for each resident in the facility, consistent with the resident's rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the resident's comprehensive assessment. The resident's care plan was reviewed every 90 days or more frequently if necessary with a significant change. Care plans were updated on an ongoing basis as needed based on changes that occur between care conferences.

Based on interview and document review the facility failed to timely notify the physician when a hematoma (localized collection of blood outside of blood vessels) was identified and subsequently opened requiring a new intervention for 1 of 2 (R18) residents reviewed for wound care. Findings include: R18's significant change Minimum Data Set (MDS) dated [DATE], identified R18 had severe cognitive impairment and did not exhibit behaviors during the assessment period. Diagnoses included Alzheimer's disease and a methicillin-resistant staphylococcus aureus (MRSA) infection. R18 had an open lesion other than ulcers, rashes or cuts. No pressure, venous or arterial ulcers. R18's undated care plan, identified R18 had impaired skin integrity due to a tissue injury. Staff were directed to encourage R18 to elevate legs, R18 had an air mattress on my bed, measure ulcer on at regular intervals, monitor ulcer for signs of infection, monitor ulcer for signs of progression or declination, notify provider if no signs of improvement on current wound regimen and provide wound care per treatment order. R18's nursing progress note dated 11/22/24 at 1:15 a.m., identified a loud scream was heard and then a crash. R18 was found almost up against the door. Staff had to push the door open until staff could fit through. Stepped over R18 walker R18 was sitting up against her closet. R18 was confused. R18 said she was just getting up. R18 did say she hurt everywhere A quick exam was done. R18 asked to be put back to bed. When R18 was put in bed, nursing assistant noted a big black bruised lump on her right inner shin. R18 continues to say she hurt everywhere. Vitals were obtained while phones calls were made to R18's son. At 1:30 am., R18's son said to send her to the emergency room . On-call RN was notified. R18's medical record failed to identify R18's hematoma until 12/12/24. R18's Skin/Wound note dated 12/12/24 at 2:19 p.m., identified the medical director (MD) was in the facility doing monthly wound rounds. R18 was sitting in the hallway in her wheelchair and nursing asked MD to take a look at R18's leg and assess. The MD examined the right calf and stated that area appeared to be a hematoma in which the skin was fully intact. R18 asked the provider if there was anything MD could give R18 to take care of it and MD told R18 that it just takes time to heal. MD stated to the current plan of care was adequate and that no further treatment was needed at this time. R18's N Adv - Skin Check dated 12/12/24 at 2:43 p.m., identified bruising purple and red inner lower right leg approximately 18 centimeter (cm) x 10cm, warm with dark purple raised area in middle of 2 cm x 2 cm, skin intact. R18's Skin/Wound note dated 12/19/24 at 7:30 a.m., identified the hematoma on R18's right leg broke open during the night and bled all over her bed. Old dressing was taken off and the swelling had gone down, and copious amounts old blood was draining from the wound. The note failed to identify if R18's physician was notified of R18's change in condition. R18's Skin/Wound note dated 12/19/24 at 5:03 p.m., identified wound dressing to R18's lower right extremity was changed again this afternoon due to bleeding through the dressing. Copious amounts of old blood were coming out of the hematoma wound itself. The note failed to identify if R18's physician was notified of R18's change in condition. R18's Skin/Wound note dated 12/21/24 at 1:02 a.m., identified changed wound dressing to R18's right lower extremity due to bleeding through the dressing. The wound to mid-calf had copious amounts of serosanguineous drainage saturating the dressing. R18 tolerated dressing change without concern or complaint. The note failed to identify if R18's physician was notified of R18's change in condition. R18's Skin/Wound note dated 12/21/24 at 10:27 a.m., identified R18 got a shower that morning. Dressing to R18's wounds on her right leg were changed and redressed. Hematoma did not have any drainage on old dressing but skin tear near the ankle had a small amount of greenish drainage noted on old dressing. The note failed to identify if R18's physician was notified of R18's change in condition. R18's nursing progress note dated 12/26/24 at 12:18 p.m., identified R18 had been out for both meals that morning. R18 denied any pain, unless she bumped her right leg on something. No new injuries or new bruises have been noted. Dressing to her right lower extremity continued to drain and did have an odor to it. The note failed to identify if R18's physician was notified of R18's change in condition. R18's Transfer Out of Building note dated 12/23/24 at 2:52 p.m., identified dressing change was being done on right skin, wound appears to be worsening, a photo was sent to the medical director (MD) and per MD, R18 sent to the ER. During an interview on 2/27/25 at 1:40 p.m., RN-A stated she responsible for the facility's wound care. RN-A was not aware of R18's tissue injury until 12/12/24. The MD was in the building and RN-A asked for the MD to evaluated R18. Point of care (POC) treatment (measuring and monitoring) was ordered. Then, on 12/19/24, the deep tissue injury opened. RN-A was not working that day and RN-A was not informed until 12/23/24. RN-A contacted the MD and received an order to send R18 to the emergency room for evaluation. RN-A stated the on-call RN should have contacted the physician on 12/19/24 to update on R18's condition and request dressing orders. During a phone interview on 2/27/25 at 2:43 p.m., the MD stated he was not R18's primary physician but was the medical director for the facility. The MD did evaluate R18 on 12/12/24 and R18 had a large hematoma to the upper right shin. The area was not warm to the touch or open. The MD recommended monitoring the area for changes. MD was notified on 12/19/24, R18's hematoma had opened and the MD recommended transfer to the emergency room for evaluation. Normally, the MD would expect staff to contact the primary physician unless the physician was unavailable and to do so on 12/19/24 when R18's condition had changed. During an interview on 2/27/25 at 3:38 p.m., the director of nursing (DON) stated any bruise/deep tissue injury should be followed and documented daily and/or when there were changes. The physician should have been notified on 12/19/24 when R18's condition had changed. The facility policy Notification of Significant Changes revised 5/22/22, identified the facility would immediately inform the resident, consult with the physician, and notify the resident representative (consistent with his or her authority), when the resident had a significant change. The primary physician will be updated during regular business hours. If the primary physician is not available, the on-call physician will be updated, and the primary provider will be sent notification.

Based on observation, interview and record review, the facility failed to ensure assistance was offered with meal setup to promote safety and independence with eating for 1 of 1 resident (R38) reviewed for activities of daily living (ADL) and needed set up and supervision to eat. Findings include: R38's admission Minimum Data Set (MDS) dated [DATE], identified R38 had intact cognition and required supervision or touching assistance with eating, maximum assistance with dressing and grooming and was dependent on staff for toileting, and transfers. Diagnoses included hemiplegia following cardiovascular disease and venous insufficiency. R38's Occupational Therapy (OT) Evaluation dated 2/7/25, identified R38 required supervision with eating and assistance to cut up his food. R38's Speech-Language Pathology Evaluation dated 2/11/25 identified R38 was edentulous (without teeth) and had top and bottom dentures but chose not to wear them. R38 was admitted on a soft and bite sized diet. R38 reported he was not having difficulty with regular textured food and would like to be upgraded. R38's progress note(s) identified the following: - 2/6/25, identified R38 was eating lunch in his room when his friend came to visit. The friend was upset that the lunch tray had been left for R38 in his room but had not been prepared so he could eat it. It was determined R38 should eat in dining area for his meals to ensure he received the assistance when needed. - 2/12/25, R38 required supervision with eating and setup of his meal trays. R38 was a choking risk and was required to be in the dining room for meals to be observed. R38 was unable to cut up his foods and required food to be cut up small to prevent choking. R38's care plan dated 2/12/25, identified R38 had a swallowing problem related to coughing or choking during meals or swallowing medications. Interventions included for all staff to be informed of resident's special dietary and safety needs, eat only with supervision and to instruct R38 to eat in upright position, eat slowly and chew each bite thoroughly. R38 had hemiparesis on his left side and staff were to discuss concerns or issues regarding diagnosis. R38's care plan failed to identify R38's preference to have his food cut into small bites and/or his inability to cut up the food into small bites himself due to limited range of motion as assessed by OT. On 2/25/25, at 12:05 p.m. R38 was observed sitting at the dining room at a table in the back, away from most of the other residents and staff. R38 was served a sloppy joe bun cut into quarters, whole french fries, a lettuce salad and two cups of liquid in covered cups with straws. R38 made no attempt to eat and remained seated in his wheelchair with his hands in his lap. At 12:25 p.m. R38 stated he was hungry but he did not think he could eat the food in front of him. He needed it cut up or something different. Three staff members were in the dining room assisting other residents, however, no one approached R38 to offer assistance. At 12:44 p.m. R38 remained seated in his wheelchair with his hands in his lap and food untouched. No staff approached him to offer assistance. At 4:47 p.m. the director of nursing (DON) approached R38 and asked if she could assist him. R38 stated he was hungry but could not eat the meal and needed to have help to cut it up. The DON noticed R38 was overly warm and obtained another staff member to assist him to his room, bringing his lunch tray with him. During joint interview on 2/27/25, at 9:10 a.m. with nursing assistant (NA)-A and NA-H, NA-A stated R38 did not need help to eat but needed to eat in the dining room for supervision. NA-H stated R38 needed to have his food cut up in very small bites in order for him to eat. When interviewed on 2/27/25, at 9:44 a.m. registered nurse (RN)-B stated it was an issue if R38 had not gotten assistance to cut his food in small pieces. Cutting his sloppy joe bun into quarters and serving whole baked french fries was not small bite size pieces and she was not sure if he should have even been served french fries as they would be difficult for him to eat. When staff put the plate of food in front of him they should immediately cut up the food into small bite size pieces. RN-B always asked R38 what she could do for him when she delivered his food. RN-B stated residents should be checked on in the dining room and 45 minutes was to long not to have someone to have had checked with him and offer assistance. During interview on 2/27/25, at 1:45 p.m. dietary aide (DA)-A stated if a resident had an order to have food cut up small and bite sized, the dietary staff would do that before serving the resident the meal. A sandwich cut into quarters and whole crispy french fries would not be considered small and bite sized. DA-A did not think R38 had an order for small bite sized food anymore. R38 had graduated to a regular diet level and just could not have any food on the bone and his bacon needed to be soft. The dietary order indicated he was to take small bites and sips and alternate between bites and sips but not for dietary to cut up the food in small bites. R38's medical record lacked documentation R38's dietary needs, assistance with eating and food preferences had been reassessed, after being upgraded to a regular diet. During interview on 2/27/25, at 2:12 p.m. the director of nursing (DON) stated staff should have checked with R38 in the dining room when he had not attempted to eat. There wasn't a physician order to cut up R38's food in small bite size pieces but she would have expected the intervention to be on his care plan or at least to offer assistance with every meal. The facility's undated policy Activities of Daily Living, identified the purpose was to provide assistance to residents as necessary, to supervise and assess resident function in order to plan care to maintain optimum ADL function and to improve quality of life.

Based on observation, interview and document review, the facility failed to perform ongoing monitoring and wound care for an injury for 1 of 2 residents (R18) reviewed for wound care; and the facility failed to implement interventions for edema for 1 of 1 resident (R38) reviewed for edema. Findings include: R18: R18's significant change Minimum Data Set (MDS) dated [DATE], identified R18 had severe cognitive impairment and did not exhibit behaviors during the assessment period. Diagnoses included Alzheimer's disease and a methicillin-resistant staphylococcus aureus (MRSA) infection. R18 had an open lesion other than ulcers, rashes or cuts. No pressure, venous or arterial ulcers. R18's undated care plan, identified R18 had impaired skin integrity due to a tissue injury. Staff were directed to encourage R18 to elevate legs, R18 had an air mattress on my bed, measure ulcer on at regular intervals, monitor ulcer for signs of infection, monitor ulcer for signs of progression or declination, notify provider if no signs of improvement on current wound regimen and provide wound care per treatment order. R18's nursing progress note dated 11/22/24 at 1:15 a.m., identified a loud scream was heard and then a crash. R18 was found almost up against the door. Staff had to push the door open until staff could fit through. Stepped over R18 walker. R18 was sitting up against her closet. R18 was confused. R18 said she was just getting up. R18 did say she hurt everywhere A quick exam was done. R18 asked to be put back to bed. When R18 was put in bed, nursing assistant noted a big black bruised lump on her right inner shin. R18 continues to say she hurt everywhere. Vitals were obtained while phones calls were made to R18's son. At 1:30 am., R18's son said to send her to the emergency room . On-call RN was notified. R18's N Adv - Skin Check dated 12/2/24 at 10:13 a.m., identified a skin tear on R18's right lower leg. However, the note failed to identify R18's hematoma (an abnormal pooling of blood in the body under the skin that results from a broken or ruptured blood vessel) on the upper right shin. R18's medical record failed to identify R18's hematoma until 12/12/24. R18's Skin/Wound note dated 12/12/24 at 2:19 p.m., identified the medical director (MD) was in the facility doing monthly wound rounds. R18 was sitting in the hallway in her wheelchair and nursing asked MD to take a look at R18's leg and assess. The MD examined the right calf and stated that area appeared to be a hematoma in which the skin was fully intact. R18 asked the provider if there was anything MD could give R18 to take care of it and MD told R18 that it just takes time to heal. MD stated to the current plan of care was adequate and that no further treatment was needed at this time. R18's N Adv - Skin Check dated 12/12/24 at 2:43 p.m., identified bruising purple and red inner lower right leg approximately 18 centimeter (cm) x 10 cm, warm with dark purple raised area in middle of 2 cm x 2 cm, skin intact. R18's Order Summary Report dated 12/14/24, identified treatment for open wound on right upper calf shallow crater: With minimal drainage, apply generous layer of protective ointment/ Bacitracin Zinc (an antibiotic ointment). Cover with non-adherent foam dressing. Secure with rolled gauze. Change every other day. R18's Skin/Wound note dated 12/19/24 at 7:30 a.m., identified the hematoma on R18's right leg broke open during the night and bled all over her bed. Old dressing was taken off and the swelling had gone down, and copious amounts old blood was draining from the wound. The note failed to identify if R18's physician was notified of R18's change in condition. R18's Skin/Wound note dated 12/19/24 at 5:03 p.m., identified wound dressing to R18's lower right extremity was changed again this afternoon due to bleeding through the dressing. Copious amounts of old blood were coming out of the hematoma wound itself. The note failed to identify if R18's physician was notified of R18's change in condition. R18's Skin/Wound note dated 12/21/24 at 1:02 a.m., identified changed wound dressing to R18's right lower extremity due to bleeding through the dressing. The wound to mid-calf had copious amounts of serosanguineous drainage saturating the dressing. R18 tolerated dressing change without concern or complaint. The note failed to identify if R18's physician was notified of R18's change in condition. R18's Skin/Wound note dated 12/21/24 at 10:27 a.m., identified R18 got a shower that morning. Dressing to R18's wounds on her right leg were changed and redressed. Hematoma did not have any drainage on old dressing but skin tear near the ankle had a small amount of greenish drainage noted on old dressing. The note failed to identify if R18's physician was notified of R18's change in condition. R18's nursing progress note dated 12/26/24 at 12:18 p.m., identified R18 had been out for both meals that morning. R18 denied any pain, unless she bumped her right leg on something. No new injuries or new bruises have been noted. Dressing to her right lower extremity continued to drain and did have an odor to it. The note failed to identify if R18's physician was notified of R18's change in condition. R18's Transfer Out of Building note dated 12/23/24 at 2:52 p.m., identified dressing change was being done on right skin, wound appears to be worsening, a photo was sent to the MD and per MD, R18 sent to the ER. R18's Hospital Discharge Summary dated 12/30/24, identified R18 presented from outside ER, for surgical management of her right lower extremity wound. R18 had a fall about a month ago and developed a hematoma. About two weeks ago, R18 started having drainage from that wound. R18 was transferred to the ER yesterday because of worsening wound and purulent discharge. R18 does not remember, she had underlying dementia and was not able to provide any history. Right lower extremity wound with purulent (consisting of, containing, or discharging pus) drainage. R18 underwent debridement (the surgical process of removing dead skin and foreign material from a wound. This can help to reduce the risk of infection and promote healing) on 12/25/24. R18's CT (a series of X-rays and a computer to create detailed images of your bones and soft tissues) shows soft tissue defect (refer to localized or multifocal pathologic syndromes involving the periarticular tissues, including muscle, tendon, ligament, fascia, aponeurosis, retinaculum, bursa, and subcutaneous tissue) involving medial mid lower leg 6 cm x 1.7 cm. Antibiotics were previously, vancomycin cefepime and Flagyl. Most recently on cephalexin. Wound culture over the weekend showed MRSA (Methicillin-resistant Staphylococcus aureus) (a type of bacteria that many antibiotics don ' t work on) and Morganella (a species of Gram-negative bacteria. It has a commensal relationship within the intestinal tracts of humans, mammals, and reptiles as normal flora. Although M. morganii has a wide distribution, it is considered an uncommon cause of community-acquired infection, and it is most often encountered in postoperative and other nosocomial (acquired while admitted to a health-care facility) infections), both sensitive to treatment. During a phone interview on 2/27/25 at 12:02 p.m., registered nurse (RN)-D stated R18 had a wound on her leg that R18 had gotten during a fall in her room. It began as a large hematoma. It was about the size of a golf ball, hard to touch, deep dark purple in color. Staff did look at it, but didn't do anything else. RN-D was unsure when but was told by another RN, the area had broken open. RN-D wasn't sure if R18 had bumped it or if it opened on its own, but it started to bleed out. The RN had said there was more underneath it. RN-D stated she couldn't remember the exact details but R18 had gone to the emergency room and was transferred to another hospital from there. When R18 returned from the hospital, R18 had a wound vac (vacuum-assisted closure) is a therapeutic technique used to promote healing in acute or chronic wounds and burns. It involves using a suction pump, tubing, and a dressing to remove excess exudate, reduce swelling, clean the wound, and remove bacteria.) and declined a lot from there. During an interview on 2/27/25 at 1:09 p.m., RN-E stated R18 was hospitalized due to an open wound and came back with a wound vac. However, RN-E stated she was aware of the where the original injury that caused the wound came from. During an interview on 2/27/25 at 1:40 p.m., RN-A stated she responsible for the facility's wound care. RN-A was not aware of R18's wound until 12/12/24. The MD was in the building and RN-A asked for the MD to evaluated R18. Point of care (POC) treatment (measuring and monitoring) was ordered. Then, on 12/19/24, the deep tissue injury opened. RN-A was not working that day and RN-A was not informed until 12/23/24. RN-A contacted the MD and received an order to send R18 to the emergency room for evaluation. RN-A stated the on-call RN should have contacted the physician on 12/19/24 to update on R18's condition and request dressing orders. Further, RN-A stated she should have been informed of R18's tissue injury on 11/22/24 so the area could be monitored and cared for appropriately. During a phone interview on 2/27/25 at 2:43 p.m., the MD stated he was not R18's primary physician but was the medical director for the facility. The MD did evaluate R18 on 12/12/24 and R18 had a large hematoma to the upper right shin. The area was not warm to the touch or open. The MD recommended monitoring the area for changes. The MD then was notified on 12/19/24, R18's hematoma had opened and the MD recommended transfer to the emergency room for evaluation. Normally, the MD would expect staff to contact the primary physician unless the physician was unavailable and to do so on 12/19/24 when R18's condition had changed. MD was not sure if the outcome would have been different for R18. During an interview on 2/27/25 at 3:38 p.m., the director of nursing (DON) stated an injury should be followed and documented daily and/or when there were changes. The physician should have been notified on 12/19/24 when R18's condition had changed. The facility policy Skin Integrity dated 11/26/24, identified nursing staff will monitor resident's skin integrity and address issues promptly while providing care and services consistent with professional standards of practice. NEW SKIN INTEGRITY ISSUE A. Care center staff will notify the licensed nurse when a new skin integrity issue is observed. B. Licensed nurse will: a. Assess the area and identify the cause, if possible. b. Remove any source of pressure or trauma to the area. c. Clean the area and provide treatment per care center House Standing Orders. d. Determine if the skin integrity issue is reportable to the State Agency (SA). If yes, notify the Administrator and Director of Nursing and proceed with the SA reporting process. (CCEP.MP.005 Maltreatment Investigation & Reporting) e. Complete a Skin Incident report in the resident EHR. f. Notify resident and/or responsible party. g. Notify Provider and request treatment orders, if applicable. h. Notify the Nurse Manager, Wound Nurse, or designee. i. Initiate a new tissue tolerance for any newly opened area or redness. j. Initiate appropriate preventive measures based on the immediate root cause. C. Nurse Manager, Wound Nurse, or designee will assess and complete a root cause analysis. D. Interdisciplinary Team (IDT) will review the skin incident report and evaluation of root cause for further recommendations. E. Provider will review, to diagnosis, if root cause was not related to an injury (i.e., skin tear, bruise), make recommendations, and/or initiate order(s). F. Nurse Manager, Wound Nurse, or designee will review/update the resident's current care plan. Intervention(s) will be initiated, as needed, based on resident/representative input, assessments, and Provider orders. MONITORING A. A licensed nurse will complete the skin check weekly and documented in the EHR. B. Nurse Manager, Wound Nurse, or designee will assess all applicable wounds weekly including pressure ulcers, venous ulcers, arterial ulcers, diabetic ulcers, MASD, other wounds of concern. a. Documentation will be completed in the resident electronic health record and will include describing the following characteristics: i. Location ii. Stage if pressure ulcer iii. Measurements, including any undermining or tunneling/sinus tract. iv. Exudate v. Pain vi. Wound bed vii. Wound edges and surrounding tissue viii. Signs and symptoms of infection ix. Progress towards healing x. Current interventions, including treatment, and any changes made to plan of care. b. Provider will be notified of any significant changes and/or a delay in healing. C. Licensed Nurse will observe and measure weekly all skin integrity issues that are not followed by the Nurse Manager, Wound Nurse, or designee. a. Documentation will be completed in the EHR and will include escribing the following characteristics: i. Location ii. Measurements iii. Exudate iv. Pain v. Signs and symptoms of infection vi. Progress toward healing b. If any significant changes are observed and/or delay in healing, notify the Nurse Manager, Wound Nurse, or designee and Provider. D. Licensed Nurse will observe changes in skin integrity and treatments. Will notify the Nurse Manager, Wound Nurse, or designee with any changes. E. Pressure ulcers will be observed daily by the licensed nurse. Documentation will include: a. Evaluation of pressure ulcer if no dressing present. b. Evaluation of the status of the dressing if present (intact, draining, and/or leaking). c. Status of area surrounding (observed without removing dressing). d. Presence of complications (i.e., increasing size, drainage, redness, swelling). e. Pain, if present, adequately controlled. F. Nurse Manager, Wound Nurse, or designee will update resident and/or representative with any significant change G. Provider to assess wound(s) during routine visits and will make any referrals, recommendations, or treatment changes based on assessment/evaluation. H. Care center may utilize wound care specialists. I. Nurse Manager, Wound Nurse, or designee will track and trend skin integrity issues. Tracking and trending reports will be included in QAPI meetings. If the QAPI committee identifies significant causative factors and/or specific trends and patterns, measures will be taken to correct the identified areas. 41575 R38: R38's admission MDS dated [DATE], identified R38 had intact cognition and required maximum assistance with dressing and grooming. R38 was dependent on staff for toileting, and transfers. Diagnoses included hemiplegia following cerebrovascular disease and venous insufficiency. R38's care plan dated 2/11/25, identified R38 received diuretic therapy for edema (swelling) and hypertension. Interventions included to administer diuretic medications as ordered and monitor for effectiveness and side effects. The care plan also included a focus that R38 had a diagnosis of peripheral vascular disease. Interventions included to educate on importance of proper foot care, elevate legs when sitting or sleeping and to monitor for excessive edema. R38's Order Summary Report dated 2/26/25, identified an order to apply Ace Wraps to his legs each morning before getting out of bed and to remove the wraps at bedtime. The care plan did not idenitfy the Ace Wraps were ordered or who was respondible for applying them. On 2/24/25, at 1:05 p.m. R38 was observed sitting in his wheelchair in his room watching television. R38's legs and feet were in a dependent position with his feet resting on the wheelchair foot pedals and had visible edema present on both his legs, from his knees to his feet. R38 stated the swelling in his legs was not a new problem for him but the doctor had recently ordered wraps to his legs for the swelling. Two long Ace Wraps were resting on R38's bedside table in a pile. R38 stated the staff did not put them on that morning and he was not sure why they had not been applied. On 2/25/25, at 10:58 a.m. R38 was again seated in his wheelchair in his room watching television. R38 was fully dressed and his legs and feet were in a dependent position with his feet resting on the wheelchair foot pedals. Edema was visibly present on both legs and feet. Ace Wraps were observed on R38's bedside table. R38 stated he did not know why staff had not applied the wraps to his legs when assisting him that morning. When interviewed on 2/25/25, at 11:25 a.m. nursing assistant (NA)-E stated she had assisted R38 to get dressed that morning. She did not put R38's Ace Wraps on as that was the nurses duty to do them. NA-E had not even known R38 needed wraps to his legs but she had seen them in his room that morning. During interview on 2/25/25, at 11:26 a.m. licensed practical nurse (LPN)-A stated R38 was supposed to have Ace Wraps on his legs. LPN-A had not been able to get to R38 yet. LPN-A stated R38 really should have them on before he gets out of bed in the morning. Wrapping his legs should be scheduled for night shift to do in the morning, as R38 was usually up and dressed before the day shift got out of report and she planned to change the scheduled time so it would not get missed again. During interview on 2/27/25, at 9:44 a.m. registered nurse (RN)-B stated R38's Ace Wraps should be applied daily and done before he got out of bed in the mornings. RN-B stated the problem with not putting the wraps on before he got up was that his legs tended to swell up quickly and if you waited to long, the swelling would have already happened. During interview on 2/27/25, at 2:12 p.m. the director of nursing (DON) stated she would have expected staff to apply R38's wraps as ordered prior to getting up in the mornings. The wraps were ordered to decrease the inflammation and dependent edema in R38's legs and feet. The facility policy Skin Integrity dated 11/26/24, identified nursing staff would monitor resident's skin integrity and address issues promptly while providing care and services consistent with professional standards of practice.

Based on interview and document review, the facility failed to ensure one of one resident (R1) remained free of an avoidable accident and injury when R1 was transferred by one staff with an improper sling on a mechanical lift operated by one staff member. R1 was dropped from a mechanical lift resulting in a laceration to her left posterior scalp, requiring three staples at the emergency room . Findings include: Minimum Data Set (MDS) assessment, dated 1/18/2023, indicated R1's diagnoses included Alzheimer's disease, dementia, psychotic disorder, and non-traumatic brain dysfunction. R1's functional mobility indicated she was dependent on staff for transfer and repositioning. R1's Brief Interview for Mental Status (BIMS) score was 2 out of 15 indicating sever cognitive impairment. R1's service/care plan dated 2/26/22 indicated R1 was dependent with transfers using a Hoyer mechanical lift with a sling and the assistance of two staff. R1's medical record did not include a mechanical lift assessment, sling size, and type to transfer R1 or a Therapy to Nursing Communication. R1's progress note dated 2/4/2023 indicated R1 suddenly moved her arms while in the sling and slipped out of the sling falling to the floor. R1 landed on her head, sustained a laceration. R1 was transferred to the hospital. R1's Fall Scene Investigation, dated 2/4/2023 indicated R1 fell from the mechanical lift when she brought her arms inside the toileting sling and slipped through the bottom of the sling. A facility document titled Total Mechanical Lifts dated 2/6/2023 indicated for staff to please read and sign. The document read: All total floor lifts are to be used with 2 people when transferring residents. There should be no exception to this. Basic Care Aides (BCAs) should not be running to controls but can be the second person while operating the lifts. The second person is to be guiding the resident and ensuring the process is running smoothly. If a lift sling or lift is not working appropriately for a resident, inform a licensed staff member (RN or LPN) of this immediately. During an interview on 2/15/2023 at 2:30 p.m., nursing assistant (NA)-A stated she entered R1's room to transfer her to the toilet using the mechanical lift. NA-A stated R1 was lying in her bed with a toileting sling of unknown size underneath her. NA-A stated she was familiar with R1 and recognized R1 did not normally transfer with a toilet sling. NA-A stated she connected the toileting sling underneath R1 to the mechanical lift and transferred her to the toilet without the assistance of another staff member. NA-A indicated she was aware a mechanical lift should be operated with at least two staff members. NA-A stated she did not seek out another staff member for assistance because she knew NA-B was busy. NA-A said while transferring R1 from the toilet back to bed, R1 shifted her weight, fell through the opening at the bottom of the toileting sling and struck her head. NA-A stated she called for assistance, and support staff provided additional medical care until emergency services arrived. During an interview on 2/15/2023 at 3:05 p.m., NA-B stated she was not with NA-A when R1 fell from the mechanical lift. NA-B stated she exited the resident rooms she had been in when she heard yelling and was told by NA-A to retrieve a nurse and call 911 for R1. NA-B stated she secured additional support staff and medical aid was issued to R1 while emergency services were contacted. NA-B stated NA-A approached her when they were alone and requested NA-B report she had been with NA-A when R1 fell from the mechanical lift. During an interview on 2/15/2023 at 3:43 p.m., the manufacturing representative for the mechanical lifts stated the toileting sling is rarely used because facilities usually use a sit and stand device for brining residents to and from the toilet, making falls from toileting slings rare. The representative stated it is possible for a resident without enough upper body strength to be placed in a toileting sling, retract their arms, and fall through the bottom. The style and size of sling needs to be determined by licensed individuals to make an assessment, the wrong sling size and style can easily result in a fall. During an interview on 2/15/2023 at 4:40 p.m., the director of nursing (DON) stated R1 was scheduled to be seen the next business day by physical therapy (PT) for a complete assessment for the size and type of sling to be used while transferring in a mechanical lift. The DON stated at the time of the fall, R1's care plan did not include the sling size or type to be used with the mechanical lift. The DON stated she expects staff to have at least two lift operators in the room while transferring residents with a mechanical lift. During an interview on 2/16/2023 at 8:45 a.m., PT-A stated sling size is determined by weight and certain physical measurements obtained by the PT during their assessment. PT-A stated sling type is determined by the combined cognitive and physical abilities of the resident. PT-A stated a toileting sling should only be used by residents with enough upper body strength to keep their arms around the outside of the sling while transferring. PT-A stated a full-back sling is appropriate for patients that have limited upper body strength or lack the cognition to follow simple instructions. According to the manufacturer instructions for the Volaro Series 4 Lift PC450/HD450, the section titled Volaro Lift Slings instructs users how to select the sling type based on the physical attributes and capabilities of the resident. The section entitled Safe Working Loads instructs users to determine the appropriate size sling by referencing their chart detailing the resident's weight and bodily dimension requirements for each size sling. The section entitled Volaro PC450/HD450 General Procedure Guide for Training instructs operators to ensure the proper sling size has been selected prior to transferring a patient. The manufacture instructions include a General Procedural Guide for Training recommended that everyone be in-services by the manufacturer's in-service video before operating and a copy of the training and check off list be kept in personnel records. The training list includes but is not limited to having an assistant to assist with the transfer, make sure the correct sling and size is being applied, inspect the sling for damage, ensuring the battery is charged, the lift legs are positioned correctly, and the sling is secured to the lift applied appropriately. A facility policy titled Care Planning, dated 10/23/2017, states it is the responsibility of nursing or an otherwise appointed designee to update a resident's plan of care to reflect the assessments from each medical discipline. The document states the plan of care will be updated at all times and be changed on an as needed basis by nursing staff.

Based on observation, interview, and document review, the facility failed to comprehensively assess facility acquired pressure ulcers, consistently implement identified interventions, reassess nursing interventions to promote healing when the pressure ulcer deteriorated and communicate with the medical provider regarding current treatment and pressure ulcer status for 1 of 4 residents (R10) reviewed for pressure ulcers. This caused actual harm to R10 who's pressure ulcer worsened to an unstageable pressure ulcer and warranted physician and surgeon recommendation for [MEDICAL CONDITION]. In addition, the facility failed to ensure the medical provider's orders for a pressure reducing cushion was processed and implemented for 1 or 4 residents (R39) reviewed for pressure ulcers. Findings include: The National Pressure Ulcer Association define the following pressure ulcer stages and wound descriptions as follows: Stage I: An observable, pressure-related alteration of intact skin, whose indicators as compared to adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ ruptured blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar). Slough: Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. Eschar: Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. R10's admission Minimum Data Set ((MDS) dated [DATE], identified R10 had no cognitive impairment and required extensive assistance for bed mobility, transfers and toileting. Further, R10 was at risk to develop pressure ulcers, however his skin was dry and intact with no pressure ulcers or skin concerns present. The MDS included [DIAGNOSES REDACTED]. R10's Admissions Observation assessment dated [DATE] through 12/18/20, identified R10's skin was dry and intact. R10 was at risk for altered skin integrity related to incontinence of bladder. R10 utilized a wheelchair for mobility. R10's admission progress note dated 12/10/20, indicated R10 had some trace [MEDICAL CONDITION] in his lower extremities and no significant skin issues were noted. R10's care plan dated 12/14/20, identified R10 was at risk for skin breakdown due to incontinence. Several interventions were listed including to observe skin daily with cares, encourage fluid intake, encourage and assist R10 to turn and reposition at least every 2 hours, and observe skin-especially lower extremities for [MEDICAL CONDITION]. On 12/22/20, the care plan identified a pressure ulcer to R10's right heel with a goal for the ulcer to heal without signs and symptoms of infection. Several interventions were listed to help R10 meet this goal, including float heels when in bed, blue booties while in bed, pressure reducing mattress, and trial removal of R10's foot board. The care plan did not address pressure relieving interventions when out of bed. During observation on 3/15/21, at 3:17 p.m. R10 was wheeling his wheelchair backwards down the hall, while visiting with staff. R10 was pushing the wheelchair with his left foot and his right foot was dragging on the hallway floor. R10 had socks on both feet and was not wearing shoes. On 3/15/21, at 5:47 p.m. R10 stated he had a sore on his foot he obtained at the facility. He did not have the right equipment on his wheelchair and was dragging his foot and ended up wearing a hole in his heel. R10 did not know he was dragging his foot but had noticed a trail of wet on the floor. He then looked at his heel and it was a mess. R10 did not know how long he was dragging his foot as he could not feel it dragging. He notified staff and they bandaged the heel up. R10 stated he should have went to the doctor right away but did not go until things started going sour with it and by the time he was seen by the doctor, they could not do anything with it. The heel was kind of a hole with a big scab on it. The dressing was being changed two times daily and he was meeting with a surgeon the following day. R10 indicated it was almost a necessity to take the foot off because he had an infection in it a couple times already and so the foot needed to come off. R10 stated his last infection was about 2 weeks ago. On 3/17/21, at 7:24 a.m. nursing assistant (NA)-B entered R10's room and assisted R10 with his am cares. After completing dressing and grooming, R10 was assisted to his wheelchair with a stand lift. NA-B offered to put a Prevalon (a pressure relieving foam) boot on R10's right foot. R10 declined the boot and was observed to place his right foot on the wheelchair pedal with his right heel resting on the top edge of the wheelchair foot pedal and the remainder of his foot hanging over the pedal. The foot was wrapped from mid foot to heel with stretch bandaging wrap (kerlix). R10 notified NA-B the surgeon was going to amputate his leg because of the shape the heel was in, he would always have an infection in it and it would never heal. NA-B moved R10's wheelchair in front of the television as they talked and placed the bed side table in front of the wheelchair in preparation for breakfast. R10's foot was observed to slip off the foot pedal during the repositioning of the wheelchair and bedside table. NA-B lowered her self under the bedside table and repositioned R10's right heel back on the top edge of the pedal with 3/4 portion of the foot hanging over the pedal, due to his long legs. NA-B stated there were no other positioning devices for R10's right foot when sitting in the wheelchair except for the foam boot. On 3/17/21, at 11:13 a.m. R10 was observed seated in his wheelchair. R10's right foot was resting directly on the floor, well past the foot pedal. Trained medication aide (TMA)-A and registered nurse (RN)-C entered the room to assist R10 into bed for his dressing change. RN-C stated the treatment had been to use an antiseptic wound cleanser (Dakins solution) to clean the wound but had been switched to use a [MEDICATION NAME] (a providone-iodine disinfectant solution) wet to dry dressing about a week ago. R10 stated the pressure ulcer had either occurred when his foot jumped and came down on his foot board at the end of his bed or when he had drug it around when seated in his wheelchair. - TMA-A lifted R10's right leg as RN-C removed the ACE bandage and kerlix dressing. The dressings appeared tight around R10's foot and ankle when the ACE wrap and Kerlix wrap was removed. [MEDICAL CONDITION] (swelling) was identified on the top of the right foot and the dressing marks and ridges were visibly apparent on R10's skin. R10's upper 3/4 portion of his right heel was covered in black tough eschar tissue which was surrounded by slough tissue on the mid and bottom portion of his heel. No odor or drainage was noted. RN-C cleansed the wound and patted the wound dry. She then applied the [MEDICATION NAME] as ordered and re-wrapped R10's right foot with kerlix wrap and ACE wrap as ordered. - R10 requested to sit up in his wheelchair for lunch and was assisted back into his wheelchair using the stand lift. RN-C put the right foot rest onto the wheelchair, placed the Prevalon boot on the top of the foot rest and positioned R10's right leg and foot on top of the Prevalon boot and elevated the foot rest. R10 stated he liked the boot under his foot on the wheelchair pedal, and staff had never done it before, and stated, but now I think I will. R10's skin condition/wound progress note(s) identified the following: -12/18/20, A new blister was identified on R10's right heel that measured 7.8 centimeters (cm) X 6.4 cm. Skin was assessed and was macerated. An ABD (sterile abdominal pad) pad was applied and secured with roll gauze. Treatment would continue for one week. R10 did agree not to wear his shoes until the blister healed and would wear grippy socks instead. The medical doctor (MD) or nurse practioner (NP) was notified via fax communication of the deterioration noted in the site and pressure relieving devices were in place on the bed surface. The likelihood of healing was good. -12/22/20, serosanguinous (thin drainage, usually with a pink or red tinge) drainage was weeping through the dressing. R10 was dragging his foot across his floor. He was encouraged to use his heel protector even when in he wheelchair and encouraged the nursing assistant staff to keep his foot on the foot pedal. R10 complained of pain with the dressing change. Therapy was notified. MD was notified of the present status of the ulcer and deterioration noted in the wound. No recent changes were made to the treatment orders for the wound. A pressure relieving mattress was on the bed and a foam Prevalon boot was being used. Likelihood of wound healing due to overall condition was identified as fair. -12/31/20, Unable to accurately stage ulcer due to slough and eschar (dead skin tissue) covered. The ulcer was identified as being present on admission; although it developed after admission. The pressure ulcer measured 9.4 cm by 10.6 cm. The MD was updated on the wound status and recent changes for treatment had been ordered. The note identified a pressure reducing mattress on the bed, a Prevalon boot was used, a turn and repositioning program was being implemented and a heels up pillow was in use on the bed. -1/5/21, Unable to accurately stage due to slough and eschar covered. The affected area had [MEDICAL CONDITION]. Recent changes were made to the treatment of [REDACTED]. R10 did not have his foot elevated on the heels up pillow and was encouraged to do this. R10 was informed of the risks associated with refusing the treatment recommendations. R10 signed an informed consent for refusing to comply with elevating his heel on the heels up pillow when in bed; however, did not idenify interventions to try if R10 refused. -1/11/21, Pressure ulcer remained unstageable. The affected area has non-[MEDICAL CONDITION]. Wound improvement was noted and measured 8 cm X 9.6 cm. No odor was present. Drainage was minimal. -1/18/21, Unstageable wound measured 6.2 cm X 8.8 cm. The ulcer was identified as being present on admission; although it developed after admission. No change noted in the wound. No recent changes in treatment orders. Pressure reducing devices were in place and unchanged. Likelihood of wound healing due to overall condition was fair. -1/23/21, R10 was seen via virtual visit this morning, accompanied by his daughter. MD referred to another physician who traveled to the area to perform a sharp debridement of the pressure ulcer. MD ordered ACE wrap to right extremity from toe to knee. MD stated to continue with twice per day dressing changes, however an ABD pad did not need to be placed during the day to avoid extra cost but to put in place at night. -1/26/21, Pressure ulcer measured 7 cm x 8.5 cm. No odor was apparent. Dressing was changed with son present. Stable eschar remained. Sanguineous drainage was present. R10 had [MEDICAL CONDITION] in right lower extremity. Pressure reducing devices and interventions remained unchanged -2/4/21, Pressure ulcer measured 5.8 cm x 8.8 cm. No odor was apparent and minimal drainage was present. The ulcer was identified as being present on admission; although it developed after admission. The wound had improved a great deal since last assessed. No changes were made to plan of care. R10 had an appointment with podiatry scheduled for 2/10/21. Pressure reducing devices and interventions remained unchanged -2/9/21, Pressure ulcer measured 6.6 cm x 7.9 cm. No odor was apparent. Continued to have stable eschar. Soft [MEDICAL CONDITION] was observed in the pedal area. Deterioration of the wound was identified. No changes were made to the treatment orders. R10 had an appointment with podiatry on 2/10/21. Pressure reducing devices and interventions remained unchanged -2/14/21, Pressure ulcer measured 6.7 cm x 7.9 cm. Scant drainage was present. No odor was identified. No change in the wound was identified. Recent changes were made to the treatment ordered. Pressure reducing devices and interventions remained unchanged -2/18/21, Pressure ulcer measured 6.7 cm x 8.1 cm. Minimal drainage was present and no odor was apparent. Wound improvement was identified. No recent changes were made to the treatment ordered. Pressure reducing devices were in place and remained unchanged. A multi-vitamin was initiated and was being administered. -2/26/21, Pressure ulcer measured 6.5 cm x 8.2 cm. Minimal drainage was noted. A moderate odor was apparent. Deterioration in the wound was noted and the MD was notified. Recent changes were made to the treatment order and antibiotics were ordered. Pressure reducing devices and interventions remained unchanged. Likelihood of wound healing due to overall condition was fair. -3/3/21, Pressure ulcer measured 6.4 cm x 8 cm. A moderate odor was noted as well as a large amount of drainage. Pressure reducing devices and interventions remained unchanged. Likelihood of healing due to overall condition was changed to be noted as poor. -3/6/21, Pressure ulcer measured 6.2 cm x 8 cm. The ulcer was identified as being present on admission; although it developed after admission. A faint odor was apparent and a moderate drainage was present. Deterioration was observed in the wound. No recent changes were made to the treatment orders. No antibiotics were prescribed. Pressure reducing devices and interventions remained unchanged. -3/11/21, Pressure ulcer measured 6 cm x 7.8 cm. The ulcer had a moderate odor with thick moderate drainage present. Ulcer was redressed as ordered, which had been changed back to a [MEDICATION NAME] wet to dry dressing. Deterioration was observed in the wound. Recent changes were made to the wound treatment. Antibiotics were prescribed. Pressure reducing devices and interventions remained unchanged. Likelihood of healing due to overall condition was continued to be documented as poor. R10's medical record lacked a comprehensive assessment to determine the causative factors of the development of R10's pressure ulcer as well as reassessment of nursing interventions when wound deterioration was noted. The record also lacked evidence the pressure reducing/relieving devices were evaluated for consistent use and effectiveness or elevation of R10's leg was being performed as ordered when the pressure ulcer was identified to worsen. R10's Physical Therapy Module Evaluation dated 12/11/20, lacked evidence R10 was assessed for positioning in his wheelchair in regards to his foot pedals in relation to the length of R10's legs. R10's physician communication form dated 12/17/20, identified R10 was reporting problems with jumpy legs, more dominant on the right and they were concerned about his right foot flopping inward with inability to control the foot. An order was written to have physical therapy evaluate and treat right foot and to schedule to be seen on next rounds to address restless legs. R10's medical record lacked evidence the therapist was notified of concerns related to R10's wheelchair, evaluation of R10's wheelchair to ensure proper pressure relief was in place or notification of the order to evaluate and treat R10's right foot. R10's Hospital Discharge Summary dated 12/31/20, indicated R10 was admitted to the hospital for progressive right foot/heel wound. Imaging demonstrated he should have sufficient arterial flow to heal his right heel ulcer. Would recommend offloading pressure at all times and keep clean and dry. Follow up recommendations were for Prevalon heel boots to offload and to wear at all times except with transfers and to follow up with wound clinic in 2-3 weeks. R10's progress note dated 1/5/21, indicated R10 had signed an informed consent for non-compliance with elevating the right heel using a heels up pillow and heel protector when in bed. The risk associated with refusal of treatment was that it could increase the pressure to the right heel and could increase friction to the area; however, did not identify interventions to reduce pressure when R10 refused. R10's physician office visit note dated 2/10/21, indicated since the ulceration was unstageable, debridement was not necessary unless signs of infection arose. The ulcer did not seem to be acutely infected and conservative treatment was advised. R10 was to limit activities, minimize weight bearing, and use sterile dressings to cover the ulcer. Discussed control of [MEDICAL CONDITION] and offloading were the keys to healing the ulcer. R10 must wear offloading boot at all times while in wheelchair or bed. Dressing order placed for [MEDICATION NAME], exufiber, abdominal pads (ABD) and kerlix dressing to right heel twice daily. R10's physician order [REDACTED]. Cover the entire wound with a dakins moist gauze. Pad with a dry 4x4 dressing and secure with a kerlix wrap. Have him wear the Prevalon boot at all times other than when ambulating or transferring. Avoid all pressure to the right heel at all times. Elevate the right leg as much as able. R10's physician rounds note dated 2/25/21, indicated R10 was seen on rounds in his room. Wound care would continue with Dakins moist gauze twice a day, Prevalon boot and protection. On 3/17/21, at 12:54 p.m. RN-C stated she thought the ulcer on R10's heel started when he was hitting his heel on the foot board of his bed, so they removed the foot board. The physical therapist was who would evaluate wheelchair fit and positioning but they did not automatically evaluate this when they saw a resident. Interventions of a foot pillow and heel boot were implemented in bed to reduce pressure on the foot on 12/22/20. Family wanted him sent to theER on [DATE] and he was admitted and sent to Duluth to be seen by a specialist. RN-C was unable to find communication to physical therapy for the 12/16/20 order for PT evaluate and treat right foot. On 3/17/21, at 1:50 p.m. NA-C indicated R10 had a Prevalon boot or a foot pillow. NA-C stated R10 was usually ok with using the foot pillow but would refuse the Prevalon boot. She had never elevated R10's right leg and he had never asked her to elevate it. She had never been instructed R10 needed to have his leg elevated, but she did not feel R10 sat in his wheelchair for very long periods of time. The nursing assistants were suppose to apply the ACE (an elastic bandage used to control swelling) wrap to R10's right leg with morning cares until the nurse could do his dressing. NA-C stated she had not been trained to apply ace wraps. R10's nursing assistant assignment sheet dated 3/17/21, lacked any direction to use positioning devices or elevate R10's right leg in or out of bed. On 3/18/20, at 8:46 a.m. physical therapist (PT)-A stated she did look at wheelchair positioning when she did resident evaluations and felt R10 was positioned adequately in his wheelchair. PT-A stated she had put the longest leg extension she could find on the wheelchair and if you stretched his leg out you could get his leg on the foot pedal and then you had to rest the ball of his foot on the foot pedal. PT-A stated she had not been notified of the 12/10/20, order to evaluate and treat R10's right foot. An order was not placed for longer foot pedals to accommodate R10's long legs and relieve the foot from pressure. On 3/18/21, at 12:48 p.m. RN-C stated the nursing assistant assignment sheet did not direct the nursing assistants to position R10's foot with a pillow or Prevalon boot. There would not be any documentation in R10's record on 3/15/21, to indicate if R10 had refused to wear the Prevalon boot because a trained medication aide (TMA) had been working on the wing and they did not document in resident charts. RN-C stated she was disappointed R10's foot was not being positioned correctly in the wheelchair and the nursing assistants should be positioning it with the Prevalon boot. On 3/18/21, at 1:09 p.m. RN-A stated if R10 refused the Prevalon boot, his foot should still be positioned on the foot rest to avoid any pressure to the heel, such as placing a pillow or something to float the heel and the leg should be elevated. During telephone interview on 3/19/21, at 11:08 a.m. family member (FM)-A stated R10 was placed in the nursing home for some sub acute care and time to heal. R10 had everything back from [MEDICAL CONDITION] his right foot. Ten days after his admission, the nursing home had called and reported to FM-A R10 had a small blister on his foot. They mentioned maybe he had kicked the foot board on his bed because of his long legs or maybe his shoes had caused it. On 12/23/20, the nursing home called and informed FM-A R10's heel was pretty bad, the blister had busted and the heel was black in color. When FM-A visited on 12/25/20, they were shocked as the wound on his heel had went from a tiny blister to that. FM-A could smell the stench of the pressure ulcer when FM-A walked into the room. FM-A took pictures and sent them to several doctors. All three doctors told them the wound was a pressure ulcer and was completely preventable. The doctor told FM-A they needed to get R10 into the ER. FM-A called and told the facility they wanted him sent to the ER to be evaluated. FM-A wished they had seen it earlier, but nobody had told them it was a pressure ulcer, it was always a blister. On 3/19/21, at 1:14 p.m. RN-A stated she had done the initial admission skin assessment for R10 and did not find any skin concerns. A week later a blister was found on his right heel. In February the facility reached out to the wound clinic and got orders to use the Daikins solution. RN-A stated, We started seeing some improvement in the wound. The eschar (dead skin tissue) and slough was coming off. The following week he was seen by the podiatrist who changed the treatment back to the former [MEDICATION NAME] wet to dry dressing. RN-A indicated an updated med list, the treatment record and the physician order [REDACTED]. RN-A did not write an update to the podiatrist for that appointment and did not clarify if the podiatrist was aware of the Daikins ordered treatment that had made improvement in the wound or verify the change in treatment was a purposeful change in treatment back to the old dressing orders. RN-A stated R10 would frequently refuse the Prevalon boot because it was to hot or to tight. The nurse aides were informed today (3/19/21), if R10 refused his boot they were to put a pillow under it and they should elevate the leg and foot. During an interview with the administrator and the DON on 3/22/21, at 4:44 p.m. the DON stated the registered nurses should be identifying wheelchair positioning problems and issuing the order for therapy to evaluate it. When the facility identified a pressure ulcer, the process should include an evaluation of the resident's positioning. The facility is working on improving their assessment process. The DON indicated she had called the wound specialist and had gotten a new treatment order to use the Daikins solution to the wound instead of [MEDICATION NAME]. It looked like the Daikins solution was working and there might be some hope but then R10 went to the podiatrist and the order was changed back to [MEDICATION NAME]. The podiatrist would have known about the new treatment of [REDACTED]. The administrator indicated the doctor needed to have some responsibility to look at the residents order sheet. The undated facility policy Adaptive and Positioning Equipment indicated an RN would contact the provider for referral to occupational therapy (OT) or PT for wheelchair positioning, seating assessment or other adaptive equipment recommendation. OT or PT would conduct the assessment and make recommendations for wheelchair modification and/or equipment and communicate these recommendations to nursing. The RN would document equipment use in the care plan and on the nurse aide care sheets. Nursing and/or therapy would observe appropriateness of continued use of the equipment. R39's significant change MDS dated [DATE], indicated she had intact cognition and did not display rejection of care. The MDS indicated R39 required total assistance from staff for bed mobility, transfers and toileting, was occasionally incontinent of bowel and had an indwelling catheter. The MDS further identified a Stage I pressure ulcer and an unstageable pressure ulcer present on admission. R39's undated Face Sheet, identified [DIAGNOSES REDACTED]. R39's care plan dated 3/14/21, identified a risk for skin breakdown related to decreased mobility and at risk for developing additional pressure ulcers. The care plan directed staff to observe skin with cares and to encourage R39 to reposition every two hours and as needed for comfort. The care plan dated 2/8/21, identified a pressure ulcer to R39's buttocks along with the use of an alternating pressure mattress in bed and a pressure reducing cushion in her wheel chair. On 3/15/21, at 3:25 p.m. was observed seated in her recliner chair with a dressing on her right heel and a Prevalon boot on her left heel. R39 stated the dressing was a precaution as she had a soft spot that could develop into a pressure area. R39 also stated she did have a pressure ulcer on her bottom. R39's Physician order [REDACTED]. A facility communication form to the physician dated 1/25/21, indicated R39 had three new areas. One to her right buttock which appeared to be a shearing injury, staged as an unstageable pressure ulcer. The area measured 8.8 centimeters (cm) long x 6.2 cm wide and was covered with eschar. The entire right buttock from the top of the gluteus maximus to the right gluteal fold was purple even after several minutes of offloading and was rock hard . The area had almost tripled in size since the writer saw it 6 days prior. The second open area on her left buttock measured at 1.2 cm x 1.2 cm x 0.1 cm and appeared to be from friction. The third open area was on the right gluteal fold and measured 0.8 cm x 0.8 cm x 0.1 cm. R39's hospital Discharge Summary dated 2/15/21, indicated R39 had an indwelling Foley catheter since January 2021, due to ongoing skin breakdown and sacral pressure ulcers. She was sent to the emergency department for increased temperature and increased confusion. R39 was found to have an infected appearing right buttock pressure ulcer as well as an urinary tract infection. They recommended a wound consult and indicated, may need some debridement verses local wound cares. R39's physician's orders [REDACTED]. Wound care was ordered to the right buttock, left buttock and the left 4th and 5th toes. R39's Video Visit note dated 2/18/21, indicated R39 was recently hospitalized for [REDACTED]. During observation on 3/18/21, at 1:54 p.m. RN-C completed R39's dressing changes. RN-C measured R39's buttocks wounds, R39 had an area described by RN-C as a five inch line, deep, dark purple in color which RN-C stated was new. R39's buttocks was red and macerated ( the softening and breaking down of skin resulting from prolonged exposure to moisture) with induration (deep thickening of the skin resulting from inflammation) noted. R39 also had four shallow open areas in the gluteal cleft. At 2:26 p.m. RN-C observed the cushion in R39's wheel chair and described it as approximately a one inch regular foam cushion. A cushion was not observed in R39's recliner chair. RN-C stated R39 had never been assessed for a specialty cushion. During interview on 3/22/21, at 10:24 a.m. the DON stated she was not aware what kind of cushion R39 had in her chair. The DON stated the nurses process orders which should then be entered onto the Medication Administration Record [REDACTED]. At 10:49 a.m. the DON stated R39 did not have a cushion in her recliner as ordered by the nurse practitioner. At 1:45 p.m. nursing assistant NA-D stated R39 did not have a cushion when seated in her recliner chair. NA-D stated she had never received direction to place a cushion in the recliner chair. The undated facility policy Skin Ulcer Protocol indicated residents would not develop pressure sores or other skin ulcers unless it was clinically unavoidable and appropriate care and services would be provided to prevent, treat, and monitor progress of all healing ulcers. The policy defined an avoidable pressure injury as having developed because one or more of the following were not done: a resident's clinical condition was not evaluated, risk factors were not identified, interventions were not implemented and/or effectiveness of interventions were not monitored or revised. An unavoidable pressure injury was defined as having developed even though the facility had evaluated the resident's clinical condition and risk factors, implemented proper interventions and monitored and revised interventions due to underlying disease process and ulcer developed. Staff were directed to obtain a physician's statement that the ulcer was unavoidable.

Based on observation, interview and document review, the facility failed to comprehensively assess, per manufacturer's recommendation, the level of assistance required for use of the bath chair prior to use and failed to assess cause of injury and implement interventions to prevent subsequent injury while bathing for 1 of 1 resident (R39) reviewed for facility acquired lacerations while in the tub chair. This resulted in actual harm to R39 who sustained a second injury in the tub room resulting in a second laceration which required 16 sutures. Findings include: R39's significant change Minimum Data Set ((MDS) dated [DATE], indicated she had intact cognition and required extensive assistance for transfers. The MDS indicated R39 required physical assistance from two staff to complete bathing activity. In addition, R39's MDS identified a lower extremity impairment on both sides. Further, R39 was taking a blood thinning medication. R39's undated, Face Sheet identified [DIAGNOSES REDACTED]. R39's care plan dated 3/14/21, indicated she was unable to transfer without assistance and directed staff to provide assistance from two staff for all transfers using a mechanical lift device. R39's care plan indicated she would receive three baths per week and directed staff to monitor for changes in abilities and provide supplies as needed. The care plan did not identify level of assistance needed or number of staff required. R39's medical record lacked an assessment related to bathing and the use of a mechanical bath chair. During interview on 3/15/21, at 3:27 p.m. R39 stated she had 16 stitches on the top of her foot from an incident that occurred in the tub room the previous week. R39's progress note(s) identified the following: -1/25/21, indicated staff came to get the nurse as R39 was bleeding excessively and had a large pool of blood beneath her. R39 had sustained a superficial laceration to all four of her small toes. The lacerations required the use of a pressure dressing to stop the bleeding. - 2/1/21, indicated areas on R39's 4th and 5th toes appeared to be a result of her toes being bumped on the bath scale on 1/25/21, while in the tub room. The note indicated on 1/25/21, R39 had excessive bleeding, the ends of her toes were soft and minor lacerations were noted. - 3/12/21, indicated R39 had been transferred to the emergency departement for evaluation and wound care for right foot laceration with uncontrollable bleeding. - 3/13/21, indicated R39 returned to the facility and ice was applied to her affected foot. - 3/15/21, indicated review with R39 regarding laceration to foot resulting in R39 stating her foot hit a bolt on the shower chair. R39 reported while being lifted out of the tub the injury occurred. R39 also stated she did not have control of that leg and it does what it wants. The outside of the tub was noted to have two hinges to hold the door closed. The hinges were colored in a bright color to draw attention to them. - 3/17/21, indicated after interview with R39 and observation of the tub room equipment, R39's description of the incident was unclear. R39 was brought to the tub room and when she described the incident, nurse was unable to determine what caused the laceration. R39 stated she did not know what she hit her foot on. The bottom of the tub chair had two spots which appeared to be dried blood behind the right wheel of the chair. Still no conclusive understanding of the incident until staff member involved can demonstrate. Will remind staff to monitor body parts with use of equipment, especially when there are flaccid body parts. R39's Incident Details Report dated 3/12/21, indicated R39 sustained a laceration during transfer to the top of her right foot. The report indicated R39 was transferred to the emergency department and required sutures. Wound measured 9.2 centimeters in length. The report lacked a follow up assessment or interventions to prevent further incident. During a subsequent interview on 3/16/21, at 3:22 p.m. R39 stated when the incident occurred in the tub room on 3/12/21, nursing assistant (NA)-F had transferred her by herself and stated the facility had been short of help that day. On 3/16/21, at 3:59 p.m. NA-F stated R39 had scraped her foot while in the bath tub lift chair. NA-F stated there was a white part on the bottom where the wheels are at, her foot must have gotten caught on it. NA-F stated another NA had assisted her to place R39 in the tub chair using the ceiling lift but had left before R39 was in the tub. On 3/19/21, at 12:05 p.m. the director of nursing (DON), administrator and corporate clinical consultant (CCC) were interviewed. The DON stated she had spoken to R39 about the incident and R39 told her she had cut her foot on a hinge on the door of the tub. The DON stated when she went in with maintenance she had seen something different and stated she had seen some spots of blood on the bottom of the bath chair. The DON said R39 later told her she may have hit her foot on the bottom of the chair. The DON stated she needed to talk to the NA that was working when the incident occurred but had not yet spoken to her. At 12:09 p.m. the administrator stated she had gone to the facility the evening after the incident occurred and talked to the NA that had performed the bath. The administrator stated NA-F told her she had made sure R39's feet were on the pedestal in the tub and went slowly, then saw the foot bleeding and stopped. The administrator stated she did not have documentation of her conversation with NA-F. The administrator stated they needed to re-enact the incident with NA-F to determine what had happened. The corporate clinical consultant (CCC), present during the interview, stated to the DON the tub chair only needs one person and wouldn't you think your aides would let you know if they needed additional help? The DON stated the facility did not use an assessment to determine safety when using the mechanical tub chair. The CCC again spoke to the DON and stated, it's never happened before so you will have to assess. At 12:19 p.m. when asked what the facility was doing to ensure a similar incident did not occur with other residents who used the tub chair the administrator said she had talked to staff the night of the incident and told them always to be careful when moving residents in the tub chair and to watch their limbs. The administrator stated she did not have documentation of the education. At 12:29 p.m. the tub room was observed with the DON and the administrator who demonstrated the tub chair lift. The tub chair had the ability to be raised to a height that would allow a residents feet to hang down and still clear the base of the tub. During the demonstration the administrator stated, when we find the cause, we will take care of it. On 3/22/21, at 11:05 a.m. registered nurse (RN)-C stated when the first incident occurred on 1/25/21, staff were assisting R39 out of the tub and R39's toes scraped a wheel on the tub seat. RN-C stated she did not know if any interventions had been placed at that time to prevent further incident. On 3/22/21, at 1:01 p.m. the DON stated there was no follow up after the incident occurred on 1/25/21. The DON stated an incident report should have been completed and the interdisciplinary team should have followed up. In regard to assessing a residents safety with regard to use of a mechanical tub chair, the DON stated she had never performed an assessment and stated the NAs were the ones who determined resident safety while bathing. The DON stated the NAs had training on how to use the tub chair and felt they would come to her if they had questions. The DON further stated now that there had been an injury everyone would be asessed. At 5:12 p.m. during interview with the administrator and DON, the administrator stated in regard to assessments for safety with the tub chair, I think it's one of those things missed in most care centers. The DON stated assessment for safety was re-active on the part of the facility. The Cascade Patient Transfers Lift System Safe Operations and Daily Maintenance Instructions, revised 11/7/17, indicated the following: Patient Assessment for the Penner Transfer Lift Systems. - Before using the Penner Transfer Lift System, patients must be assessed by the facility's professional nursing or professional rehabilitation staff to determine which patients are suitable for transfer, which type of Transfer to use, and the number of staff members necessary to transfer each patient. Although one person can perform patient transfers, certain patients or situations may require the help of one or more additional staff members. For example, patients with unpredictable behavior due to dementia may require additional help if their behavior poses risk of injury to themselves or to staff members, patients being transported in the Penner transfer with or without scale outside of the patient ' s room. The above information must be recorded in the patient ' s record and must be communicated to the staff. Penner Transfer Lift Criteria - The Patient Must: a. Have no injuries or medical conditions that might be aggravated by the Penner Transfer Lift procedure. b. Weight less than 400 pounds. c. Be able to follow simple directions. d. Be able to sit upright by the optional chest safety belt. e. Evaluated for safety of extremities that are rigid or any problem he or she has that could cause injury or conflict with the safe operation of the Penner Transfer Lift System.

Based on observation, interview and document review the facility failed to comprehensively assess facility acquired pressure ulcers and provide consistent weekly pressure ulcer monitoring for 2 of 3 residents (R1, R2) reviewed for pressure ulcers. In addition, the facility failed to identify and implement new and timely interventions to promote the healing of pressure ulcer(s) for R1. This caused actual harm to R1 whose stage 2 left buttock pressure ulcer worsened to an unstageable pressure ulcer and acquired a second pressure ulcer. Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 was cognitively intact and required limited assistance with bed mobility and transfers. The MDS included [DIAGNOSES REDACTED]. R1 had no symptoms of [MEDICAL CONDITION] or behavioral symptoms and exhibited no rejection of care. Further, the MDS identified R1 had two, unhealed stage 2 pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister) which were not present upon admission. R1 required a pressure relieving device for the chair, a turning and repositioning program and pressure ulcer care. A subsequent MDS tracking record identified R1 died in the facility on [DATE]. R1's Pressure Ulcer Care Area Assessment (CAA) dated [DATE], indicated R1 was independent with bed mobility and R1's Tissue Tolerance (TT) (the ability of the skin to withstand the effects of unrelieved pressure) was 4 hours sitting. R1 transferred surface to surface with assist of one and utilized [MEDICAL CONDITION] (continuous positive airway pressure) throughout the night. R1 had history of skin breakdown. Currently, R1 had a stage 2 pressure ulcer on coccyx, covered with [MEDICATION NAME] (absorbent foam dressing), 1 centimeter (cm) X 1 cm, wound bed 100% white, drainage moderate, tan in color; presented on admission with stage 2 pressure ulcer on coccyx which healed; pressure ulcer on left heel, 1 cm X 1 cm-skin will not blanche; left lower buttocks [MEDICATION NAME] denudation-blanches, no odor, moderate thin drainage. R1 was at risk for skin breakdown, related to decreased mobility. A goal was identified for R1 to remain independent in all toileting tasks; pressure ulcer(s) would heal without signs & symptoms of infection; would be free of clinical signs/symptoms of breakdown. Approaches included: observe skin daily with cares; inspect skin weekly; moisturizing lotions with cares; monitor pressure ulcer-report any changes; occupational therapy evaluation & treatment for [REDACTED]. Further, R1 had a pressure reducing mattress on bed R1's Care Plan History (Entire) provided [DATE], identified R1 had a pressure ulcer, stage 2 to coccyx. Interventions implemented on [DATE] included: inspect skin weekly, observe skin daily with cares, encourage and assist resident to turn and reposition self at least every two hours and as needed for comfort, monitor for clinical signs and symptoms of wound infection and report, Occupational therapy (OT) evaluation and treatment for [REDACTED]. An additional intervention dated [DATE], directed staff to encourage to turn/reposition every two hours due to pressure sore to coccyx (TT dated [DATE] indicated every 4 hours). R1's care plan lacked identification of further pressure related injuries and lacked any further interventions related to the care of R1's pressure ulcer or to minimize the risk of additional pressure ulcer development until R1's admission to Hospice services on [DATE]. At that time the care plan identified alteration in skin integrity actual or potential related to terminal illness and indicated Hospice would provide a specialty mattress and Hospice would assess pain during each visit. R1's care plan did not include wedge pillows, keep heels off bed, boots or any further intervention. On [DATE], at 7:28 a.m. family member (FM)-A stated the pressure ulcer care R1 had received at the facility had been inadequate. FM-A indicated she was not exactly sure when R1's pressure ulcer had started; however, had been able to physically see R1 on [DATE]. When FM-A entered R1's room, FM-A stated the smell from his pressure ulcer was horrible; It smelled like necrotic (dead) flesh and could be smelled all the way down the hallway. FM-A stated she had previously contacted a facility RN about R1's pressure ulcer and wound care on [DATE], but was not given any answers at that time. FM-A stated she did not believe a medical provider had been contacted about R1's pressure ulcer and stated she had contacted nurse practitioner (NP)-A regarding R1's pressure ulcer and the odor she had noticed during her [DATE], visit. FM-A stated to her understanding NP-A looked at the pressure ulcer, a culture had been done due to concern about bacteria and NP-A had ordered some treatment for [REDACTED]. FM-A stated R1 had acquired the pressure ulcer while in the facility's care, the facility had not provided the proper care to prevent this from occurring and had not provided the proper care for the pressure ulcer after it had been acquired. R1's Skin Condition/Wound Progression documentation from [DATE] to [DATE], included the following pressure ulcer monitoring/assessments: Coccyx On [DATE], a recurrence of a pressure ulcer to R1's coccyx was identified as a stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence) measuring 1 cm x 0.5 cm. On [DATE], the staging of the coccyx pressure ulcer was identified as stage 2 and the pressure ulcer measured 1 cm x 1 cm. Wound monitoring/assessments were completed weekly through [DATE]. On [DATE], the pressure ulcer measured 1 cm x 0.5 cm x 0.2 cm. The record lacked further monitoring or assessment of the coccyx pressure ulcer. In addition, R1's medical record lacked a comprehensive assessment: to include the potential causative/contributing factors when the pressure ulcer developed, to ensure appropriate interventions were identified and implemented to promote pressure ulcer healing. Left Heel On [DATE], a new pressure ulcer was identified on R1's left heel as a stage 1 pressure ulcer measuring 1 cm x 1 cm. The pressure ulcer was described as a red area on the heel with a light purple spot in the middle measuring 0.25 cm x 0.25 cm. The pressure ulcer was assessed the next two weeks with changes to the size of the purple area noted. R1's left heel ulcer was assessed/monitored 4 of next 11 weeks ([DATE], [DATE], [DATE], and [DATE]) with measurements identified at 0.5 cm x 0.5 cm x <0.1 cm at each assessment. The record lacked assessments for 7 of 11 weeks. The record included two additional assessments of R1's left heel pressure ulcer . On [DATE], the pressure ulcer had increased in size to 1.5 cm x 1.5 cm x 0.1 cm. On [DATE], the pressure ulcer was now identified as a partial thickness, open area measuring 1.1 cm x 1.3 cm x 0.1 cm, with a white wound base, a scant amount of drainage and some complaints of pain while applying pressure to the area. The record lacked further monitoring or assessment of the left heel pressure ulcer . In addition, R1's medical record lacked a comprehensive assessment: to include the potential causative/contributing factors when the pressure ulcer developed, to ensure appropriate interventions were identified and implemented to promote pressure ulcer healing. Left Lower Buttocks On [DATE], a recurrence of a pressure ulcer to R1's left lower buttocks was identified which measured 1 cm x 0.5 cm x 0.1 cm. With a partial thickness pressure ulcer on the fatty part of buttocks. The pressure ulcer was assessed again on [DATE], and then no assessment or monitoring was completed until [DATE], over 5 weeks later. On [DATE], the pressure ulcer had increased in size and measured 2.5 cm x 3.5 cm with eschar tissue (dead tissue found in a full-thickness wound) present, covering the majority of the pressure ulcer , 90%. The depth of the pressure ulcer was unable to be determined due to the presence of eschar tissue. R1 reported pain while applying pressure to the area. The pressure ulcer was assessed [DATE] and again measured 2.5 cm x 3.5 cm. Slough (necrotic tissue that needs to be removed from the pressure ulcer for healing to take place)/eschar tissue present, covering about 85% of pressure ulcer. The depth was unable to be determined due to cover. A scant amount of sanguineous drainage was present. On [DATE], the pressure ulcer had again increased in size and measured 3 cm x 4 cm x 0.2 cm with slough covering 85% of the wound bed. The record lacked further monitoring or assessment of the left buttock pressure ulcer . In addition, R1's medical record lacked a comprehensive assessment: to include the potential causative/contributing factors when the pressure ulcer developed, to ensure appropriate interventions were identified and implemented to promote pressure ulcer healing. Right Heel: On [DATE], a new pressure ulcer was identified on R1's right heel described as a closed, blister-like area, reddish-purple with brown around the edge, located on outside of right heel measuring 3 cm x 4 cm. The record lacked further monitoring or assessment of the right heel pressure ulcer . In addition, R1's medical record lacked a comprehensive assessment: to include the potential causative/contributing factors when the pressure ulcer developed, to ensure appropriate interventions were identified and implemented to promote pressure ulcer healing. After [DATE], R1's Skin Condition/Wound Progression documentation lacked further monitoring or assessments of R1's skin integrity regarding the left buttock, coccyx and left and right heel pressure ulcers. R1's progress notes from [DATE] to [DATE], identified the following: -[DATE]: Resident had no dressing to his bottom, removed soiled clothing and bedding and assisted with a dressing change. The pressure ulcer had an odor and continued to deteriorate. The pressure ulcer was cleansed well and a fresh dressing was placed, this time a larger Allevyn (moist wound environment dressings designed specifically for the management of chronic and exuding wounds) was used as the smaller size did not seem to be working well. Barrier Wipe was applied to the intact skin to help with dressing staying intact as ordered. The note lacked identification of the location of the pressure ulcer. -[DATE]: Resident's wound culture had not come back yet. Did ask we check back again on [DATE]. The note lacked identification of the wound culture location. -[DATE]: The pressure ulcer on R1's left gluteus (buttocks) was very hard and red around the entire thing. He had a lot of pain with it. -[DATE]: Dressing was changed to the left gluteal. No dressing present at this time, as R1 had just received a bath. There was a slight amount of purulent drainage on R1's bed protector. The wound base was covered with eschar/sloughing. Area was cleansed with warm water. Mupirocin (generic form of [MEDICATION NAME] a topical antibiotic) was applied to the site. Cut [MEDICATION NAME] (non-adherent antimicrobial alginate dressing) to fit, and placed on pressure ulcer. Covered with Allevyn dressing. -[DATE]: There was a small amount of drainage from his dressing on R1's buttocks. There is a red area on the top of the left outer buttock. Heel boots and heels up are in place. -[DATE]: Dressing on his bottom had some drainage and was changed. The note lacked identification of the location or description of the pressure ulcer . -[DATE]: Resident had several black spots throughout his scrotum, some do feel soft to the touch as though they may break open soon. -[DATE]: Inter-dry (moisture-wicking fabric with antimicrobial silver) was cut into a strip and applied to resident's scrotum to make a sling to help keep the scrotum dry and elevated. -[DATE]; Resident's daughter requested that resident's pressure ulcer to his left buttock be inspected by a physician or resident's PCP (primary care provider). [DATE]: Resident's son called today to report that he was disappointed in the care his father had received, in particular the pressure ulcer care. Daughter was here and also complained no one had addressed the residents buttocks PU. NP-A agreed on [DATE], to have PT look at the PU and debride the pressure ulcer , if that was appropriate. Hospice admitted this resident on Monday. Hospice required different training for PT so the decision was made that our resident PT would not observe the pressure ulcer. After the daughter and son expressed their frustrations and anger in regards to the pressure ulcer (the writer) proceeded to research steps taken in regards to residents integument system. Resident was admitted with a stage two ulcer in February (2020). The pressure ulcer was documented as healed at one point, so the pressure ulcer did close. The resident always had a pin hole type of wound on his coccyx, threatening to open up from the inside out. An RN followed his skin weekly. About 2 weeks ago it was reported the resident had a pressure ulcer that opened up and was progressing rapidly. This RN spoke with NP-A who agreed to have therapy evaluate the pressure ulcer. The repositioning documentation was reviewed and there was an evening shift on the 16th of October and R1 was not repositioned as scheduled. Education and guidance would be provided to the NA's (nursing assistants) and the LPN (licensed practical nurse) on duty was educated as well. NP-B was contacted and planned to do a visit with the resident to assess the pressure ulcer. Hospice would be involved going forward. The note did not identify which pressure ulcer. -[DATE]: Received a call from (NP-B's nurse) stating to discontinue wound debridement and R1 would be seen by NP-B via Telehealth visit. Measurements would be needed prior to this appointment. Measurements were L-2.6 (cm), W-2.2 (cm), D-2.9 (cm). The pressure ulcer was cleansed and re-dressed as per orders at 4:45 p.m. The note did not identify which pressure ulcer. -[DATE]: Resident was seen for pressure ulcer inspection per NP-B. She inspected scrotum ulcerations, wound to left buttock, back (reddened skin) and both heals. NP-B asked that (the writer) re-dress the pressure ulcer to R1's heels with foam dressing with the surrounding skin covered with foam and eschar tissue left open to air and secured with a Kerlix (woven gauze bandage) dressing and be kept on until dressing falls off and then re-placed with the foam only on intact skin. NP-B ordered pressure ulcer care to left buttock - flush wound with 25% peroxide/0.9 normal saline (NS) solution using a ,[DATE] cubic centimeter (cc) syringe then pack with [MEDICATION NAME] gauze (cotton gauze strip impregnated with formulated [MEDICATION NAME] solution primarily used for sterile drainage of open and/or infected wounds) and cover with Kerlix fluff. Change the dressing twice daily and as needed if saturated. Pressure ulcer care to left heel is - surround the pressure ulcer with padding and apply [MEDICATION NAME] 2% to ulcer twice a day then cover with gauze. Right heel pressure ulcer would be dressed with a padded dressing and covered with gauze. Petroleum Jelly for a skin barrier to scrotum 3 times daily and as needed. -[DATE]: Late entry for [DATE], Heels were dressed as order on the evening shift. Left inside had a callus that was open but dry. Tissue around callus was hard and starting to peel. Outside of right heel was black with no drainage. -[DATE]: Dressing change completed at 10:30 a.m. Left buttock pressure ulcer had mucous drainage but less odor then last evening. Did flush pressure ulcer well as per MD orders and re-packed pressure ulcer with packing, covered with a loose gauze pad. Right heel dressing continued to be intact on surrounding skin - area cut out as per verbally instructed from NP to pad area surrounding callous. Left heel dressing was intact to skin surrounding wound - area still cut out as per NP orders, did apply [MEDICATION NAME] to callous. Resident did grimace with touch of left heel ulcer. - [DATE]: Resident passed away at 1:42 p.m. that afternoon. R1's Resident Concerns form (to communicate changes to medical provider) dated [DATE], included a note to the provider which identified R1's pressure ulcer to left gluteal fold had increased pain and redness. Could we please obtain a culture? The provider responded on [DATE], with an order to culture pressure ulcer on left gluteal fold. The note did not provide any further information related to the deterioration of R1's pressure ulcer (s). R1's Visit Note dated [DATE], completed by NP-A identified the reason for visit as an evaluation of pressure ulcer on the left buttock and the right heel. Staff and family reported malodor. R1 was lying in bed with a wedge cushion under the calves to prevent R1's heels from touching the bed; however, R1 had adjusted the wedge under his legs so his heels were actually touching the bed. Skin Exam Common Findings: there is a stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the pressure ulcer bed. Often includes undermining and tunneling.) on the left buttock which was approximately 5.5 cm in diameter. The entire pressure ulcer was covered in green/black slough and eschar. Undermining on the edges of the pressure ulcer. Pressure ulcer was 0.75 to 1 cm in depth. Pressure ulcer was extremely malodorous. Right heel had a a red/purple closed pressure pressure ulcer on the lateral side which was covered in hard calloused tissue. The left heel had a small pink area approximately 1.5 cm in diameter. Impression: 1. Stage IV pressure ulcer-left buttock. 2. Stage unknown pressure ulcer-right heel. 3. Stage 1 pressure ulcer - left heel. 4. [MEDICAL CONDITION]. Plan: Pressure ulcer culture of the buttock was done and positive for [MEDICATION NAME] faecalis. Order written temporarily for [MEDICATION NAME] topically until PCP (primary care physician) returns to the office. Given his condition, oral antibiotics would likely cause more harm than good. Any attempts to try to heal these areas will likely fail due to terminal condition. Order for PT debridement to remove loose slough on the left buttock. Heel protectors ordered while patient is in bed. I did discuss this with the patient who has agreed at this time to keep them in place. Will also keep wedge in place for added protection. Will discuss with PCP next week. R1's Telehealth Visit Report dated [DATE], completed by NP-B, identified R1 was seen related to concerns of skin integrity. NP-B's physical exam observations were completed with the assistance of nursing. NP-B was able to visualize, in fairly good detail, the pressure ulcers. The left buttock pressure ulcer was a little better than 3 cm in diameter and was 3 cm deep. It had some thick areas of eschar that had partially softened. There also was some pseudomembranous mucoid appearing discharge. Most of the tissue and discharge was gray in appearance. The undersurface of R1's scrotum was red and irritated in appearance and had several areas of stage ,[DATE] ulcerations that spanned nearly the entire undersurface. Wherever the scrotum was in contact with the bed, essentially. There were so many different ulcerations that were confluent they essentially become one very large pressure ulcer. This area expanded greater than 10 cm in length and greater than 5 cm in width. On the left heel he had a stage ,[DATE] ulceration on the medial aspect. The pressure ulcer base was pink. On the right heel the lateral area had a 3 cm diameter area that was red with one area in particular that was a bit soft and mushy making this a ,[DATE] stage pressure ulcer. Assessment 1) Stage IV pressure ulcer left buttock 2) Stage ,[DATE] pressure ulcers on scrotum, and left heel. 3) Stage ,[DATE] pressure ulcer on right heel. 4) low urinary output. Plan 1) In an effort to ensure improved skin integrity and to keep moisture off the scrotum, apply petroleum jelly up to three times daily and will straight cath patient, if greater than 100 milliliters (ml) of urine, leave the catheter in place, remove if less than 100 ml. 2) For the stage IV pressure ulcer will flush with a diluted peroxide/saline flush and pack with [MEDICATION NAME] 2 inch gauze changing twice daily and as needed. Cover with large Kerlix fluff. This should help with both bacteria as well as debridement of the eschar. 3) For his heels, surround both pressure ulcers with a [MEDICATION NAME] foam cutting out the area of ulcerations to take the pressure off those. On the left heel apply [MEDICATION NAME] to the ulceration and cover with gauze; for the right heel simply cover with gauze and place padded boots over both heels. 4) Use wedged pillows and other padding to ensure the patient is not laying on his back and is turn side to side every 2 hours to relieve pressure and keep pressure off the scrotum as well as the left buttock. Nursing staff was instructed to be liberal with R1's pain medications especially prior to any of his dressing changes. During interview on [DATE], at 9:14 a.m. NA-A stated R1 had a pressure ulcer on his left hip and for awhile also had one on his coccyx; however, indicated that one kind of healed up. NA-A indicated R1 preferred to stay in his recliner most of the time with his feet down and indicated staff did not do anything with R1 regarding repositioning. R1 was capable of letting them know if he needed the restroom or anything. NA-A stated toward the end, approximately the last month, R1 would lay down on his bed between breakfast and lunch, otherwise his care didn't change much. NA-A denied R1 ever being on a turning/repositioning program. When interviewed on [DATE], at 9:35 a.m. NA-B stated R1 was pretty mobile in bed and until the end and then staff had used a sit to stand lift for transfers. NA-B indicated R1 sat in a recliner about 95% of the time. NA-B verified R1 had sores on his bottom and stated he had a lot more pain with them toward the end as they got bigger. NA-B also indicated R1 used a wedge under his feet and booties as he got open sores on his heels. NA-B stated until the very end R1 could reposition himself in bed but once in his chair, he didn't like to move. On [DATE], at 9:51 a.m. RN-B stated RN-C was the one responsible for doing the pressure ulcer care as RN-C had been trained by their previous wound nurse, RN-D. RN-B indicated RN-D had left employment with the facility in [DATE], and since then RN-C had been managing resident pressure ulcer care. RN-B indicated other nurses had assisted by performing dressing changes and assessments, however RN-C was the only one who measured the pressure ulcer. RN-B indicated RN-C documented his assessments in the Wound/Skin documentation section of the electronic record but when other nurses completed resident dressing changes, they signed off on the eTAR (electronic treatment administration record) and some nurses would also do a progress note. RN-B stated to her knowledge, pressure ulcers should be measured every week and assessed for signs of infection or pressure ulcer worsening. RN-B verified R1 was admitted with a pressure ulcer on his coccyx and also developed a pressure ulcer on the left buttock that healed and then came back. RN-B also verified R1's left heel ulcer started in [DATE], and a right heel ulcer developed in [DATE]. RN-B stated in [DATE], over the course of a few days, the buttock pressure ulcer really blew up and indicated she hadn't laid eyes on it until it really opened up a couple weeks before he passed. RN-B indicated they were putting dressings on it but it kept opening up. RN-B stated the pressure ulcer was painful for R1 toward the end. RN-B indicated NP-A had seen the pressure ulcer in the beginning of [DATE], and had ordered to have PT see the pressure ulcer for debridement but then R1 had been admitted to Hospice and the therapist did not work with Hospice so there was a bit of a mess over that. RN-B indicated NP-A had come in person to see R1's pressure ulcer but she was not sure if any provider had seen the pressure ulcer prior to that. When interviewed on[DATE], at 11:02 a.m. the quality consultant (QC) stated resident pressure ulcers should be monitored and assessed weekly. Following review of R1's record, QC stated R1's medical record lacked evidence of weekly pressure ulcer monitoring and assessments. She had addressed this concern with RN-C and had provided education on the importance of weekly documentation. QC thought R1 had been seen by NP-A and indicated she would request the documentation of the visit from the clinic. QC was not able to speak to the deterioration of R1's pressure ulcers as she had never assessed the pressure ulcers. During interview on [DATE], at 2:35 p.m. NP-B identified she was R1's primary care provider prior to R1's admission to the nursing home. However, when COVID-19 hit, the facility wouldn't let them (providers) in there. NP-B identified she saw R1 for a preoperative exam in May (2020) and at that time R1 had a small pressure ulcer on his heel and stage 2 pressure ulcer on his coccyx, in the gluteal crease. NP-B indicated the pressure ulcer was being taken care of and was getting better and also indicated R1 had no pressure ulcers on his buttocks at that time. NP-B stated she had seen R1 via telehealth on [DATE], after being contacted by R1's family. - At the time of the pressure ulcer assessment, NP-B indicated she had been completely overwhelmed by condition of R1's skin and stated I almost started to cry. It was impressive. NP-B indicated her examination was limited by the technology (the telehealth exam was conducted via video); however, stated the buttock pressure ulcer had eschar that was several inches thick and the pressure ulcer was quite deep. NP-B indicated she had not been contacted by the facility regarding R1's pressure ulcers prior to the telehealth visit and stated she would have expected they contact either her or the local providers regarding the condition of R1's pressure ulcers. NP-B indicated she was also contacted by the Hospice registered nurse (HRN) prior to the telehealth visit who had enquired if NP-B had been aware of the condition of R1's skin. NP-B identified HRN had contacted her as soon as she (HRN) had evaluated R1 with concerns related to the care of R1's pressure ulcers. When interviewed on [DATE], at 2:57 p.m. NP-A stated she saw and evaluated R1's pressure ulcers on [DATE]. NP-A stated she recalled the visit as she had not physically been at the nursing home except for that visit. NP-A stated neither she, nor the physician had seen R1's pressure ulcers prior to the [DATE], appointment. The pressure ulcer was not good and described it as pretty deep and very odorous, almost gagging. The pressure ulcer edges had undermining and the pressure ulcer bed was pea green/black in color. R1 was rolled on his side and she lifted up his left foot and noted a stage 1 pressure ulcer on the left heel. She then looked at his right heel, which also had a pressure ulcer and noted it was worse than the left. NP-A stated R1 sis not like wearing heel protectors and stated she had to talk him into that. NP-A stated if a resident pressure ulcer was worsening the facility usually let her know and stated she should have been contacted sooner regarding R1's pressure ulcers. NP-A stated they could have put interventions in place; she was not sure if intervention would have helped heal the pressure ulcer but could have potentially made R1 more comfortable. On [DATE], at 3:08 p.m. HRN identified she had completed an initial evaluation of R1 for admission to Hospice services on [DATE], and stated she was concerned as R1's buttocks pressure ulcer was open, had stringy stuff coming out if it and a horrible, horrible odor. HRN stated when she evaluated R1 on the [DATE], and again on [DATE]. R1's pressure ulcer had smelled like stool. HRN indicated the area had no wound care to it and stated the last order was to apply [MEDICATION NAME] twice daily. HRN stated [MEDICATION NAME] wasn't usually applied to pressure ulcers with that depth and she had concerns regarding the adequacy of the pressure ulcer care for the condition of R1's pressure ulcer. HRN stated she did not know what pressure ulcer care the facility had been providing prior to hospice but identified on [DATE], there had been nothing/no dressing on the pressure ulcer and also nothing on the pressure ulcer when she returned on the [DATE]. Further, she could not get any direction for the care of R1's pressure ulcer from the nursing home, as there were no pressure ulcer care orders, so she had contacted NP-B as she needed direction on what to do with R1's pressure ulcer. HRN stated NP-B had given the order to do wet to dry dressing changes twice daily and had faxed an order to HRN which she had faxed to the nursing home. HRN stated she absolutely felt this should have been evaluated by physician. During interview on [DATE], at 3:26 p.m. RN-A stated it was planned for her to have training in wound care, however she had not been trained yet. RN-A indicated RN-C was doing all of the pressure ulcer measurements and she had assisted with dressing changes. RN-A could not explain the gaps in R1's pressure ulcer documentation. R1's pressure ulcer to his buttocks came on quickly; within a matter of days. However, identified a progress note dated [DATE], which identified R1 had an open area on the left buttocks the size of a quarter. RN-A also stated a progress note dated [DATE], identified R1's pressure ulcer had odor and continued to deteriorate. RN-A stated R1 had complained of terrible pain in the pressure ulcer at the end. After review of R1's medical record RN-A stated R1's left buttock pressure ulcer had first been visualized on [DATE], by NP-A. RN-A stated a physician should be notified for new pressure ulcers, foul odor, fever, or other signs or symptoms of infection pressure ulcer, including deterioration or pain. On [DATE] at 3:56 p.m. RN-C stated he was responsible for wound care in the facility until the middle of [DATE], when he had taken another job, at another facility, for a period of time. RN-C stated it was his understanding RN-A took over, the pressure ulcer monitoring; however, it appeared that had not happened. RN-C stated he had only completed pressure ulcer care monitoring from [DATE] to mid-[DATE]. He worked with RN-D, the previous wound nurse, who had left at the end of [DATE] or beginning of [DATE]. RN-C stated when he was doing pressure ulcer care for R1, the only pressure ulcer requiring a dressing change was on on his coccyx. There was only a small ulcer on R1's coccys at that time. Further, one of the LPN's later noticed a spot further down on R1's buttocks and had described it as a round, purple spot. RN-C stated he spoke with RN-D about it, who had indicated R1 had developed spots like that previously which cleared up after a while. RN-C stated RN-A would have taken over so he did not recall seeing the pressure ulcer again after that. However, RN-C stated he did not think the pressure ulcer had healed and redeveloped. RN-C identified his documentation and what had been documented by RN-D sounded like the same area. RN-C stated he had received direction from RN-D on what to use on R1's left buttock pressure ulcer when it had reappeared in [DATE]. RN-C stated a medical provider had not assessed R1's pressure ulcers until NP-A had done so on [DATE]. During interview on [DATE],

Based on observation, interview, and document review, the facility failed to ensure the availability of prescribed anxiolytic (medication used for anxiety) or narcotic medications for 2 of 3 residents (R1, R2) resulting in an immediate jeopardy (IJ) for R1 who had an acute decline in her medical condition following the abrupt discontinuation of a prescribed narcotic which required hospitalization for opioid withdrawal resulting in cardiac intervention and monitoring. The immediate jeopardy began on 9/13/19, when R1 required a [MEDICATION NAME] change and the facility did not have the medication available and was identified on 9/24/19. The administrator and the Director of Nursing were notified of the immediate jeopardy at 11:25 a.m. on 9/24/19. The immediate jeopardy was removed on 9/25/19 at 2:25 p.m., but noncompliance remained at the lower scope and severity level of G, which indicated actual harm that is not immediate jeopardy. Findings include: A facility Health Regulation Division - Nursing Home Incident Reporting form submitted by the facility on 9/15/19, at 12:40 p.m. indicated R1 had been receiving a [MEDICATION NAME] 100 mcg patch and was expected to have a refill on Friday 9/13/19. The pharmacy did not send any more patches when the facility medications were delivered Friday evening. The pharmacy is closed on weekends and were not available to ask why the patches had not come. By Saturday (9/14/19) evening this resident started experiencing uncontrollable pain and was sent to the ER. It was suspected that resident could have been experiencing withdrawal symptoms. R1's Disease [DIAGNOSES REDACTED]. R1's 14 day Minimum Data Set ((MDS) dated [DATE], indicated R1's cognition was intact and she was receiving scheduled and as needed (PRN) medications for occasional, moderate pain rated at 8 on a scale of 1-10. R1 indicated pain had limited her day to day activities. R1's Pain Care Area Assessment (CAA) dated 8/14/19, indicated R1 described her pain as sharp, aching and was located in the lower back and right shoulder. Pain was rated 8/10 at its worst and after medication given, pain rate went to 4/10 which was a pain goal that R1 was comfortable with. [MEDICATION NAME] 100 micrograms (mcg)/hour was changed every three days. Encouraged to get out of bed but would refuse due to too much pain. R1's Active Medication Orders included with Admissions Observation completed on 8/14/19, included an order for [REDACTED]. R1's care plan dated 8/7/19, identified chronic pain related to severe [MEDICAL CONDITION] disc disease and directed staff to: - administer [MEDICATION NAME] per medical doctor (MD) nurse practioner (NP) order - medication as ordered - observe signs and symptoms of pain (grimacing, moaning, guarding) report to MD/NP as needed - offer PRN [MEDICATION NAME] prior to therapy - offer/attempt position/repositioning - 1:1 interactions/distractions - physical therapy evaluation and treatment as indicated and ordered. Thrifty White fax Reorder Forms dated 9/8/19, and 9/10/19, identified requests made by the facility to refill R1's [MEDICATION NAME] 100 mcg/hour patch. A return fax from Thrifty White Pharmacy received on 9/11/19, at 3:19 p.m. indicated Prior Authorization was required in order to fill the medication. Per [MEDICATION NAME] ([MEDICATION NAME]) patch package insert by Janssen Pharmaceuticals dated 2009, section 9.3 indicated physical dependence resulted in withdrawal symptoms after abrupt discontinuation or a significant dosage reduction of a drug. [MEDICATION NAME] should not be abruptly discontinued. If [MEDICATION NAME] was abruptly discontinued in a physically-dependent patient, a withdrawal syndrome may occur. Some or all of the following can characterize this syndrome: restlessness, lacrimation (excessive amount of tear production), rhinorrhea (watery discharge from the nose), yawning, perspiration, chills, myalgia (muscle pain), and mydriasis (dilation of pupil). Other signs and symptoms also may develop, including: irritability, anxiety, backache, joint pain, weakness, abdominal cramps, [MEDICAL CONDITION], nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate. Do not stop using [MEDICATION NAME] without talking to your healthcare provider. On 9/19/19, at 11:32 a.m. R1 was observed lying in bed, awake and alert. R1 stated when the nurse removed her pain patch on Friday 9/13/19, she told me she did not have another patch to apply due to R1's insurance was not covering the cost. R1 stated the next day, Saturday morning, she felt like she was going into medication withdrawal as she was twitching all over, crawling out of her skin, itching, nauseated, and going from being hot to cold. R1 stated she was scared as these symptoms had never happened to her before. R1 stated the symptoms persisted and early Sunday morning she ended up going to the hospital where it was discovered she was in [MEDICAL CONDITION] which required medication to convert to a normal rhythm. R1 stated in the past, she had required four cardio conversions (electrical shocks through paddles to regulate your heartbeat) to regulate her heart rhythm. R1 stated her pain patch was now covered by insurance for one year so she does not have to worry about it. R1's Progress Notes (PN) reviewed failed to include information related to R1 not having [MEDICATION NAME]es available for use. The last notation was made prior to event on 9/10/19, and was written by physical therapist. -PN dated 9/15/19, at 12:54 a.m. indicated R1 was complaining she was feeling like her skin was crawling and nausea without vomiting. R1 was worried that she was going to lose her mind because she had been out of her [MEDICATION NAME]es since the evening of 9/13/19. The note also indicated no pain relief has been obtained for the resident and had no reports of visual or auditory disturbances. This writer had offered for R1 to go to the emergency room due to the facility not having medication delivery today; however, R1 stated she was worried about her insurance not covering that expense. Vital signs obtained: temperature 98.1, Pulse 110, Respirations 18, and blood pressure 125/62. -PN dated 9/15/19, at 4:58 a.m. indicated R1 requested to be transferred to emergency room due to complaints of crawling out of her skin due to not having the [MEDICATION NAME] since Friday evening. Vital signs within normal limits with exception of her pulse of 122 (normal range 60-100). R1 appeared visibly shaken and wanted further pain control as she stated that she hurt all over. Pain was rated at about 7 out of 10. Skin was cool and clammy to touch. R1 stated she was hot and cold and could not find an in between. R1's hospital History and Physical (H&P) dated 9/15/19, indicated R1 presented today for pain all over. She stated 5-6 days ago her [MEDICATION NAME] used for chronic pain management was removed and not reapplied due her insurance not covering it anymore. R1 stated there was no replacement patch to reapply nor was there a tapering of the dosage. R1 stated over the last 3-4 days she began to feel shaky and have severe body aches. R1 also reported some mild substernal chest pain this morning which lasted about five minutes, but has since improved. R1 stated she has increased pain in lower and mid back which has been improved with some intravenous (IV) [MEDICATION NAME] given in the emergency room . Other associated symptoms included nausea and burning with urination, tingling in hands and face that had completely resolved as of this morning. R1 was noted to be in [MEDICAL CONDITION] with RVR (abnormal heart rate characterized with excessively rapid heartbeat) and had soft blood pressures (low blood pressure). The H&P assessment section indicated: -opiate withdrawal with history of [MEDICAL CONDITION] disc disease of the spine and chronic pai[DIAGNOSES REDACTED] -[MEDICAL CONDITION] with rapid ventricular response -history of [MEDICAL CONDITION] with underlying chronic lower extremity [MEDICAL CONDITION] -hypertension currently with soft blood pressure The Plan section of the H&P indicated: we suspect many of her symptoms are related to the abrupt withdrawal of [MEDICATION NAME]. We will go ahead resume a [MEDICATION NAME] at reduced dosing of 50 mcg/hour. R1 had been receiving 100 mcg when she was last discharged from the hospital. We will monitor for improvement in symptoms and also adverse effects such as excessive sedation and respiratory depression. We will also consult discharge planning to further investigate insurance coverage for this medication as well as seek any alternatives to manage her chronic pain before returning to the nursing home. Resume home dose of [MEDICATION NAME] (used to treat irregular heartbeat). Cautiously resume home dose of [MEDICATION NAME] (used for hypertension). Watch for worsening [MEDICAL CONDITION] (low blood pressure). Soft blood pressures are suspected to be related to [MEDICAL CONDITION] with RVR, opiate withdrawal, and recent administration of IV [MEDICATION NAME] (used for high blood pressure). Based on assessment and after consideration of the resident's co-morbidities, severity of illness, treatment needs and risk for adverse events, I suspect this patient will require a hospital stay of greater than two midnights. On 9/18/19, at 12:56 p.m. the director of nursing (DON) stated the pharmacy delivered medications on Monday-Wednesday-Fridays. The licensed practical nurse (LPN) working on the evening of 9/13/19, did not know that the pharmacy was not going to deliver the [MEDICATION NAME]es that evening and the facility was not aware the MD had not completed the Prior Authorization form in order for R1 to have the medication refilled. The DON confirmed there was no documented evidence related to the medication not coming in or actions taken by the LPN once it was discovered R1 would abruptly be without the [MEDICATION NAME] medication. The DON stated the process for re-ordering medications was for the staff to monitor for when a medication count was low, pull the prescription sticker off the medication card or box and fax it to the pharmacy for timely re-fill. Following this incident the DON stated she had begun a spreadsheet which included all prescribed narcotic medications and the amounts left. This would be reviewed at the beginning of each week to ensure availability of the medication. Although the DON confirmed she was aware of the potential for withdrawal concerns after abruptly stopping the [MEDICATION NAME], she was not aware of how quickly the withdrawal symptoms would occur. -At 1:18 p.m. LPN-A stated she kept the medication re-order forms for ease of access on the medication cart and would usually re-order medications when they get down to four doses remaining. LPN-A stated the registered nurses (RN) were responsible for follow up when new prescriptions or prior authorizations are required. LPN-A stated the entire previous week she was aware of R1 having been out of the [MEDICATION NAME]es and had communicated this to both RN-A and RN-B as well as the pharmacy. -At 1:23 p.m. RN-A stated last Wednesday 9/11/19, she had received a fax from the pharmacy requesting prior authorization in order to refill the [MEDICATION NAME] medication at which time she placed the fax received on the nurse practioner (NP) rounding board for review the next day, Thursday. On Thursday, RN-A discovered the NP was not going to be doing rounds at the facility, rather the MD, who was R1's primary care provider, was coming to see the residents. RN-A stated she handed the Prior Authorization requested to the MD and informed the MD that R1 was wearing the last available [MEDICATION NAME]. RN-A stated after it was discovered that R1's [MEDICATION NAME]es had not been delivered, she would have expected the nurse working to contact the pharmacy, inform the on-call RN, and the on-call MD. RN-A verified there was no documentation indicating this process was followed and stated the documentation was very poor here at times. -At 1:43 p.m. LPN-B stated she started working at 2 a.m. on 9/14/19. LPN-B stated the facility often ran out of controlled medications and the staff were expected to obtain the medication from the facility emergency kits (E-Kits), but the E-Kit do not contain [MEDICATION NAME]es. -At 2:20 p.m. the DON verified the lack of documented evidence which indicated R1's [MEDICATION NAME] medication was not available on 9/13, or attempts made to contact the on-call MD and/or the on-call RN. -At 2:48 p.m. LPN-C stated the residents narcotic medications quite frequently ran out and the staff have to access the E-Kit to obtain the medication; however, confirmed [MEDICATION NAME]es were not available in the E-Kit. LPN-C stated there were three other residents who recently ran out of current prescription medications and the staff had to obtain them from the E-Kit. LPN-C verified she had worked over the weekend of 9/13/19, and stated what had happened to R1 was absolutely awful. LPN-C stated R1 was in so much distress and what happened to her should never have to happen to anyone. LPN-C stated on Sunday 9/8/19, and again on 9/10/19, she had sent a fax request to Thrifty White Pharmacy requesting R1's [MEDICATION NAME]es and had also informed the RN on duty that R1 would not have any patches available after 9/10/19. LPN-C stated she had heard of horrible things that could happen when a narcotic medication was stopped abruptly, but this was the first time I had ever witnessed it. -At 3:17 p.m. when asked, the DON stated the facility did not have a policy/procedure related to the re-ordering of medications. On 9/20/19, at 9:11 a.m. the DON stated she was not made aware of R1 not having [MEDICATION NAME]es available until 9/15/19, when R1 was hospitalized . The DON stated the nursing staff should have followed the Missing/Unavailable Medication policy, which directed them to contact the pharmacy and Physician for further direction and resolution. The DON verified there was no documentation that was procedure was followed. -At 11:29 a.m. RN-B stated she was the on-call RN the weekend of 9/13/19, and verified she had not received any communication from the facility regarding R1 being out of [MEDICATION NAME], experiencing withdrawal symptoms, or having been hospitalized . RN-B stated she would have expected to be notified about this since withdrawal from narcotics was very serious. -At 4:00 p.m. during a telephone interview, the pharmacist stated when prior authorization was required, the pharmacy would send a fax to both the MD and the facility. The pharmacist confirmed this was done for R1's [MEDICATION NAME]es on Wednesday 9/11/19, and the facility verified they had received the fax and had given it to the MD on 9/12/19. The pharmacist stated the only way the facility could get medications after pharmacy hours or on the weekends was to use the medication supply provided in the facility E-kit, which did not contain [MEDICATION NAME]es. The pharmacist confirmed R1's prior authorization to fill the medication was not received until 9/16/19. -At 4:10 p.m. an attempt was made to contact the NP who followed R1 while hospitalized ; however, was informed the NP would not be available until 10/1/19. -At 4:15 p.m. an attempt to contact R1's MD who was responsible to complete the prior authorization; however, was informed the MD was not available until 9/30/19. On 9/24/19, at 3:24 p.m. LPN-D stated if a resident's condition changed after hours or weekends, the staff were directed to call the on-call RN and for concerns related to resident blood sugars, the staff called the on-call MD. LPN-D stated there had been times, even after several attempts, that the on-call MD could not be reached, however; confirmed they could also contact the emergency department on-call MD, if needed. The facility's Missing/Unavailable Medications policy/procedure dated 11/15, identified procedures for nursing staff to take when medication was missing or unavailable. The procedure directed: -check resident Medication Administration Record [REDACTED]. -call the pharmacy to inquire about missing medications. Nursing staff would attempt to identify if the medication had been sent from pharmacy or when the pharmacy would be able to provide medication to facility. -if pharmacy was unable to provide a medication in a timely manner, nursing staff would coordinate with the pharmacy for resolution. If a resolution was unavailable and the pharmacy was not able to deliver the medication as directed, nursing staff would assess the resident and notify the physician for further direction. -after discussion with the physician, nursing staff would call the nurse on-call and update them on situation and plan of correction. -nursing staff would document the resolution and parties notified in the progress notes. The IJ that began on 9/23/19, was removed on 9/25/19, at 2:25 p.m. when the facility developed and implemented the following interventions which were verified through document review and interview: -reviewed resident medication counts to ensure availability including stock medications -developed a medication monitoring spreadsheet -development of Narcotics Inventory/Reordering Policy -development of Stock out and Last Administration policy -reviewed and updated the Missing/Unavailable Medications -reviewed and updated the Medication Error policies -educated licensed nursing staff and trained medication aides (TMAs). -developed an auditing system to ensure compliance is sustained for all residents. R2's quarterly MDS dated [DATE], indicated R2's [DIAGNOSES REDACTED].g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) during 4-6 days of the assessment reference period. R2's [MEDICAL CONDITION] CAA dated 9/10/19, indicated R2 continued on [MEDICATION NAME] (antianxiety medication) one milligram (mg) for treatment of [REDACTED]. Target behaviors included agitation, swearing, impulsivity and yelling. R2 had an increase in [MEDICATION NAME] related to yelling and agitation and not responding with redirection. R2 would navigate down halls yelling out about the lord, wanting a woman, and needed multiple reminders to use his quiet voice. R2's care plan dated 4/18/19, indicated R2 received antianxiety medication related to increased anxiety, agitation and restlessness and directed staff to: - provide antianxiety medications per provider orders - monitor resident's mood and response to medication - non-pharmacological interventions: paper shredding, box shredding, watch TV, participate in groups - observe for changes in behavior and update provider with concerns - psych to follow R2's physician's orders [REDACTED]. During interview on 9/19/19, at 2:48 p.m. LPN-C stated this past weekend R2 had run out of [MEDICATION NAME] medication and even after depleting the two facility E-Kit's of [MEDICATION NAME], R2 still went one and half days without receiving the scheduled medication. LPN-C stated the staff had to utilize the E-Kits for prescribed medications happened frequently because resident medications were not always available. Review of provided E-Kit Log indicated the following were removed and administered to R2: - On 9/12/19, 4 tablets of [MEDICATION NAME] 0.5 mg - On 9/13/19, 2 tablets of [MEDICATION NAME] 0.5 mg - On 9/13/19, 4 tablets of [MEDICATION NAME] 0.5 mg - On 9/14/19, 2 tablets of [MEDICATION NAME] 0.5 mg R2's eMar Monthly Report for (MONTH) 2019, indicated R2's [MEDICATION NAME] 1.0 mg was not administered as follows: - 9/14/19 at 8 p.m. - 9/15/19 at 5 a.m. - 9/15/19 at 1 p.m. - 9/15/19 at 8 p.m. - 9/16/19 at 5 a.m. - 9/16/19 at 1 p.m. R2's medical record lacked any documentation from 9/2/19, at 2:36 a.m. until 9/17/19, at 11:19 a.m. related to the missed doses. On 9/20/19, at 10:15 a.m. the DON confirmed R2's medical record lacked documentation related to R2 having been out of the medication, notification of MD, or the missed medication doses until 9/17/19. The DON stated she would have expected the staff to document in R2's progress notes any changes in R2's behaviors or absence of behaviors during the timeframe of the missed medications. The DON stated the nursing staff should have followed the Missing/Unavailable Medication policy and procedure and verified and there was no evidence the policy was followed. - At 11:30 a.m. nursing assistant (NA)-A confirmed she had worked the weekend of 9/13/19, and stated R2 was louder than he usually was and was yelling across the dining room at other residents. NA-A stated she had reported this change to the nurse.

Based on interview and document review, the facility failed to ensure the residents were free from abuse when an allegation of abuse was made when 1 of 1 resident (R1) was observed to be physically abused and the facility failed to remove the perpetrator from work which had the potential to affect the additional 43 residents who resided in the facility. This failure resulted in an immediate jeopardy (IJ) due to the facility's failure to immediately protect the residents from potential further abuse when the alleged perpetrator was allowed to continue to work the evening and night shift following receipt of the report of abuse. The IJ began on 1/5/19, at 7:30 p.m. when the director of nursing (DON) received the initial report of an observed abuse allegation of R1 having been handled roughly and expressing fear of licensed practical nurse (LPN)-A. The facility allowed LPN-A to continue to work the evening and night shift following receipt of the allegation even though the DON was aware LPN-A had a history of [REDACTED]. The administrator and the DON were notified of the IJ at 5:30 p.m. on 1/11/19. The IJ was removed on 1/12/19, at 3:00 p.m. but noncompliance remained at the scope and severity of Level G, actual harm that is not immediate jeopardy. A facility Health Regulation Division - Nursing Home Incident Reporting form submitted by the facility on 1/6/19, at 3:51 p.m. indicated nursing staff alleged LPN-A had handled R1 roughly while transferring him. The report indicated on 1/5/19, at 7:15 p.m. LPN-B reported she had returned from her break and had heard a commotion from the adjoining common/dining area at which time she observed R1 sitting on the front edge of his wheelchair appearing like he was trying to get away. LPN-A was standing behind R1's wheelchair with his hand on R1's left shoulder, holding R1's left arm behind his back. LPN-B saw LPN-A pull R1 backward into the wheelchair. R1 stated, Help, help! When LPN-A observed LPN-B, he let go of R1's arm. LPN-B asked LPN-A to assist her in getting R1 to the bathroom and then to obtain a suppository and a NA to help. LPN-B stated after LPN-A left, R1 stated, Please don't let him hurt me again. LPN-B stated R1 had a reddened area on the shoulder where LPN-A's hand had been. LPN-B took pictures of the reddened area. The redness was still present two hours after the incident had been observed, but was gone after three hours post incident. The report indicated LPN-A stated R1 was standing next to the recliner, therefore he had stood behind R1 and grabbed his pants to slide him back into the chair. The report further indicated that throughout LPN-A's version of the incident, he had changed the story as to whether he had been standing in front of or behind R1's wheelchair. LPN-A stated R1 was swinging/grabbing at him, R1 was combative and trying to punch him. The report indicated R1 had not been known to be combative or aggressive with other staff. The facility indicated LPN-A was suspended pending investigation effective 1/6/18. The report indicated LPN-A was no longer employed at the facility and a report had been made to the Minnesota Board of Nursing. Although the facility was made aware of the incident at the time of occurrence on 1/5/19, at 7:15 p.m. the incident had not been reported to the State agency until 1/6/19, at 3:51 p.m. (20+ hours after the allegation had been made). The facility's Maltreatment Prohibition Policy, dated 2/19/18, indicated maltreatment was a general term that meant inappropriate treatment or exploitation of a vulnerable adult (VA) and included abuse, neglect, and financial exploitation. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish and indicated the individual must have acted deliberately. The section of the policy titled, Staff to VA Abuse indicated when a nursing home accepted a resident for admission, the facility assumed the responsibility of ensuring the safety and well-being of the resident and was responsible to ensure all staff were trained and knowledgeable in how to react and respond appropriately to resident behavior. The policy further indicated when an alleged violation occurred, it was to be reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse that was observed or reported. The facility's Protecting Victims of Maltreatment policy and procedure amended on 2/19/18, indicated once an incident was reported, the facility would take immediate action to protect the VA from further abuse. Employees accused of participating in the alleged abuse would be suspended pending the outcome of the investigation. The facility's SNF (skilled nursing facility) Maltreatment Investigation & Reporting policy and procedure dated 1/30/16, indicated all accident/incident reports and allegations would be initially assessed by the person in charge at the time the incident took place. An initial investigation would be immediately conducted to determine what happened and whether the incident required a report to the State agency. The administrator or designee would be notified of all reportable incidents immediately. R1's undated Face Sheet indicated R1's [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 had severe cognitive impairment and required extensive assist of two for toileting, bed mobility, dressing, and transferring. The MDS also indicated R1 utilized a wheelchair for locomotion, and had not exhibited any physical or verbal behavioral symptoms directed towards others. On 1/11/19, at 8:42 a.m. nursing assistant (NA)-B and NA-C were observed providing R1 with morning cares. R1 assisted with cares when cued by NA-B. No behaviors or resistance by R1 was noted. -At 9:23 a.m. R1 was observed positioned at a dining room table interdependently eating his breakfast meal. No behaviors noted. -AT 10:20 a.m. R1 was observed independently propelling himself in the hallway. R1 had a smile on his face with no behaviors nor attempts to self transfer noted. On 1/11/19, at 10:20 a.m. LPN-B stated she had observed LPN-A on 1/5/19, around 7:15 p.m. with his hand on R1's left shoulder and had his left arm twisted behind his back, which he had dropped when he had seen her. LPN-B stated she had asked LPN-A to obtain a suppository for R1 and they both assisted R1 to the bathroom at which time, she had asked LPN-A to get a nursing assistant (NA) to help her with R1 while in the bathroom. LPN-B stated she had taken pictures of R1's bright red neck/shoulder area and had also called the registered nurse (RN) on call and reported the incident to her. LPN-B stated later in the shift, the director of nursing (DON) had called her and she explained the observation to her. LPN-B indicated the DON had stated she would speak with LPN-A and go from there. LPN-B stated the DON had also spoken with NA-A who had been in the bathroom and observed R1's red neck and shoulder area. LPN-B stated she had not confronted LPN-A about the incident as she had not known what his reaction would be, but she had reported the incident. LPN-B was unsure of what steps the facility would have taken after her report was made and was unsure if she should have put a note in R1's clinical record, or what else she should have done about what she had observed. LPN-B stated she had taken the picture of R1's red areas as she wanted to show the abuse as she had never witnessed someone physically rough with a resident prior to this. However, LPN-B stated she had deleted the pictures after having been directed to do so by the RN. LPN-B also stated the DON and administrator had not come to the facility following her report of the incident. LPN-B further stated she had left the facility at 10:30 p.m. which was the end of her shift, but LPN-A remained at the facility and continued to work the overnight shift until 6:00 a.m. the next day. Additionally, LPN-B indicated LPN-A had a known history of rough behavior with residents. On 1/11/19, at 12:26 p.m. RN-A confirmed she had received the report from LPN-B alleging LPN-A had been physically rough with R1 at which time, she had called and reported the incident to the DON. RN-A believed the DON had called both LPN-A and LPN-B. RN-A stated on 1/6/19, she had been working the morning shift and LPN-B came into the facility and explained the incident again and had also sent her the pictures of R1's neck/shoulder redness at which time she directed LPN-B to delete them. RN-A stated she reassessed R1 and noted no areas of redness or injuries and R1 had no recollection of the incident. RN-A stated LPN-C had been working the day shift on 1/6/19, and after hearing of the incident, had called the DON and informed her she needed to come into the facility and further investigate the incident. The DON arrived to the facility around 1:00 p.m. and with RN-A, interviews with LPN-A, LPN-B and NA-A had been conducted. RN-A stated after completing the interviews with the DON, she had informed the DON the incident met the definition of abuse and indicated the DON needed to take action. RN-A stated she had indicated LPN-A should be suspended. RN-A stated she had reported the incident to the DON, therefore at that time, she felt the DON had taken over with the investigation. Additionally, RN-A stated she had received several comments from staff related to LPN-A's behavior towards residents and indicated staff felt as though the reports had been made, the DON had swept them under the rug. RN-A stated when allegations were reported to the DON, she would respond by asking staff if they were going to pick up LPN-A's shifts if he was not able to work. On 1/11/19, at 2:10 p.m. LPN-D stated she was aware of three previous reports of LPN-A having been involved with mistreatment of [REDACTED]. LPN-D stated she had not approached LPN-A regarding the incidents. On 1/11/19, at 2:31 p.m. the DON confirmed she had received a call from the on-call RN the evening of 1/5/19, regarding an incident of abuse/rough treatment towards R1. The DON stated at the time of the report, she had called and interviewed the LPNs and the NA involved and confirmed she had not come into the facility to complete an investigation. The DON also confirmed after having received the report, LPN-A continued to work the remainder of the evening shift as well as the overnight shift. The DON stated the following day she had went to the facility to meet with the RN at which time interviews with the LPNs and NA-A were completed. The DON stated LPN-A went home following the interview as he had not been working at the time of the interview. The DON stated later that day she had called LPN-A to inform him he was suspended from work while an investigation was being conducted. At this time, LPN-A's employee file was reviewed with the DON who confirmed the following performance notes: -11/15/18: a written complaint indicated LPN-A failed to complete general observation documentation. The DON provided written comments on the complaint indicating, this is not acceptable. -10/23/18: -Written Employee Concern form indicated staff reported a female resident was found 1/2 in her bed and 1/2 on the floor, however no incident/fall report was completed. -Documentation related to bowel movements had not been completed. -A family member reported a resident had scratched her leg causing bleeding and no incident report was completed. -A family member also reported staff out front smoking and call light was not answered. -Staff report that you (LPN-A) disappeared for 45 minutes and staff did not know whereabouts. The DON confirmed she had spoken with LPN-A regarding the aforementioned issues and LPN-A had verbalized an understanding of the concerns. The DON and LPN-A also had a long conversation about avoiding conflict with staff and avoiding drama. -4/17/18: Corrective action form indicated the DON, administrator, and LPN-A discussed: -Policy violation: residents are to be treated with respect. -Proper notification of family and providers for fall events. -Events resulting in corrective action. -Multiple staff members reported LPN-A had been yelling at residents. Staff reported LPN-A appeared angry if the residents were awake at night and LPN-A did not have patience with them. Some residents had complained LPN-A was rough with them and often yelled. Staff and resident C reported LPN-A squeezed resident C's hands and yelled at him and resident C referred to LPN-A as that man that yells at me. On 4/17/18, Resident- C had an early morning fall and family had not been notified. Resident C was found to have gauze on the shin and no incident report had been completed. -A fall report stated a resident had fallen forward. Proper procedure had not been followed following a fall. LPN-A's corrective action plan include interventions to: continue to review the schedule to ensure hours do not exceed 80 hours per pay period to avoid staff burnout, bi-weekly feedback related to any concerns brought forward by staff, residents or family member, LPN-A would be off the schedule for one day without pay. -3/23/18: Word document related to progress. Staff reported LPN-A did not always answer call lights, had been found sleeping in the recliner, however LPN-A stated he never slept in the recliner, and had called the provider following a resident fall even though the DON ended up notifying the provider of falls that had occurred on his shift. LPN-A was reminded of the importance of good communication. -2/21/18: Word document regarding a resident complaint that LPN-A had pushed/pulled his wheelchair early this a.m. causing his right wrist to hurt. LPN-A stated the resident removed his hands from the wheelchair. The resident had been interviewed and stated his call light had been on for 15 minutes at 4:30 a.m. and the resident did not feel LPN-A was very friendly in his response to his call light. The DON audited the residents call light and noted it had been on for 29 minutes without staff response, however, LPN-A stated other staff had been down the other hallway and they could have answered the resident's call light as he was busy with something else. The DON reminded LPN-A of a conversation the two of them had had in (MONTH) related to answering call lights timely. LPN-A stated he wanted an apology from the resident because the resident had sworn at him. The DON reminded LPN-A that the facility was the residents home and the staff work there and he should not expect an apology from the resident as the resident wanted his call light answered in a timely manner and we (staff) had not delivered the service timely. -12/26/17: Corrective Action form: complaint of LPN-A yelling at two residents at the nurses station to knock it off in a tone that was heard from outside of the front door. LPN-A admitted has loud voice and he would need to work on this. The DON/administrator and human resources met with LPN-A to discuss the report of two fell ow staff members who observed LPN-A physically and forcibly pick up a resident off her feet from the behind and removed the resident from behind the nursing station. LPN-A had not attempted to redirect the resident prior to this action and staff had stated it was upsetting to them and felt it needed to be reported. LPN-A had not denied removing the resident from behind the nursing station and stated the resident did not belong there, however, denied lifting the resident off her feet to move her. The form also indicated in the previous six months, two family members had witnessed/reported LPN-A entering resident rooms without greeting or conversing with the resident or family rather would administer medication and exit the room. The form also indicated there were increasing reports of inappropriate interaction between LPN-A and the residents. Discussion had been held regarding LPN-A working long hours which had been impacting his ability to interact with the residents. -12/14/17: staff concerns regarding LPN-A's treatment of [REDACTED]. The DON questioned LPN-A who stated he had raised his voice at times which was directed to those male residents, however, LPN-A stated he had not intended for it to be in a threatening way. LPN-A stated he yelled at them because they were still awake and had been up all night. LPN-A stated he had not flicked the resident's ear with the intent for it to be painful rather, to get his attention. The DON informed LPN-A it was inappropriate to yell and flick anyone's ear. LPN-A stated he had not meant to harm anyone as he treated the residents' like they were his family. The DON informed LPN-A he should treat the residents better than he treated his family. Followng review of the aforementioned reports, the DON verified the complaints against LPN-A's behavior and treatment towards residents should have been addressed and the allegations should have been reported. The DON stated hindsight has been a very awakening experience. The DON stated on 1/5/19, following the receipt of the alleged abuse, she had called and interviewed LPN-A, LPN-B and NA-A but no further interventions/actions had been implemented at that time as LPN-B could be very reactive to situations and felt it was a he said-she said situation. However, when asked, the DON confirmed when she had conducted the initial phone interview with NA-A, NA-A verified R1's reddened shoulder/neck areas. The DON stated on 1/6/19, she again interviewed the staff and after discussing the incident with RN-A, she realized the situation was abuse, therefore she had notified LPN-A of his suspension. The DON stated when she received the initial telephone report on 1/5/19, she should have immediately came to the facility and handled the allegation and again confirmed LPN-A had been reported and reprimanded for incidents of rough handling and rough treatment of [REDACTED]. The DON confirmed the allegation had not been reported within the two hour timeframe requirement nor were the residents protected from abuse. The DON also stated she should have immediately sent LPN-A home, pending an investigation, and not allowed him to continue to work in order to ensure the residents safety. On 1/12/19, at 8:40 a.m. the administrator stated upon review of the allegation, she immediately knew it was abuse and had taken steps she felt necessary to protect the residents. The administrator also verified the allegation should have been immediately addressed per facility protocol and had already personally discussed the abuse protocol requirements with the DON. The administrator stated she had reviewed LPN-A's employee record and was blindsided by the prior allegations with no action or reporting completed. The administrator confirmed the facility's abuse policy and procedures had not been implemented and stated the facility had identified this breakdown in their abuse prohibition process. The IJ that began on 1/5/19, was removed on 1/12/19, when the facility provided education to all staff including key personnel who had not followed the established facility abuse protocol related to maltreatment prohibition, reporting guidelines and protection of the victims/residents of maltreatment. In addition to the aforementioned policies, education was also provided on policies related to the response to substantiated maltreatment, reporting suspicion of a crime and delegation authority. All staff not present during the education, would be provided the education prior to their next working day and before any direct resident contact would be made. Training for the administrator was provided by the regional director of Saint(NAME)Health Services (SFHS), who was the administrator's direct supervisor and training for the DON, ADON, and an RN charge nurse was provided by the SFHS RN consultant. The training components which were verified as completed included: -Maltreatment Prohibition -Skilled Nursing Facility Maltreatment Guidelines -Protecting Victims of Maltreatment -Response to Substantiated Maltreatment -Reporting Reasonable Suspicion of a Crime -Delegation of Administrative Authority The facility will audit compliance by conducting one-on-one interviews with both residents and staff to allow for the opportunity to voice any concerns they may have. The SFHS regional director will oversee implementation of the removal plan including education provided and the auditing and review of all materials.

Based on observation, interview and document review, the facility failed to assess the skin condition and implement interventions in order to prevent the worsening of moisture related skin damage for 1 of 1 resident (R43) who had a history of [REDACTED]. This failure resulted in actual harm for R43 due to the observed worsening of the skin condition. In addition, the facility failed to identify, assess and monitor a right arm wound for 1 of 1 resident (R7) observed to have a wound without staff identifying its presence. In addition, the facility failed to ensure diabetic residents received the highest practicable care for 3 of 3 diabetic residents (R6, R7, R25) who had abnormal blood sugar results without evidence of action taken by the staff related to the treatment or physician notification of the abnormal readings. Lastly, the facility failed to ensure proper wheelchair positioning for 1 of 3 residents (R18) observed to utilize a rock and go wheelchair. Findings include: R43's facility Face Sheet dated 8/1/18, indicated R43's [DIAGNOSES REDACTED]. R43's quarterly MDS dated [DATE], indicated R43 had moderate cognitive impairment and required extensive assistance from two plus staff for transfers and bed mobility, and was dependent on two plus staff for toileting, and had an indwelling urinary catheter. The MDS also indicated R43 had [DIAGNOSES REDACTED]. The MDS further indicated R43 was at risk for pressure ulcers, had moisture associated skin damage (MASD) and required a pressure-reducing cushion in the chair and bed, a turn/repositioning program, application of non-surgical dressings, and application of ointments/medications. However, R43's clinical record lacked evidence of an assessment of the MASD for the MDS dated [DATE]. R43's most recent Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE], identified R43 was at moderate risk. The tool indicated R43 had moist skin. R43's skin care plan dated 8/15/16, indicated R43 was at risk for skin breakdown related to history of stroke and left sided weakness. History of abrasions to buttocks and scrotum. The care plan directed the following: -A&D ointment to scrotum and buttocks every shift with incontinent care and bathing per standing orders. -alternating air mattress. -Assess skin daily with morning and evening cares and weekly on bath days. Apply [MEDICATION NAME] to dry areas. -Avoid shearing resident's skin during positioning, transferring, and turning. A felty can be used for positioning. -Cotton snap pants during day and nothing at night. -Position scrotum with Interdry under the scrotum at BEDTIME. -Treatments per MD orders. - staff to turn and reposition every 3-4 hours (The bed mobility care plan dated 4/24/17, directed staff to reposition every 3 hours). -Use cleansing cream and Tena dry wipe for peri care. No wipes. -Use pressure reducing gel cushion on wheelchair. R43's nursing assistant care guide dated 7/27/18, conflicted with the care plan and indicated R43 required repositioning every 2-3 hours. R43's last Tissue Tolerance Observation tool (tool used to determine repositioning needs based on ability of skin to withstand pressure) was completed on 1/16/18, was incomplete as it did not identify a repositioning schedule when lying. The tool indicated R43 required every two hour repositioning when sitting. The record lacked evidence of an assessment/evaluation of tissue perfusion recovery over bony prominences over time that would reflect the determination R43 required every 3-4 hour repositioning to prevent and or reduce the risk of pressure ulcers/skin impairment. R43's physician orders for skin treatment included: -Barrier cream two times a day in morning and evening: Tena protective Cream 10% zinc oxide (start date 6/19/18) -Interdry two times per day at 8:00 a.m. and 8:00 p.m. place Interdry under scrotum and bring out along the thighs keep on at all times. (start date 4/16/18- end date 7/30/18) -Interdry one time per day during the night. Place at bedtime under scrotum and bring out along the thighs. Keep on all times. (start date 7/30/18) -Allevyn dressing to buttocks change every three days and as needed. (verbal order on 6/4/18) -Duoderm trial to perineum for two weeks. (telephone order 6/11/18) -Antifungal cream per standing orders topically for fungal rash for five days. (telephone order (6/18/18) -[MEDICATION NAME] (antibiotic) 875 milligrams (mg) twice per day for 10 days. (telephone order 6/29/18) -Cipro (antibiotic) 500 mg twice a day by mouth for 7 days. (telephone order 6/29/18) -Bactrim DS (antibiotic) 1 tab twice daily for 10 days [MEDICAL CONDITION]. (start date 7/12/18) R43's Skin Condition/Wound Progression Notes revealed the following: -4/16/18, Superficial breakdown related MASD to perineal and gluteal areas. Scrotal areas healed this assessment. No exudate at this time. Irregular border. The tissue blanches, is of equal temperature and slightly darker in color to surrounding tissue, overall area appears dry, scant bloody exudate noted to two areas, no visible wound bed. There continues to be no evidence of internal tissue damage or infection at this assessment. MASD appears to be healing on coccyx region. Continue with 50% A&D ointment and [MEDICATION NAME] lotion mixture. Interdry added to scrotal folds at all times. Toileting schedule per tissue tolerance remain effective continue with current treatment. R43's record did not reflect a physician order for [REDACTED]. -4/29/18, indicated superficial breakdown related to MASD to perineal and gluteal areas. No exudate and two scab areas that measured 1.0 centimeter(cm) x 1.0 cm in size with irregular border. MASD appears to be healing on coccyx region. No visible wound bed, trial of Duoderm dressing. Continue with the A&D ointment mixture. -5/7/18, superficial breakdown related to MASD to perineal and gluteal folds. No exudate, scabbed areas not visible. A 3.0 cm x 1.0 cm open area is noted to posterior scrotum. No exudate at this time, new Interdry applied. MASD to perineal and gluteal remains intact with no visible exudate. Irregular border. Color is darker red and purple to surrounding tissue. Continues to be no evidence of internal damage or infection. Half of coccyx covered with border Duoderm. A&D ointment mixture continues and Interdry. -5/14/18, MASD to perineal and gluteal remains intact with no visible openings. Small scab is noted to posterior scrotum. Indicated overall all appearance remains dry and color is darker purple in color to surrounding tissue. MASD appears to be healing. Continue with A&D ointment and Interdry. -5/21/18, assessment did not indicate any changes according to the documentation, other than large area of flaking skin to right and left gluteal regions and color remained darker red and purple. -5/29/18, assessment indicated no visible openings and significant reduction in flaking skin. Skin remained discolored and darker red and purple color to surrounding tissue. No change in treatments -6/5/18, assessment indicated a large open area 7.0 cm x 4 cm x 2 mm deep irregular open area on buttocks. Slight bleeding and blanches. Area was cleansed and Allevyn dressing was applied. Intervention changed to resident would be placed in bed for at least two hours between meals an repositioned on his side, with no Chux (absorbent mattress protector). -6/11/18, assessment indicated MASD to perineum and scrotal areas, numerous partial thickness openings, scant serious drainage. Dressing is 75% contained with fecal material. Wound bed is pink with ill defined borders. Peri-wound is raised thickened, and darker in color, and blanches. No signs and symptoms of infection. Indicated the treatment of [REDACTED]. Trial Duoderm's to perineum in addition to the barrier ointment. Intervention also included Interdry and turning and repositioning schedule. The assessment lacked assessment of the open wound that was identified on 6/5/18. -6/18/18, assessment indicated changes to the MASD to scrotal and perineum areas. No current openings, skin in scrotal area and inner thighs noted to have an odor, bright red rash with defined border. Indicated Duoderm was contraindicated due to infection of skin. MD consulted with new order for antifungal cream obtained. Other interventions remained the same except for as noted. R43's skin progress note dated 6/25/18, indicated MASD was present on the rectal area. MASD to perineum and scrotal areas, no current openings, yellow/green exudate (drainage) noted to incontinent products. Skin to scrotal area and inner thighs bilaterally noted to have an odor, bright red rash, with defined border present. Contacted provider regarding color of exudate. R43's communication to the physician dated 6/25/18, included antifungal cream to area ineffective. Drainage noted coming from urethral meatus, bright red perineum and scrotum, and afebrile. The note also indicated drainage was bright green on the incontinent garment, concerned infection of pseudomonas type. Communication recommended a culture. R43's physician telephone order dated 6/25/18, included culture and sensitivities of meatus and perineum. R43's laboratory culture and sensitivity results dated 6/29/18, indicated infection of pseudomonas aeruginosa therefore R43's physician telephone order dated 6/29/18, included [MEDICATION NAME] 875 milligrams (mg) twice a day for 10 days and [MEDICATION NAME] 500 mg twice a day for seven days. R43's 6/30/18, PN indicated peri area had Interdry in place and the skin appears less red today. Dimethicone applied after morning cares. R43's laboratory culture and sensitivity results dated 7/1/18, revealed infection of [MEDICAL CONDITION]- resistant Staphylococcus aureus (MRSA). R43's physician telephone order dated 7/12/18, included Bactrim DS one tab twice a day for 10 days for [DIAGNOSES REDACTED]. R43's progress notes (PN) and skin condition record were reviewed since the start of the antibiotic prescribed on 6/29/18. The record lacked evidence of ongoing side effect monitoring and the effectiveness of the antibiotics. In addition, the progress note lacked implementation of the contact precautions as a result of the positive culture [MEDICAL CONDITION]. -7/1/18, PN indicated [MEDICATION NAME] for positive skin cultures. Had two large loose stools/semi formed bowel movements today. Will continue to monitor. -7/2/18, Skin Progression note indicated presence of MASD to perineum and scrotal areas. Skin to scrotal area and inner thighs bilaterally noted to have odor, bright red rash with defined border present. Skin to coccyx including bilateral ischial tuberosity is dry and flaking, raised, thick, blanches, no current openings although scab is noted to right gluteal region, no exudate noted due to incontinent of loose bowel. Healing interventions included; antibiotics after culture obtained. -7/4/18, PN indicated had smearing of soft stool, no unusual odor noted. Buttocks and scrotal skin is improving and no drainage noted. Will continue to monitor.[MEDICATION NAME] continue. Had two bowel movements yesterday and one the day before. -7/8/18, Skin Progression note indicated MASD to rectal area, perineum, and scrotal areas. Skin to scrotal area and inner thighs bilaterally noted to be odorless, faded red rash with defined border present. Skin to coccyx including bilateral ischial tuberosity is dry but not flaking at this assessment, remains raised and thickened, blanches, no current scabs noted. Rash and MASD appear to be healing. Resident continues on antibiotic treatment for [REDACTED]. -7/12/18, PN indicated resident seen on physician rounds. Medication: Bactrim 1 tablet twice a day [MEDICAL CONDITION]. R43's physician visit note dated 7/12/18, indicated R43 was seen related to culture of penile drainage returned [MEDICAL CONDITION]. The note indicated plan for Bactrim DS for 10 days with a repeat culture in three weeks. The visit note lacked evidence of a physical examination or assessment of the impaired skin integrity by the physician. The Physical exam section did not include skin examination. -7/16/18, Skin Progression note indicated MASD to rectal, perineum and scrotal area. Skin to scrotal area and inner thighs bilaterally noted to be odorless, faded red rash with defined borders present. Occasional spots of bright red noted. Skin to coccyx including bilateral ischial tuberosity is dry but not flaking at this assessment, remains raised and thickened, blanches, no current openings or scabs noted. Healing interventions included antibiotics. Notified today that 3rd bacteria was isolated [MEDICAL CONDITION], antibiotic already initiated, contact precautions currently in place. Resident continues on antibiotic treatment for [REDACTED]. -7/23/18, PN indicated has completed Bactrim. The buttocks is dry, slightly reddened and no drainage. The scrotum has no open areas and there is redness on the inner thighs with no drainage. -7/24/18, PN indicated bottom and groin area continue to be red and raw -7/25/18, Skin Progression note included: MASD to rectal, perineum, and scrotal areas. Skin to scrotal area and inner thighs bilaterally noted to be odorless, bright red rash with defined border present. Skin to coccyx including bilateral ischial tuberosity is dry with minimal flaking at this assessment, remains raised and thickened, blanches, no current openings or scabs noted. Interventions included: antibiotics completed. Continue current plan, continue on contact isolation. Follow up culture obtained per MD to verify [MEDICAL CONDITION] has resolved. R43's telephone physician order dated 7/25/18, included: Re-culture meatus and perineum for [DIAGNOSES REDACTED]. R43's culture results for swab of perineum indicated ongoing moderate amount of the bacteria Proteus Mirabilis and susceptibility was not performed. The lab results also indicated negative [MEDICAL CONDITION]. However, R43's record revealed the positive culture for Proteus Mirabilis was not followed up on until 7/30/18, when a communication to the physician questioned if treatment was wanted and if isolation precautions were to be continued. The physician returned the communication with an order to discontinue isolation precautions. The communication did not reflect communication of the ongoing impaired skin integrity to the R43's bottom. -7/30/18, Skin Progression note indicated MASD to rectal, perineum, and scrotal areas is healed. Skin to scrotal ara and inner thighs bilaterally noted to remain darker pink then surrounding skin, odorless, defined border remains present. Skin to coccyx including bilateral ischial tuberosity is dry and smooth without flaking at this assessment, tissue itself remains raised and thickened in appearance of scar tissue, blanches, no current openings or scabs noted. Antibiotics completed. Culture revealed normal flora, no current infection,[MEDICAL CONDITION] resolved, isolation precautions discontinued. Highly pigmented skin as noted above appears to be scar tissue and has remained stable (not spreading). -7/31/18, Skin Progression note indicated site clarification 7/31/18, MASD to perineum and scrotal areas was inadvertently healed out yesterday as there was no additional maceration remaining at that assessment. On today's assessment, skin to coccyx including bilateral ischial tuberosity is dry with mild flaking of barrier ointment, However, skin to scrotal and inguinal area is wet preventing barrier ointment from sticking in multiple spots. Skin to coccyx area, and inner thighs remains darker, raised, and thickened in appearance of scar tissue, blanches throughout, and no current openings visualized. One superficial dry scab with irregular border, triangular shape, measuring 2.2 centimeters (cm) by 1.5 cm to left buttock. This area was identified yesterday but mistaken for fecal smear. Culture results from 7/28/18, identify proteus mirabilis consistent with normal flora, [MEDICAL CONDITION] and pseudomonas skin infection has resolved and isolation precautions were discontinued. However, R43's record lacked evidence the physician had evaluated the impaired skin integrity even after the course of antibiotics. On 7/30/18, at 4:45 p.m. continuous observations began: -At 4:45 p.m. p.m. R43 was observed in the dining room, seated in the wheelchair for the evening meal. When R43 completed his meal, an unidentified staff member wheeled R43 into the adjacent living room area and remained seated in the wheelchair without staff assistance until 7:53 p.m. -At 7:53 p.m. R43 wheeled himself out of the living room area back into the dining room area. R43 stated he was tired. -At 7:55 p.m. nursing assistant (NA)-M referenced the nursing assistant care guide and stated R43 was supposed to be repositioned every 2-3 hours. NA-M indicated she had thought R43 had been out of bed since around 4:30. NA-M indicated she had not written down on the care guide what time he gotten out of bed and confirmed R43 had not been repositioned since getting out of bed. -At 8:56 p.m. NA-M and NA-N stated they were working without a bath aide so did not have the time to reposition the residents' as they were supposed to. The NAs transferred R43 from the wheelchair to the toilet using the ceiling mechanical lift. R43's bottom was not totally visible to surveyor at this time, however, appeared reddened with white flaking ointment on the buttocks. No Interdry was present in groin areas. R43 had remained seated without pressure relief assistance for four hours and 11 minutes. -At 9:18 p.m. licensed practical nurse (LPN)-B stated R43's bottom has had skin breakdown for a long time and had previously been on antibiotics. LPN-B stated, I'm sure there is skin issues, but it was better. On 7/31/18, at 2:14 p.m. R43 was observed lying in bed. NA-Q removed soft cotton underwear which exposed the groin and bottom. R43's bilateral groin areas had remnants of white ointment, and the inner upper thighs, groin, scrotal areas were bright red and very excoriated. NA-Q stated the area was very red and asked R43 if it hurt. R43 replied by stating it hurt and burned. No Interdry was present in the groin areas. R43 rolled to his left side exposing his buttocks. Both buttocks were reddened in color and had dry flaking barrier ointment on the outer aspects. The Left buttock revealed an area that was approximated 2.0 cm by 1.0 cm irregularly shaped with a very thin reddish/yellowish/brownish scab present. On 8/1/18, at 8:21 a.m. R43 was observed lying in bed. Registered nurse (RN)-B/acting wound nurse viewed the wound and stated R43 has had long history of moisture associated skin damage, he sweats a lot. RN-B confirmed R43 developed infections in the MASD areas and was on antibiotics. RN-B stated the wound on the left buttock currently was not considered unstageable and was assessed as MASD because that area had historically formed thin layers of scabs that sheared off and would then reform. RN-B further indicated the shape of the wound was also not consistent with a pressure ulcer because it was irregular. RN-B stated the reddened areas of the buttock were related to hyperpigmentation of the skin from having the long history of moisture problems. RN-B stated R43 should be repositioned according to the care plan. 8/01/18, at 2:17 p.m. RN-B verified the lack of extent and/or area of the skin damage and lacked documentation of root cause analysis of impaired healing with the interventions that were in place. RN-B stated she didn't think the physician had ever physically examined the impaired skin integrity. RN-B indicated the facility's standing orders included the different types of ointment, however, the current physician's orders did not reflect the A&D mixture, and stated the physician's orders should have been followed and/or updated. On 8/2/18, at 2:05 p.m. RN-A verified there was no assessment for skin in the General Nurse's Observation for the MDS completed on 7/17/18. RN-A indicated a skin assessment should have been completed after worsening of the MASD was identified. On 8/3/18, at 11:30 a.m. The director of nursing (DON) stated she expected staff to follow the care plan for repositioning. DON indicated Braden Scales were supposed to be done quarter and with change of condition and Tissue Tolerance Observations were supposed to be done upon admission, upon hospital returns, significant changes, and changes in surface such as a new wheelchair cushion. R7's facility Face Sheet dated 8/2/18, indicated R7's [DIAGNOSES REDACTED]. R7's quarterly MDS dated [DATE], indicated R7 had moderate cognitive impairment, could usually make self understand, and could usually understand others. The MDS also indicated R7 had a [DIAGNOSES REDACTED]. R7's physician orders dated 8/2/18, indicated R7 picked at skin and ordered wound care which consisted of: picked sites once a day during evening. Special instructions: apply skin prep each evening. Cover with [MEDICATION NAME], change weekly and as needed. R7's endocrine care plan dated 8/17/16, directed staff to report any slow or unhealing wounds (skin tears, ulcers, ect.) The skin care plan dated 8/17/16, indicated R7 was at risk for skin breakdown and potential for infections due to excoriations secondary to dermatillomania (Excoriation disorder also referred to as chronic skin-picking is a mental illness related to obsessive-compulsive disorder) and directed the following: -apply dressings to open areas as ordered as needed -observe for any changes in skin and report to nursing -wound care as ordered. On 7/30/18, at 6:31 p.m. R7's right upper arm, directly under the tattoo, revealed a quarter sized raised lesion that was open with scant amount of reddish, light yellow drainage partially covered with a thin scab. R7 stated it had been there for a long time and did not itch or hurt. R7 stated he was not aware if staff knew about the area on his arm or not. On 7/31/18, at 2:25 p.m. R7 was observed walking down the hallway. The lesion on the right arm remained open and uncovered, no drainage was present. On 8/1/18, at 7:12 a.m. R7 was observed seated on the side of his bed. The lesion on his right upper arm remained uncovered with a thin red scab with small open areas that were not draining. R7 denied the area itching and stated it was not from picking at his skin. R7 again stated the area had been there for a long time but could not recall when the area first developed. R7's skin records, PNs, and treatment administration records were reviewed since 7/1/18, which lacked identification of the lesion on the right upper arm. R7's PNs reflected the following: -PN dated 7/7/18, indicated no skin concerns. -PN dated 7/15/18, indicated R7 was picking at his right upper arm but stopped when asked. The progress note did not identify injuries obtained as a result. On 8/1/18, at 1:26 p.m. without looking at the right arm, RN-B stated the lesion was scar tissue from a picked site. The ADON was then asked to look at the area on R7's arm. RN-B viewed the lesion and stated it was not scar tissue or a picked at site. RN-B stated an unawareness of the lesion and could not recall ever seeing the lesion before. RN-B asked R7 how long the area had been present to which R7 responded it had been there for a long time and was not able to articulate the date or time frame of onset. RN-B palpated the lesion and indicated it was firm to touch. RN-B measured the area and asked R7 if he would like it evaluated by the physician in which R7 agreed to have the area looked at and further evaluated. RN-B confirmed the clincial record lacked identification of the area and stated it was expected that the nurses performed a weekly skin inspection and document any changes to skin integrity. -At 1:28 p.m. the DON confirmed R7's clinical record did not identify the [MEDICAL CONDITION] and the last documentation of a skin evaluation was on 7/7/18. The DON stated the nursing assistants were to be looking at the resident's skin every evening and were to report if/when they observed any changes to the nurses. if/when they observed any changes in the skin and were supposed to be looking at the skin every evening. Facility policy Skin Ulcer Protocol dated 11/1/15, included steps for identifying residents at risk for skin breakdown. Monitoring interventions to start if an open area is noted on any shift and to implement the following general measures: -all open skin ulcers are to be reported to the facility wound nurse. -repeat Tissue Tolerance Test, G. Repeat Braden/Norton Scale (address all identified risk areas-care plan), -review all current interventions to ensure remain appropriate including pressure relieving devices. -wound nurse to complete a root cause analysis of any new skin issue. Rule out pressure, Preventive interventions that were in place. Wound nurse to obtain a physician order for [REDACTED]. -moisture and its impact--exposure to urine and feces contain substances which may make skin more susceptible to skin breakdown. Perineal [MEDICAL CONDITION] appears as a more diffuse area of [DIAGNOSES REDACTED] or skin discoloration where urine and stool have come into contact with the skin. Minimize exposure to moisture and keep skin clean from urine and fecal contamination. Apply a barrier cream, as individually assessed to be appropriate, following cleansing. -documentation: may request physician documentation related to the ulcer or potential ulcer development. Difficult/complex cases may also be reviewed by the medical director on a monthly basis. R6's facility Face Sheet dated 8/2/18, indicated R6's [DIAGNOSES REDACTED]. R6's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R6 had severe cognitive impairment and staff were to anticipate her needs. The MDS also identified R6 had a [DIAGNOSES REDACTED]. R6's standing orders for Diabetic monitoring/treatment dated 2/22/18, indicated the following: 1. Any new admission with a [DIAGNOSES REDACTED]. 2. Blood glucose checks as needed per nurse discretion. 3. Notify physican if two blood sugar results are lower than 70 mg/dl or greater than 400 mg/dl in a 24 hour period and/or when there was a change in condition. (unless otherwise ordered when on a sliding scale.) 4. If hypoglycemic (blood sugar less than 70), if able to swallow, may administer eight ounces of fruit juice or milk or six ounces of a supplement. Recheck blood sugar in 15 minutes. If no improvement, give oral gluose gel, and recheck blood gluose in 15 minutes. If still no improvement notify physician or nurse practitioner. 5. If unable to swallow or with altered consciousness, administer [MEDICATION NAME] 1 milligram (mg) intramuscularly (IM) and recheck blood sugar after 15 minutes. If still no improvement, administer an additional dose of 1 mg [MEDICATION NAME] IM, call for emergency assistance and notify the physican or nurse practioner. R6's care plan dated 8/4/16, indicated R6 was at risk for hyperglycemic or hypoglycemic episodes related to her [DIAGNOSES REDACTED]. Interventions directed staff to not administer insulin more than 15 minutes before meals, obtain fasting blood sugars as ordered, insulin administration as ordered, lab work and report all abnormalities as ordered, monitor weight, and to provide R6 with a menu listing of low calorie/low carbohydrate selections as ordered. An order to monitor for signs and symptoms of hypo-[MEDICAL CONDITION] and to report to the medical doctor was initiated on 3/20/18. R6's PN dated 3/12/18, at 4:32 p.m. indicated R6 had a blood sugar (BS) reading of 60 mg/dl. however, did not identify any further action related to the low BS. -The PN at 6:56 p.m. indicated R6 fell from her wheelchair to her knees. However, the PN had not indicated if a physican was called regarding the fall or the low blood sugar. Approximately 1.5 hours after the fall. -The PN at 8:25 p.m. indicated R6's BS level was 59 mg/dl. and did not identify any action taken related to the low BS and no monitoring of R6's blood sugars was identified. Although R6's PNs revealed two low blood sugars within a 24 hour period, including a fall, there was no evidence of physician notification as directed by the standing order protocol. Additional PNs revealed the following: -3/13/18 at 4:16 p.m. BS level was 47 gm/dl, however, no further action was identified. -3/17/18, at 12:13 p.m. BS level was 56 mg/dl, however, no further action was identified. -3/18/18, at 5:54 p.m. BS level was 42 mg/dl, however, no further action was idenfied. -3/20/18, at 4:23 p.m. BS level was 40 mg/dl, R6 was given eight ounces of orange juice. -3/26/18, at 11:37 p.m. BS level was 46 mg/dl, R6's insulin was held until R6 ate a meal. -3/27/18, at 4:39 p.m. BS was 36 mg/dl, R6 was not responding, was sweating heavily, skin was pale, and flaccid muscle tone. Glucose syrup 15 grams (gms) was administered by licensed practical nurse (LPN). BS 35 mg/dl following the glucose syrup administration. An ambulance was called and R6 was transferred to the hospital for a hypoglycemic episode. R6's Rainy Lake Medical Center Emergency Department form dated 3/27/18, indicated R6 was treated for [REDACTED]. R6's PN dated 3/27/18, at 10:56 p.m. indicated R6 returned to the facility. Upon R6's return, a change to her physician orders was noted and were to begin 3/28/18. The orders were as follows: -Humalog (insulin [MEDICATION NAME]) 100 unit /ml administer 21 units subcutaneous (under skin) one time per day at 7:30 a.m Give no more than 15 minutes before breakfast. Report blood sugars >400 mg/dl or <100 mg/dl to provider. -Humalog (insulin [MEDICATION NAME]) 100 units/ml administer 34 units subcutaneous one time per day at 11:30 a.m. Report blood sugars >400 mg/dl or <100 mg/dl to provider. - Humalog (insulin [MEDICATION NAME]) 100 units/ml administer 36 units subcutaneous one time per day at 4:30 p.m Do not give more than 15 minutes before mealtime. Report blood sugars >400 mg/dl or <100 mg/dl to provider. -Toujeo [MEDICATION NAME] (insulin [MEDICATION NAME]) 300 units/ml administer 36 units subcutaneous 1 time per day at 8:00 p.m. Report blood sugars > 400 mg/dl < 100 mg/dl to provider. The new orders revealed parameters which were different from the facility's standing orders and directed the facility to notify the provider if R6's BS was > 400 mg/dl or < than 100 mg/dl. R6's Diabetic Log indicated the following readings outside of the doctor ordered blood sugar notification parameters with no evidence of action taken by staff or physican notification as directed by the physician orders: -4/5/18, at 11:58 a.m. BS level was 463 mg/dl -4/21/18, at 4:40 p.m. BS level was 64 mg/dl -4/22/18, at 4:42 p.m. BS level was 75 mg/dl -4/25/18, at 5:13 p.m. BS level was 82 mg/dl -4/26/18, at 5:18 p.m. BS level was 57 mg/dl -5/1/18, at 11:47 p.m. BS level was 61 mg/dl -5/06/18, at 4:02 p.m. BS level was 63 mg/dl -5/09/18, at 7:34 p.m. BS level was 97 mg/dl -5/10/18, at 8:46 p.m. BS level was 71 mg/dl. R6 was fed a banana with pudding and a glass of orange juice. No further BS check was documented. -5/12/18, at 8:37 p.m. BS level was 92 mg/dl -5/23/18, at 7:21 p.m. BS level was 53 mg/dl -5/26/18, at 4:11 p.m. BS level was 91 mg/dl -5/29/18, at 4:46 p.m. BS level was 89 mg/dl -5/30/18, at 4:37 p.m. BS level was 72 mg/dl -6/1/18, at 7:

Based on observation, interview and document review, the facility failed to accurately assess/reassess the skin condition and ensure timely repositioning was provided as directed by the individualized care plan in order to minimize the prevention of and/or promote the healing of pressure related ulcers for 4 of 6 residents (R42, R20, R9, R32) in the sample identified at risk for pressure ulcers and/or had active pressure related ulcers. This failure resulted in actual harm for R42 due to the development of pressure ulcers, and for R20 who was diagnosed with [REDACTED]. Findings include: R42's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R42 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS also indicated R42 required total assistance with bed mobility, transfers and all other aspects of activities of daily living (ADL). In addition, the MDS indicated R42 was at risk for the development of pressure ulcers and did not have pressure related ulcers. R42's Pressure Ulcer Care Area Assessment (CAA) dated 4/14/18, indicated R42 had a moisture associated skin damaged area on her coccyx. The CAA identified superficial skin damage to the perineal and coccyx related to bladder incontinence. The CAA also indicated R42 had superficial skin damage on the gluteal fold which measured 1.0 centimeter (cm) x 1.2 cm with minimal clear exudate. The staff were to apply barrier cream with cares. R42's care plan dated 5/9/17, indicated R42 required assistance with bed mobility, was at risk for skin breakdown and directed the staff to assist with repositioning every three hours. R42's Braden Scale assessment (tool used for the prediction of pressure sore risk) dated 7/15/18, indicated R42 was at high risk for the development of pressure ulcers. R42's Tissue Tolerance Assessment (tool to use to determine the amount pressure tissue can sustain over bony prominences over time) dated 1/14/18, indicated R42 was able to tolerate being positioned in the same position for three hours. On 7/30/18, at 4:50 p.m. R42 was observed seated in a wheelchair, in the dining room. Staff were providing R42 total assistance to eat the supper meal. -At 6:00 p.m. R42 was assisted to living room area and positioned in front of the television. -At 7:06 p.m. nursing assistant (NA)-H wheeled R42 from the living room to her room. Once in her room, NA-H exited the room. R42 remained seated in the wheelchair. -At 7:14 p.m. NA-H returned to the room and began assisting R42 with evening care. -At 7:24 p.m. R42 was transferred from the wheelchair to the bed via a ceiling lift. R42's wheelchair was noted to be equipped with a pressure redistribution cushion on it. -At 7:27 p.m. NA-H positioned R42 on her side, which exposed a thin Duoderm ([MEDICATION NAME] dressing used for the management of lightly exuding wounds) on R42's coccyx which was peeling off. NA-H informed licensed practical nurse (LPN)-E that the dressing was coming off. LPN-E observed the wound and stated she would notify the registered nurse. -At 7:33 p.m. NA-H stated R42 had been assisted out of bed and into the wheelchair around 3:30 p.m. -At 7:37 p.m. registered nurse (RN)-B removed the Duoderm dressing which revealed an approximately three inch by two inch area on R42's coccyx with two open areas within the wound. The wound bed had deep red / purple colored areas which were not bleeding. RN-B stated R42 had a history of [REDACTED]. RN-B stated the wound was not due to pressure rather was due to moisture related skin damage. -At 7:58 p.m. LPN-E stated she had not seen the wound for several days, however, thought the wound appeared worse than it had a week ago. -At 8:02 p.m. NA-H reviewed the nursing assistant assignment sheet and confirmed R42 had last been assisted with repositioning at 3:15 p.m. (a total of 4 hours and 10 minutes without repositioning). Review of R42's Skin Contrition/Wound Progression documentation revealed the following: - 6/25/18, at 1:06 p.m. R42 was observed to have moisture associated skin damage on the left gluteal fold/coccyx region. Measurements of the area were not recorded. The area was described as having ill defined borders, denuded (missing layers of the skin) in multiple area with [DIAGNOSES REDACTED] (redness) throughout. Moist wound bed which was blanchable and painful to touch. The treatment was to apply a barrier cream for skin protection. - 7/2/18, the wound measured 4.5 cm x 3.5 cm. The wound bed was moist, pale pink with scant serosanguinous draining. The dressing at the time was Allevyn dressing (foam dressing). The staff were educated on the application of ointments, frequency of peri-cares, importance of off-loading and protecting the skin from shearing forces. - 7/9/18, the wound measured 5.0 cm x 3.5 cm. The wound bed was moist, pale pink with moderate serosanguinous draining noted to 50% of the old dressing. The wound was painful to touch. - 7/16/18, the wound measured 5.3 cm x 4.5 cm. - 7/24/18, the wound measured 5.5 cm x 5 cm. - 7/30/18, the wound measured 4.2 cm x 3.7 cm. The wound bed was moist, beefy red with no visible drainage. Dressing of Duoderm ([MEDICATION NAME] dressing) to the area. - 7/31/18, clarification of 7/30/18, documentation: wound bed was not beefy red it was bright red and bleeding due to the removal of barrier cream prior to assessment. - 7/31/18, the wound measured 5.5 cm x 3.5 cm x 0.1 mm in depth. Wound bed forms four separate open areas, irregular wound edges. Wound bed is very wet, pink and white in color, pool of clear fluid noted under Duoderm when dressing was removed. All wound edges and bed macerated in appearance. Buttock skin is moist to touch. Area shows improvement within the wound bed itself but the location and edges have extended towards the sacral region compared to the initial assessment due to further skin breakdown of the area. Denudation of the periwound migration towards boney prominences. Increased moisture to area is causing impaired healing and is continued to be at a high risk of skin breakdown. Multiple wound dressings have been attempted including but not limited to Allevyn, [MEDICATION NAME], foam with [MEDICATION NAME] and Duoderm. A trial of different incontinent products had been attempted without success. On 8/1/18, at 7:23 a.m. R42 was observed seated in a wheelchair, in the television lounge. -At 8:31 a.m. R42 was wheeled into the dining room and was fed breakfast by NA-B. -At 8:42 a.m. R42 was wheeled back into the television lounge. -At 9:35 a.m. R42 was transferred from the wheelchair to the bed via a ceiling full body lift. -At 9:38 a.m. R42 was rolled onto her side. No dressing was on the open area on her coccyx and the area was noted to be actively bleeding. - At 9:43 a.m. RN-B measured the wound and reported it was 5.2 cm x 3.3 cm x 0.1 cm. R42 winced and moaned when the wound was touched. RN-B stated the nurse practitioner had been contacted and discontinued the Duoderm dressing on 7/31/18, and the staff were directed to leave the wound open to air as much as possible. RN-B confirmed the area was bleeding but stated this was an improvement of the wound. -At 9:45 a.m. NA-A stated R42 had been assisted out of bed at 6:30 a.m. a total of 3 hours earlier. -At 9:51 a.m. RN-B stated R42's wound was related to moisture, therefore, pressure was not involved with the development of the skin breakdown. RN-B stated R42's wound started as a moisture / macerated area, however, it was now open and bleeding. RN-B stated R42 was to be repositioned every three hours according to the care plan and should not have been in the wheelchair for greater than four hours without repositioning assistance, therefore, pressure may have been a contributing factor in the area opening. - At 11:38 a.m. the director of nurses (DON) reviewed R42's repositioning schedule and skin assessments. The DON stated R42's wound had initially started as a moisture related skin damaged area, however, she had not received assistance with repositioning. The DON stated R42's tissue tolerance/tissue perfusion test may not be accurate as the repositioning schedule for a resident with damaged skin would not be appropriate at an every 3 or 4 hour repositioning interval. The DON stated she had not visualized R42's skin breakdown, however, verified that the skin documentation noted the area appeared to have gotten larger. -At 1:20 p.m. the DON observed R42's buttocks and confirmed the wound was open and bleeding. The DON stated she was not aware the area had started to bleed and confirmed the open area was due to prolonged pressure. The DON verified R42's pressure ulcer had developed while in the facility. R20's quarterly MDS dated [DATE], indicated R20 had intact cognition, and [DIAGNOSES REDACTED]. The MDS also indicated R20 required extensive assistance for all ADLs, utilized an indwelling urinary Foley catheter, had no skin concerns, and was at risk pressure related ulcers. R20's Pressure Ulcer CAA dated 3/19/18, indicated R20 had a low risk for pressure related ulcers, required assistance with repositioning and utilized [MEDICATION NAME] (medicated powder) for moisture related irritation twice a day. The CAA did not identify any open areas at the time of the assessment. R20's current Physician order [REDACTED]. The staff were to document refusals in the progress notes. R20's Braden Scale for Predication Pressure Sore Risk dated 6/19/18, indicated R20 was at low risk for the development of pressure ulcers. R20's care plan dated 8/15/16, indicated R20 was at risk for skin breakdown due to impaired mobility and history of incontinence associated [MEDICAL CONDITION] to the buttocks. The care plan directed the staff to encourage R20 to lay down in the afternoon and to complete skin inspections weekly. The plan indicated R20 required extensive assistance of 1-2 staff for repositioning, however, R20 frequently refused to reposition. On 7/30/18, at 6:04 p.m. R20 stated she had developed a pressure sore on her bottom between her leg and thigh from the catheter tubing rubbing on her skin and it had been present for the past couple of weeks. R20's Rainy Lake Medical Center Hospital admission History and Physical dated 6/13/18, indicated R20 was admitted to the hospital with [REDACTED]. R20's clinical record indicated R20 returned from the hospital on [DATE]. R20's Admission/Readmission Skin assessment dated [DATE], indicated R20 had an Allevyn dressing on her coccyx. However, the documentation did not identify what was under the dressing or any abnormal skin concerns on R20's buttocks. R20's clinical record contained an Informed Consent dated 3/30/18, at which time the facility had discussed the risk benefits for non compliance with refusing to reposition out of the recliner. R20 was informed of potential continued skin breakdown, wounds, pain and infection at side due to decreased mobility, the development of pressure ulcer and potential infections. However, the clinical record did not include any type of education provided after returning to the facility on [DATE]. On 8/1/18, at 8:10 a.m. R20 was observed in bed while NA-A and NA-J assisted with morning cares. NA-A handed R20 a washcloth and R20 was observed to wash her upper body and perform perineal cares independently. -At 8:11 a.m. LPN-D applied [MEDICATION NAME] powder under R20's abdominal folds. R20's perineum was dark red/purple in color on the right side, whereas, the left side was normal flesh tones. When questioned if R20 had any skin concerns, LPN-D stated R20's perineum was always darker on one side. The buttocks was not exposed at this time. -At 8:16 a.m. NA-J and NA-A connected R20 to a full body ceiling lift. R20 sat up in the bed while the NAs placed the sling behind R20's back and under her thighs. The NAs were not observed to assist R20 to roll over as they placed the sling, therefore R20's buttocks was not exposed. Throughout the cares and transfer assistance R20's buttocks was not exposed and could not be visualized. -At 8:17 a.m. R20 was transferred from the bed to the toilet via the ceiling lift. R20's buttocks was noted to be dark on the right side with several superficial dry areas. R20's buttocks was observed to be bleeding, however, the area could not be fully visualized while in the lift. -At 8:21 a.m. R20 was transferred off of the toilet. While in the ceiling lift, LPN-D applied barrier cream to the buttocks. LPN-D confirmed R20 had open areas on her buttocks that were bleeding, however, LPN-D did not assess the areas prior to the application of the barrier cream. R20 was transferred into the wheelchair and seated on an incontinence brief. Review of R20's clinical record lacked documentation related to the deep tissue injury or open bleeding areas. -At 2:18 p.m. the DON stated she was not aware of any open bleeding areas on R20's buttocks. The DON stated R20 had a history of [REDACTED]. The DON stated the areas would have to be assessed and documented. The DON confirmed the clinical record lacked documentation related to the open areas. -At 3:15 p.m. the DON and NA-D were observed to transfer R20 off of the toilet via the full body ceiling lift. When lifted into the air, R20's right buttocks from approximately mid buttocks to the perineal area was noted to be deep red/purple in color with multiple dry scaly areas. Blood dripped onto the floor while R20 was in the lift, however, the area to which the blood was coming from could not be determined while in the lift. The DON confirmed R20's buttocks was bleeding, yet the DON did not complete a skin assessment to identify the bleeding area. R20 was transferred into a recliner which was equipped with an open incontinence brief. -At 3:20 p.m. R20 stated she had been up in her wheelchair all day, but would inform the staff when it was time to be off of her buttocks and to sit in a different chair. R20 stated she made her own decisions. - At 3:35 p.m. the DON reviewed the discharge summary from the hospitalization on [DATE], and stated she was unaware R20 had been identified with a deep tissue injury while at the hospital. The DON stated the RN charge nurse should have identified injury when R20 returned from the hospital. The DON also confirmed R20's skin assessment completed upon return from the hospital on [DATE], did not identify what type of skin injury was under the Allevyn dressing and no further documentation related to the deep tissue injury was noted in R20's record. The DON verified R20 did not receive a comprehensive skin assessment upon return from the hospital, interventions to prevent/minimize the risk of tissue injury were not added to the record and an investigation regarding the origin of the injury was not conducted. On 8/2/18, at 3:45 p.m. RN-A/MDS coordinator confirmed she had completed R20's MDS on 6/19/18, and stated she reviewed the clinical record and completed the assessment. However, RN-A stated she had observed R20's buttocks at the time of the assessment and was unaware of the deep tissue injury identified on 6/13/18. On 8/3/18, at 8:55 a.m. the DON provided a skin assessment completed on 8/2/18. R20's Skin Assessment Tool dated 8/2/18, indicated the following areas of concern: -A 0.5 cm x 0.1 cm oval shaped open area on the right inner thigh. -A 2.0 x cm x 3 cm area with 7-8 superficial opening areas that were irregularly shaped with jagged borders on the left buttocks. -A 0.3 x 0.3 cm open area was noted on the left buttocks. -The upper portion of both buttocks had a 12.0 cm area which was red in color. -The lower buttocks had a 14 cm area which was deep purple in color. - A superficial linear excoriation on the left buttocks with an open area of 0.1 cm x 0.5 cm. -The left labia had a 0.1 x 0.3 open area. -The right labia had five open areas measuring from 0.5 cm x 1.0 cm to 1.0 cm x 0.7 cm. The open areas were noted to have jagged borders and varied in depth. The assessment indicated all the aforementioned areas were blanchable. -The skin assessment also indicated R20 and RN-B had discussed the open areas identified on the assessment. R20 had a history of [REDACTED]. RN-B assisted R20 into the restroom at which time R20 was observed to perform self rectal stimulation. -At 8:55 a.m. the DON confirmed R20 has a history of picking at her skin and self stimulating her rectum. The skin assessment did not include a root cause of the identified areas and did not indicate when the areas had developed. The deep purple/red areas were identified, however, the assessment did not identify the area as a deep tissue injury. When asked, the DON stated the deep tissue injury [DIAGNOSES REDACTED]. On 8/3/18, at 12:40 p.m. the administrator/RN reviewed R20's clinical record and confirmed the hospital had diagnosed R20 with a deep tissue injury. The administrator stated she would expect a comprehensive skin assessment to be completed upon return from the hospital. -At 1:10 p.m. RN-B/wound nurse stated she had not identified R20's purple skin area upon return from the hospital and was unaware it had been diagnosed as a deep tissue injury by the emergency room physician. RN-B stated she felt the darkened skin may have been a side effect of a medication ([MEDICATION NAME]) however, confirmed the area had not been identified in R20's record prior to the hospitalization . RN-B confirmed the skin assessment completed on 8/2/18, identified multiple open areas and a root cause analysis of the areas had not been completed. RN-B stated she did not feel the open or discolored areas were new for R20, however, RN-B was unable to provide additional documentation related to the identified areas. R9's facility Face Sheet dated 8/1/18, indicated R9 was diagnosed with [REDACTED]. R9's 30 day MDS dated [DATE], indicated R9 had severely impaired decision making skills, was dependent on two plus staff for bed mobility, and transfers and one staff member for toileting, dressing, and personal hygiene. The MDS further indicated R9 was always incontinent of bowel and bladder, was at risk for pressure ulcers, had a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough, may present as an intact or open blister) which was not identified on the MDS dated [DATE], had stage III (full thickness tissue loss) pressure ulcer which was present upon re-admission to the facility. Pressure ulcer interventions included pressure reducing device for bed and wheelchair, and a turning repositioning program. R9's General Nurse's Observation (facility Care Area Assessment documentation) dated 4/26/18, indicated R9 was at high risk for skin break down, was repositioned every two hours by staff, and peri-care was provided after soiling. R9's bed mobility care plan dated 3/30/17, directed two staff to turn and reposition every two hours. The pressure ulcer care plan dated 7/20/18, identified a pressure ulcer to the left heel and directed staff to inspect skin weekly, observe skin daily with cares, turn, and to reposition every two hours. The wheeling care plan dated 5/11/17, indicated R9 used a tilt-n-space wheelchair. The skin care plan dated 8/12/16, indicated R9 was at risk for skin breakdown related to decreased mobility, poor dietary intake, and spending most time in bed. The skin care plan directed staff to conduct a systemic skin inspection weekly paying special attention to the bony prominences, keep skin clean and dry as possible, and to minimize skin exposure to moisture, and to report any signs of breakdown. R32's clinical record lacked evidence of periodic assessment or evaluation for a turning and repositioning schedule to prevent the development or reduce the risk of pressure ulcers. On 7/30/18, at 4:48 p.m. R9 was observed lying in bed as NA-A and NA-N entered the room to get R9 up for dinner. NA-M checked R9's incontinent garment which showed yellow lines with two semi green lines which indicated some urinary incontinence. NA-M stated the yellow lines indicated dryness therefore she was not going to change R9's incontinent garment because it was not wet enough. NA-M stated the incontinent briefs were not changed unless there were only two yellow lines and the rest were blue. -At 4:55 p.m. NA-N and NA-M transferred R9 into her wheelchair. R9 was not offered to use the toilet and/or bedpan and was not provided with incontinence peri-care. -At 5:00 p.m. R9 was wheeled down to the dining room where she sat in her wheelchair until 6:11 p.m. at which time an unidentified staff member pushed her into the living room area. -From 6:11 p.m. to 7:55 p.m. R9 remained in the living room, seated in the wheelchair. At this time, NA-M assisted R9 back to her room. NA-M stated R9 was supposed to be repositioned and have her incontinent brief checked and changed every two hours. -At 8:10 p.m. NA-M and NA-N transferred R9 into bed. Once R9 was in bed, the incontinent brief was had shown all blue lines which indicated total urine saturation. Once the brief was removed, R9's left buttock revealed a half dollar size area of redness and the right upper buttock revealed five dime sized spots of redness. -At 8:25 p.m. LPN-B and RN-B observed R9's buttocks and confirmed the areas of redness. RN-B stated the areas of redness were blanchable, and verified R9 was at risk for pressure ulcers and thought she was supposed to be repositioned every two hours. R9 had not received repositioning assistance for three hours and 22 minutes. On 8/1/18, at 7:38 a.m. R9 was observed lying in bed as NA-0 provided morning cares. NA-O stated she was not sure when the last time R9 was checked and changed and was supposed to be toileted every two hours. NA-0 further stated R9 could go on the toilet and knew when she had to go. NA-O stated R9 leaked urine when she coughed, but otherwise was continent of urine. R9's incontinent brief revealed incontinence demonstrated by four blue lines, R9's buttocks continued to show the same areas of blanchable redness as on 7/30/18. NA-0 asked R9 if she needed to go to the restroom in which R9 replied no. -At 8:45 a.m. NA-O assisted R9 to transfer into the wheelchair. On 8/2/18, at 2:06 p.m. RN-A confirmed R9 was at risk for pressure ulcers and should be repositioned as directed by the care plan. R32's facility Face Sheet dated 8/2/18, indicated R32's [DIAGNOSES REDACTED]. R32's quarterly MDS dated [DATE], indicated R32 had severely impaired decision making skills, and required extensive assist of two plus staff for bed mobility, transfers, and for toileting. In addition, the MDS indicated R32 was at risk for pressure ulcers an required a pressure relieving device for wheelchair and bed, and a turning and repositioning program. R32's General Nurse's observations (facility documentation of Care Area Assessment) for skin dated 7/2/18, indicated R32 was at low risk for pressure ulcers, had urinary incontinence, and had a tendency to over wash the groin area which resulted in reddened skin. The CAA also indicated R32 was monitored and staff were directed to keep dry related to incontinence. The CAA did not reflect an assessment for a turning and repositioning program. R32's Braden Scale indicated R32 was at low risk for pressure ulcers. R32's bed mobility care plan dated 4/16/18, indicated R32 was dependent on two staff to reposition in bed. The skin care plan dated 8/15/16, indicated R32 was at risk for skin breakdown related to functional decline secondary to advanced Alzheimer's and incontinence. The interventions included reposition every 3-4 hours during the day, and on the first and last rounds during the night shift (last revised on 3/15/17). The toileting care plan indicated R32 was occasionally incontinent of bowel and bladder and to toilet every 3-4 hours. R32's aide care guide last updated 7/31/18, conflicted with the care plan in that it directed staff to toilet every 2-3 hours. R32's clinical record lacked evidence of a periodic assessment or evaluation for a turning and repositioning schedule to prevent the development or reduce the risk of pressure ulcers. The last Tissue Tolerance - Repositioning observation was dated 5/16/16, and indicated, R32 required repositioning while sitting and lying every four hours. On 7/30/18, at 4:45 p.m. R32 was observed in the dining room, seated in the wheelchair. When completed with her meal, R32 was wheeled to the adjacent living room area. -At 6:58 p.m. R32 continued to sit in the same position in her wheelchair in the living room area where she remained seated until 7:55 p.m. -At 7:55 p.m. NA-M referenced her aide care guide and stated R32 was last repositioned at 4:20 p.m. and confirmed R32 was to be repositioned every 2-3 hours. -At 9:06 p.m. R32 was wheeled to her room. NA-M and NA-N stated the bath aide had called in therefore they were working short staffed. NA-N stated that was why the residents were not getting repositioned/offloaded on time. -At 9:14 p.m. NA-M and NA-N transferred R32 from the wheelchair to the bed. When R32 stood up, a strong urine odor was noted. R32's incontinent brief was saturated with urine. R32's skin did not have any areas of redness or breakdown. NA-B stated R32 was last checked for incontinence around 3:30 or 4:00 p.m. -At 9:18 p.m. LPN-B stated R32 had been repositioned about 9:00 p.m. by tilting her wheelchair all the way back in order to change the load on pressure points. R32 was not assisted to reposition for four hours and 29 minutes. On 8/3/18, at 11:30 a.m. the DON stated she expected staff to follow the residents' toileting and repositioning care plans as directed. The DON also stated Braden Scale assessments were supposed to be done quarterly and with a change of resident condition, and Tissue Tolerance Observations were supposed to be done upon admission, upon hospital returns, significant changes, and changes in surfaces such as a new wheelchair cushion. The Skin Ulcer Protocol dated 11/1/15, indicated the staff were to identify any skin concerns and document the findings in the clinical record. The Facility's Repositioning Policy dated 10/23/16, indicated the following: -All the residents would be repositioned per their individualized assessment. -All residents would be repositioned based on the results of their individualized Tissue Tolerance Test. -Nursing assistants may utilize the aide assignment sheet to track when the resident was actually repositioned. This sheet would include a list of the residents for which the nursing assistants were responsible for during their shift. -At shift change, the nursing assistants would communicate the actual time the resident was last repositioned to the oncoming shift so a seamless transition occurred and the resident's repositioning schedule continued. The undated Skin Documentation Policy, indicated the following information: -A Braden Scale and Tissue Tolerance Test were to be completed upon admission and weekly for the first four weeks after admission, then quarterly, annually and with a significant change to assess any risk factors. -A Tissue Tolerance Test lying and Sitting would be completed upon admission, annually and with any significant changes or changes in surfaces. -The nurse manager was to assess all risk factors for impaired skin integrity and/or delay wound healing and document findings in the medical record. -The wound nurse was to coordinate with the interdisciplinary team and complete a comprehensive care plan with all identified risk factors, goals and related interventions. -Any identified skin concerns were to be reported to the nurse immediately. -A nurse was to monitor the resident skin weekly -The primary care physician was to be notified within 24 hours of any new skin alteration, except when the physican requested to only be notified on routine rounds. -Any new wound discovered were to have a comprehensive review to ensure all risk factors are identified and current integrations were in place. The care plan was to be adjusted accordingly. -Any wounds would be monitored daily by licensed nurse. -Measurements of wounds will be taken and characteristics will be monitored until the wound is healed. -If no improvement with the wounds was noted within 2-4 weeks, a new treatment was to be attempted if necessary. -All wounds would be reviewed and discussed with the IDT weekly and as needed, at quality assurance performance improvement monthly (QAPI) meeting and QAPI meeting with the medical director.

Based upon interview and document review, the facility failed to ensure fall interventions were implemented, and assessments and monitoring of the resident condition was completed after a fall for 1 of 5 residents (R1) reviewed for accidents. R1 fell from her bed and staff found her on the floor. The facility did not thoroughly investigate the fall to ensure fall interventions were in place when R1 fell . Actual harm occurred when R1 began to complain of pain several hours after the fall and the facility failed to assess the resident or seek further treatment until the resident became lethargic, had increased pain, and was not responding to staff. R1 was sent to the emergency room five days following the fall and was diagnosed with [REDACTED]. Findings include: R1's care plan, dated (MONTH) 16, (YEAR), indicated R1 had moderately impaired decision-making and required total staff assistance for activities of daily living (ADL)'s, and required two staff assistance and a mechanical lift for transfers. The resident had [DIAGNOSES REDACTED]. R1 could become confused at times, making her unable to express her needs or wants. R1's care plan directed staff to observe for non-verbal signs of distress and/ or pain such as guarding, moaning, restlessness, grimacing, and/ or withdrawal. R1's care plan indicated R1 was at risk for falls due to a history of stroke and [MEDICAL CONDITION], and interventions to prevent falls included keeping R1's bed in its lowest position with the brakes locked, place a large stuffed dog on the outside edge of her bed, and to transfer R1 with two staff and a mechanical lift. A functional status assessment, dated (MONTH) 20, (YEAR), indicated R1 was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, toilet use, and personal hygiene. R1's fall incident report dated (MONTH) 19, (YEAR) at 2:00 a.m., indicated R1 fell from her bed, was disoriented, and had an abrasion on her lower back. The report indicated R1's fall was unwitnessed by staff. R1's progress note dated (MONTH) 19, (YEAR) at 2:30 a.m. (the note was actually documented on (MONTH) 26, (YEAR), at 2:20 p.m.), written by Licensed Practical Nurse (LPN)-N, indicated the LPN was doing 2:00 a.m. rounds and walked past R1's room and noticed her on the floor. LPN-N indicated R1 was assessed for injury and the only concern was a small red spot on R1's lower back. The note indicated R1 did complain of knee pain but did not request any additional pain medication. R1 received Tylenol 650 mg two times per day for chronic pain. On (MONTH) 19, (YEAR) at 5:04 a.m., R1's progress note written by LPN-N indicated he was doing rounds at 2:00 a.m. and heard a resident yelling for help. LPN-N found R1 sitting on the floor propped up by her bedside stand facing the door. The note indicated R1 stated she was trying to get out of bed to feed the dogs. The note indicated R1 was assisted back into bed. R1's progress note dated (MONTH) 19, (YEAR) at 11:51 a.m., indicated staff was reminded R1 needs the dog pillow on the bed to prevent falls. Also, R1 told staff her knee was sore. There was no further assessment of R1's knee pain or potential injury from the fall. A progress note dated (MONTH) 19, (YEAR) at 1:40 p.m., indicated R1 complained of left knee pain that morning and was given her scheduled Tylenol. The note indicated R1 told staff the Tylenol helped with the knee pain. R1's progress note dated (MONTH) 20, (YEAR) at 6:18 a.m., written by LPN-D indicated staff reported R1 complained of knee pain when being repositioned. LPN-D indicated R1 was checked on later and had no pain or discomfort. R1's progress note dated (MONTH) 20, (YEAR) at 1:40 p.m., indicated R1 complained of left knee pain when staff assisted the resident out of bed. The progress note indicated R1's scheduled Tylenol was administered early, and Ben Gay was applied. The progress note indicated the R1, has been doing well the rest of the day. R1's progress note dated (MONTH) 21, (YEAR), at 1:30 p.m. (which was documented and entered into R1's chart on (MONTH) 26, (YEAR) at 9:02 a.m.) written by Physical Therapist (PT)-E indicated she had assessed R1 on (MONTH) 21, (YEAR) at 1:30 p.m. PT-E indicated a NA asked her to assess R1 because R1's left hip looked different and R1 appeared to have pain in her hip when staff moved her. The note indicated R1 was awake in bed when PT-E arrived, however, R1 did not verbally respond. PT-E indicated R1's left hip was slightly protruding more than her right, however, PT-E indicated R1 was laying in bed slightly rotated which may have caused the hip to appear protruding. PT-E indicated she moved both of R1's hips and determined R1's range of motion was adequate. PT-E indicated R1 groaned once when she moved R1's right hip. The progress note indicated R1 did not appear to have any pain and did not grimace or groan when she moved R1's right hip. PT-E noted R1 had a history of [REDACTED]. PT-E indicated that since R1 did not express any increased pain with right hip movement, she believed R1 was okay. Although R1's left hip appeared different and the resident had been complaining of pain in the left knee, there is no indication PT-E assessed R1's left hip. R1's progress note dated (MONTH) 21, (YEAR) at 1:53 p.m., written by LPN-R indicated staff reported R1 was touching her left hip when they attempted to get her up, and it appeared R1 might be having pain in her left hip instead of her left knee. The progress note indicated R1's hip appeared normal, and R1 did not show any sign of pain when she and PT-E touched and moved the area. The note indicated R1 continued to complain of left knee pain with movement, and LPN-R administered R1's scheduled Tylenol early. Review of a physician visit note for R1 dated (MONTH) 21, (YEAR) at 2:13 p.m., indicated it was a routine visit for the resident and R1 did not awaken for the examination. There was no mention of R1's fall, her complaints of pain, or an assessment of the resident's pain or range of motion (ROM). As part of the facility investigation a statement written by LPN-H dated (MONTH) 21, (YEAR), (un-timed) indicated the physician saw R1 during rounds, and prior to the rounds LPN-H had just learned of R1's fall due to trying to get out of bed to feed the dogs. LPN-H indicated she reviewed R1's progress notes and saw reports R1 had complained of left knee pain, which was relieved by Tylenol and Ben Gay. LPN-H indicated she relayed all of the information to the physician prior to rounds on (MONTH) 21, (YEAR). R1's progress note dated (MONTH) 22, (YEAR) at 5:31 p.m., written by LPN-H indicated she attempted to wake R1 a few times and it was very difficult to get the resident to wake up. LPN-H indicated R1 took, most of her med's (medication). R1's progress note dated (MONTH) 23, (YEAR) at 8:35 p.m., indicated LPN-Q attempted to wake R1 three times but could not get R1 to wake up. LPN-Q indicated R1 was unable to take any of her evening medications. R1's progress note dated (MONTH) 24, (YEAR) at 10:18 a.m., written by registered nurse (RN)-S indicated staff reported R1 had not eaten the prior day and only had one bite of cheese and sips of fluids for breakfast. RN-S indicated R1 fell out of bed on (MONTH) 19, (YEAR), with no injuries noted at the time. RN-S indicated after reviewing R1's prior progress notes R1 had complaints of left hip pain, and chronic right knee pain. RN-S indicated when she asked R1 about pain the resident did not respond. R1 had her eyes opened but she did not make eye contact. RN-S indicated R1's blood pressure was 200/102 with an adult cuff. RN-S contacted R1's family member and they decided to transfer R1 to the emergency room (ER) for evaluation. The undated transfer form sent with R1 to the hospital on (MONTH) 24, (YEAR), and signed by LPN-D, indicated R1 had a decreased appetite the day before, refusing to eat breakfast or lunch. The form indicated that morning R1 only consumed two sips of fluid and a small piece of cheese, and was not verbally responsive. The form indicated on (MONTH) 19, (YEAR) R1 fell out of bed, and on (MONTH) 21, (YEAR), a LPN charted R1 complained of left hip pain. The form indicated R1 also complained of knee pain. The form indicated R1's blood pressure was 200/102, and staff documented her last bowel movement on (MONTH) 20, (YEAR). A hospital nursing note, dated (MONTH) 24, (YEAR) at 11:46 a.m., indicated R1 grimaced in pain when turned, and when staff touched her left hip and asked if it hurt, R1 answered Yes. A radiology report, dated (MONTH) 24, (YEAR) at 11:56 a.m., indicated R1 had a displaced femoral neck fracture, without dislocation. A hospital nursing note, dated (MONTH) 24, (YEAR) at 12:20 p.m., indicated R1 said she had hip pain. A hospital nursing note, dated (MONTH) 24, (YEAR) at 12:47 p.m., indicated when R1 arrived at the hospital ER she was initially unresponsive except to painful stimuli. R1's hospital physician note dated (MONTH) 24, (YEAR) at 5:32 p.m., indicated R1 was seen on (MONTH) 24, (YEAR) at 11:10 a.m. The physician indicated for the past three to four days R1 had not been eating and drinking adequately, had not been responsive as before, complained of left hip pain, and was found on the floor around five days ago. The physician indicated R1 was not brought to the ER for evaluation after the fall and her family was not aware of R1's fall on (MONTH) 19, (YEAR). As part of the facility investigation LPN-D wrote a statement (undated) which indicated she worked the day shift on (MONTH) 25, (YEAR). LPN-D indicated she overheard two NA's talking in the dining room during breakfast about R1's decreased appetite and unresponsiveness. LPN-D indicated the NA's were also discussing R1's fall and the residents increased signs of pain with transfers and repositioning. LPN-D indicated she worked the previous day and no staff reported R1 was having pain. LPN-D indicated she told the NA's to report their concerns to the RN on duty. LPN-D indicated she obtained R1's vital signs and the resident's blood pressure was elevated with multiple readings. LPN-D reported this to the RN and R1 was subsequently transferred to the emergency room for evaluation. LPN-N wrote a statement dated (MONTH) 24, (YEAR), indicating on (MONTH) 19, (YEAR) staff were rounding and found R1 on the floor at around 2:00 a.m. LPN-N indicated R1 was on her back and there were no apparent unsafe conditions and no apparent injury, other than a small red mark on R1's lower back. LPN-N indicated R1's positioning pillows were in place on her bed, her bed was at the proper height, and R1 had socks on her feet. LPN-N indicated ROM was assessed and R1 did not appear to have any injury although the resident did complain of knee pain. However, LPN-N indicated knee pain was a chronic issue for R1 so he was not concerned. On (MONTH) 26, (YEAR) at 7:16 a.m., a hospital physician completed a note regarding his visit with R1 on (MONTH) 25, (YEAR). In the note, the physician indicated when R1 was brought to the ER the resident was dehydrated and had a urinary tract infection. The physician indicated R1 complained of hip pain in the ER, a hip x-ray showed a new left femur fracture, and he would conservatively manage the fracture since R1 was non-ambulatory. On (MONTH) 26, (YEAR) at 11:55 a.m., the Administrator created a progress note indicating R1 rolled out of bed on (MONTH) 19, (YEAR) at 2:00 a.m. R1 intermittently reported knee and hip pain following the fall. The note indicated R1's level of consciousness declined and she was difficult to arouse for meals or activities. R1 was transferred to the ER for eval on 12/24/17. The note indicated R1 was care planned to have a pillow on the inside edge of her bed and her bed was against the wall, and a large stuffed dog was placed on the outside edge of the bed. The Administrator also indicated, She had a fall 9 months prior to this, at which time the dog (pillow) intervention was implemented with no further instances. The bed was in the low position at the time of the fall. Documentation of the facilities internal investigation dated (MONTH) 26, (YEAR) and signed by an Administrator, indicated NA-A stated when they rolled R1 after her fall R1 placed her hand on her hip indicating she was having pain. The documentation indicated NA-A reported R1's pain to LPN-N, but NA-A was not sure if R1's pain was assessed by nursing. NA-A indicated for several days after her fall, R1 continued to have pain and the NA's continued to report R1's increase in pain to the nurses. As part of the internal investigation NA-G wrote a statement on (MONTH) 26, (YEAR) and indicated after R1's fall, NA-G and NA-A assisted R1 to turn in bed and R1 complained of pain her knee, however, NA-G indicated it seemed more like R1's hip was where the pain was coming from. NA-G stated when R1 fell she had assisted transferring R1 back into bed. R1 did not complain of pain at the time of the fall, however, when staff went into assist R1 several hours later, R1 complained of pain and it was reported to LPN-N. NA-G also indicated after R1 fell on (MONTH) 19, (YEAR), she assisted R1 back into bed. NA-G stated R1's bed was not in the low position according to the plan of care, and indicated R1's bed was, Way up. NA-G wrote a follow up statement dated (MONTH) 27, (YEAR), indicating she walked into R1's room and the resident was sitting on the floor. NA-G indicated R1's bed was in a high position and not the lowest position as directed by the plan of care. NA-G stated at the time R1 did not complain of any pain, however, when they attempted to assist the resident several hours later, R1 complained of pain and was not rolling well in bed due to pain. On (MONTH) 5, (YEAR) at 10:29 a.m., a hospital physician completed a note for his visit with R1 on (MONTH) 31, (YEAR). In the note, the physician indicated orthopedics did not plan to intervene for R1's fracture because R1 was a poor surgical candidate. A hospital physician's discharge note dated (MONTH) 10, (YEAR) at 9:43 a.m., indicated during her hospital stay R1 developed bilateral pneumonia and possible [MEDICAL CONDITION] embolism. During interview on (MONTH) 10 (YEAR), at 11:36 a.m., NA-A stated when she came to R1's room after her fall, R1 was already in bed. NA-A stated when she and NA-G rolled R1 onto her right side, R1 moaned and guarded her left hip with her hand. NA-A stated the entire time they changed R1 she kept her hand over her left hip and tried to push staff away which was not normal behavior for the resident. NA-A stated the night of the fall when they assisted R1 after the fall, R1 expressed pain. NA-A stated normally when staff assisted R1 with cares she did not express pain, however, after the fall NA-A could tell R1 was uncomfortable and in pain. NA-A stated she and NA-G told LPN-N that R1 was in a lot of pain on (MONTH) 19, (YEAR). NA-A stated at morning shift change she also reported to the nurses that R1 had a fall and was having pain. NA-A stated she worked overnights on (MONTH) 19, 20, and 21st, and worked the day shift on (MONTH) 23 and 24. NA-A stated on (MONTH) 20 she assisted R1 with cares and R1 was having pain. NA-A stated she asked R1 if she was hurting and wanted pain medication, and R1 answered yes. NA-A stated about midnight on (MONTH) 20th she told LPN-D R1 was in a lot of pain and requested pain medication. NA-A stated R1 complained of pain, or showed signs of pain such as trying to push staff away, every time she assisted R1 after the fall. NA-A stated she and other NA's continued to tell the nurses R1 was in pain from (MONTH) 19 until she was sent to the emergency roiagnom on (MONTH) 24, (YEAR). NA-A stated on (MONTH) 23, (YEAR), she attempted to talk to R1 but the resident did not respond which was not normal for the resident. When interviewed on (MONTH) 10, (YEAR) at 12:32 p.m., NA-B stated the night before R1 went to the hospital she went into R1's room to check on her and R1 did not move, even as NA-B kept saying her name and touching her. NA-B stated R1 was sleeping and she did not get a response. NA-B stated reported this to the LPN on duty. During interview on (MONTH) 10, (YEAR) at 1:20 p.m., RN-C stated on (MONTH) 20, (YEAR) he recalled being told R1 was having knee pain. RN-C indicated around 9:30 or 10:00 a.m. R1 was sleeping and looked comfortable so he did not wake R1 to assess her. RN-C stated on (MONTH) 21, (YEAR), he recalled hearing R1 had knee pain and the night nurse applied Ben Gay which was effective. RN-C stated the director of nursing (DON) directed staff to do a pain assessment for R1. RN-C thought LPN-R did a pain assessment and R1 was not having any pain. After that, RN-C stated he never got any report that R1 was having hip pain, and LPN-R never reported any concerns about R1 having pain. RN-C stated staff had not reported to him any changes in R1's alertness, eating, drinking, or ability to take medications. When interviewed on (MONTH) 10, (YEAR) at 3:31 p.m., LPN-D stated R1 was complaining of knee pain on (MONTH) 20, (YEAR), and LPN-D applied Ben Gay to the resident's knee. LPN-D stated she did not complete a whole body pain assessment on R1 because the resident only complained of knee pain. LPN-D stated she was not aware R1 had a fall on (MONTH) 19, (YEAR), nor could she recall any staff notifying her R1 was having hip pain. LPN-D stated on the morning of (MONTH) 24, (YEAR), she heard NA-A and NA-G talking in the dining room about R1 not eating the last four meals and that R1 was having pain. LPN-D stated she told the NA's to report their concerns to RN. LPN-D stated she took R1 from the dining room to the nurse's station and obtained her vital signs. R1's blood pressure was around 200/100. LPN-D rechecked R1's blood pressure and continued to get elevated readings. LPN-D stated R1 was not responsive and was not acting like her normal self. LPN-D stated RN-S read the previous weeks nursing notes and saw a note from LPN-R about hip pain, however, there was no further pain assessment or monitoring implemented. LPN-D stated R1 had never complained of hip pain in the past, and although R1 continued to express pain after the fall, the facility lacked communication to ensure the residents pain was monitored and assessed following the fall. During interview on (MONTH) 10, (YEAR) at 4:18 p.m., PT-E stated she assessed R1's hips on (MONTH) 21, (YEAR) per request of a nursing assistant. PT-E stated when she assessed R1 the resident was awake, however, she was not alert and did not respond to questions. PT-E stated she assessed R1's legs and hips, and only saw R1 grimace when PT-E bent her right knee. PT-E stated R1 was petite and she could see R1's pelvic bones, but nothing looked abnormal. PT-E stated R1 grunted when her right knee was bent but did not respond when asked if she had pain. When interviewed on (MONTH) 10, (YEAR) at 4:46 p.m., NA-F stated she had reported to multiple nursing staff beginning on (MONTH) 20, (YEAR), that R1 was having pain and that the resident was not herself and something was wrong with her. NA-F stated she felt as though the nursing staff didn't listen to her concerns when she reported R1's pain. During an interview on (MONTH) 10, (YEAR) at 5:41 p.m., NA-G stated she and NA-A were doing rounds on (MONTH) 19, (YEAR) when she was called to R1's room by LPN-N. NA-G stated R1 requires a full body sling with a ceiling lift for transfers, however, she was instructed by LPN-N to pick up R1 under each arm, without using a gait belt, and put her on the bed. NA-G stated she was aware R1 required a mechanical lift for transfers, but was instructed by LPN-N to pick up R1 so she followed instructions. NA-G stated R1 said her right knee hurt, but she was also putting her hand over her hip and moving it, as if she was trying to keep things away from it. NA-G stated she changed R1 later that night and R1 was in a lot of pain and would not roll. NA-G stated she thought R1's hand movement indicated hip pain, but did not think R1 could verbalize the pain. NA-G stated R1 was fine with rolling prior to her fall, but after her fall she would say, that hurts, that hurts, and do the hand motion over her hip. NA-G stated the NA's reported R1's pain multiple times, including initially and after they did rounds at 5 a.m. on (MONTH) 19, (YEAR), when R1 was in a lot of pain. NA-G stated they told LPN-N about R1's pain. NA-G stated at morning shift change on (MONTH) 19, (YEAR), she reported to the two oncoming NA's R1 fell from a high bed, was not rolling well, and was in a lot of pain and guarding her left hip with her hand. NA-G stated she worked the following nights and R1 continued to complain of pain with repositioning. NA-G stated she continued to let nursing know R1 was having pain. NA-G stated when she went into R1's room, R1 was sitting on the floor, and her bed was at about hip level, and not in the low position as it should be. NA-G stated R1's dog pillow that was supposed to be on her bed was not visible and the resident did not have it on her bed or on the floor near the bed. When interviewed on (MONTH) 10, (YEAR) at 6:45 p.m., LPN-H stated when she did rounds with the provider on (MONTH) 21, she informed him R1 had fallen and she was unaware of any injuries, however, R1 was complaining of knee pain. LPN-H stated on the evening of (MONTH) 22, (YEAR) she tried to give R1 some medication and R1 had difficulty but was able to take some of the medications. LPN-H stated she thought R1 was sleepy and passed the information to the next shift. During interview on (MONTH) 10, (YEAR) at 7:13 p.m., NA-I stated on (MONTH) 20, (YEAR), R1 told her that her leg hurt and asked NA-I to please stop, when NA-I was attempting to roll R1 for cares. NA-I stated R1 did not normally complain of pain when being assisted with cares. NA-I stated she told the LPN on duty about R1's pain. When interviewed on (MONTH) 10, (YEAR) at 7:43 p.m., the Director of Nursing (DON) stated when a resident falls, a nurse should evaluate the resident for injury immediately and continue to monitor the resident for any changes in the following days. The DON stated after a resident falls, staff complete a fall incident report, notifies family, and if there is no injury they can notify the provider via voice mail if it is after hours. The DON stated following a fall staff gives the fall report to her and the interdisciplinary team (IDT) follows up on the reports. The DON stated in the IDT meeting staff did not report any injuries or changes R1 experienced after the fall. The DON stated R1 had little dogs before coming to the facility. About 9 months ago, R1 had fallen from her bed when she tried to get up and feed her dogs. The intervention of the dog pillow on the bed was put into place which had been effective in preventing falls. During an interview on (MONTH) 12, (YEAR) at 1:32 p.m., family member (F)-K stated he was not aware R1 had a fall on (MONTH) 19, (YEAR), until staff called to notify him on (MONTH) 24, (YEAR) about transferring R1 to the hospital. F-K stated R1 could not always clearly articulate how much pain she was in; however, the hospital was able to communicate with R1 and determine the residents severity and location of pain. During an interview on (MONTH) 25, (YEAR) at 8:08 a.m., the physician stated he did not recall staff informing him that R1 had fallen on (MONTH) 19, (YEAR), nor was he informed R1 was having increased pain, and generally he would include information such as recent falls in his visit note. The physician stated he thought he learned about R1's fall when making rounds at the hospital and recognized R1's name. The physician stated when he rounds at the facility if residents are sleeping and there are no staff concerns he does not wake the resident. When interviewed on (MONTH) 25, (YEAR) at 2:56 p.m., LPN-N stated on (MONTH) 19, (YEAR), he heard a noise and went to check on R1 and she was on the floor. LPN-N stated he and another staff person chair-lifted R1 from the floor and onto her bed; meaning one staff grabbed R1's leg and under her arm, and the other staff member did the same on the other side, and they lifted the resident up and put her into bed. LPN-N stated R1's ROM was fine and complained of pain in her knee which was not abnormal. LPN-N stated after R1's fall he did not recall staff reporting R1 was having pain. LPN-N stated at the time of R1's fall, R1 had the dog pillow in bed, but he could not remember if R1's bed was at the low height. A facility policy dated (MONTH) 3, (YEAR) and titled MALTREATMENT PROHIBITION POLICY, in part indicated, NEGLECT is the failure or refusal of a caregiver or other responsible person to provide for an elder's basic physical, emotional, or social needs, or failure to protect them from harm. The policy further indicated, Examples include: not providing adequate nutrition, hygiene, clothing, shelter, or access to necessary health care; or failure to prevent exposure to unsafe activities and environments. Did an incident (e.g. a fall) occur due to the failure to follow the care plan? A facility policy dated (MONTH) 23, (YEAR) and titled Notification of Changes, in part indicated, The Charge Nurse will immediately inform the resident; consult with the physician, and notify the resident representative (consistent with his or her authority), for the following situations: a. An accident involving the resident which results in injury and has the potential for requiring physician intervention. b. A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). The policy also indicated, Unless the resident specifies otherwise, even when a resident is mentally competent, his or her designated representative or family, as appropriate, will be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident. A facility policy updated (MONTH) 28, (YEAR) and titled NOTIFICATION OF PHYSICIAN/FAMILY ON A CONDITION CHANGE, indicated, Family should be notified of all falls immediately, regardless of time of day, unless family requests not to be contacted during certain hours of the day.

Based upon interview and document review, the facility failed to ensure pain was assessed and monitored for 1 of 5 residents (R1), reviewed for an increase in pain. R1 fell from her bed and had on-going verbal and non-verbal indicators of pain. R1 experienced actual harm when staff failed to assess the residents increase in pain after the fall. R1 was sent to the hospital 5 days after the fall and was admitted with a displaced left femoral neck fracture. Findings include: R1's care plan, dated (MONTH) 16, (YEAR), indicated R1 had moderately impaired decision-making and required total staff assistance for activities of daily living (ADL)'s, and required two staff assistance and a mechanical lift for transfers. The resident had [DIAGNOSES REDACTED]. R1 could become confused at times, making her unable to express her needs or wants. R1's care plan directed staff to observe for non-verbal signs of distress and/ or pain such as guarding, moaning, restlessness, grimacing, and/ or withdrawal. R1's care plan indicated R1 was at risk for falls due to a history of stroke and [MEDICAL CONDITION]. R1's fall incident report for (MONTH) 19, (YEAR) at 2:00 a.m., indicated R1 fell from her bed, was disoriented, and had a small abrasion on her lower back. The report indicated R1's fall was unwitnessed by staff. R1's progress note dated (MONTH) 19, (YEAR) at 2:30 a.m. (the note was actually documented on (MONTH) 26, (YEAR), at 2:20 p.m.), written by Licensed Practical Nurse (LPN)-N, indicated the LPN was doing 2:00 a.m. rounds and walked past R1's room and noticed her on the floor. LPN-N indicated R1 was assessed for injury and the only concern was a small red spot on R1's lower back. The note indicated R1 did complain of knee pain but did not request any additional pain medication. R1 received Tylenol 650 mg two times per day for chronic pain. On (MONTH) 19, (YEAR) at 5:04 a.m., R1's progress note written by (LPN)-N indicated he was doing rounds at 2:00 a.m. and heard a resident yelling for help. LPN-N found R1 sitting on the floor propped up by her bedside stand facing the door. The note indicated R1 stated she was trying to get out of bed to feed the dogs. The note indicated R1 was assisted back into bed. R1's progress note dated (MONTH) 19, (YEAR) at 11:51 a.m., indicated R1 told staff her knee was sore. There was no further assessment of R1's knee pain. A progress note dated (MONTH) 19, (YEAR) at 1:40 p.m., indicated R1 complained of left knee pain that morning and was given her scheduled Tylenol. The note indicated R1 told staff the Tylenol helped with the knee pain. R1's progress note dated (MONTH) 20, (YEAR) at 6:18 a.m., written by LPN-D indicated staff reported R1 complained of knee pain when being repositioned. LPN-D indicated R1 was checked on later and had no pain or discomfort. R1's progress note dated (MONTH) 20, (YEAR) at 1:40 p.m., indicated R1 complained of left knee pain when staff assisted the resident out of bed. The progress note indicated R1's scheduled Tylenol was administered early, and Ben Gay was applied. The progress note indicated the R1, has been doing well the rest of the day. R1's progress note dated (MONTH) 21, (YEAR), at 1:30 p.m. (which was documented and entered into R1's chart on (MONTH) 26, (YEAR) at 9:02 a.m.) written by Physical Therapist (PT)-E indicated she had assessed R1 on (MONTH) 21, (YEAR) at 1:30 p.m. PT-E indicated a NA asked her to assess R1 because R1's left hip looked different and R1 appeared to have pain in her hip when staff moved her. The note indicated R1 was awake in bed when PT-E arrived, however, R1 did not verbally respond. PT-E indicated R1's left hip was slightly protruding more than her right, however, PT-E indicated R1 was laying in bed slightly rotated which may have caused the hip to appear protruding. PT-E indicated she moved both of R1's hips and determined R1's range of motion was adequate. PT-E indicated R1 groaned once when she moved R1's right hip. The progress note indicated R1 did not appear to have any pain and did not grimace or groan when she moved R1's right hip. PT-E noted R1 had a history of [REDACTED]. PT-E indicated that since R1 did not express any increased pain with right hip movement, she believed R1 was okay. Although R1's left hip appeared different and the resident had been complaining of pain in the left knee, there is no indication PT-E assessed R1's left hip. R1's progress note dated (MONTH) 21, (YEAR) at 1:53 p.m., written by LPN-R indicated staff reported R1 was touching her left hip when they attempted to get her up, and it appeared R1 might be having pain in her left hip instead of her left knee. The progress note indicated R1's hip appeared normal, and R1 did not show any sign of pain when she and PT-E touched and moved the area. The note indicated R1 continued to complain of left knee pain with movement, and LPN-R administered R1's scheduled Tylenol early. Review of a physician visit note for R1 dated (MONTH) 21, (YEAR) at 2:13 p.m., indicated it was a routine visit for the resident and R1 did not awaken for the examination. There was no mention of R1's fall, her complaints of pain, or an assessment of the resident's pain or range of motion (ROM). As part of the facility investigation a statement written by LPN-H dated (MONTH) 21, (YEAR), (un-timed) indicated the physician saw R1 during rounds, and prior to the rounds LPN-H had just learned of R1's fall due to trying to get out of bed to feed the dogs. LPN-H indicated she reviewed R1's progress notes and saw reports R1 had complained of left knee pain, which was relieved by Tylenol and Ben Gay. LPN-H indicated she relayed all of the information to the physician prior to rounds on (MONTH) 21, (YEAR). R1's progress note dated (MONTH) 22, (YEAR) at 5:31 p.m., written by LPN-H indicated she attempted to wake R1 a few times and it was very difficult to get the resident to wake up. LPN-H indicated R1 took, most of her med's (medication). R1's progress note dated (MONTH) 23, (YEAR) at 8:35 p.m., indicated LPN-Q attempted to wake R1 three times but could not get R1 to wake up. LPN-Q indicated R1 was unable to take any of her evening medications. R1's progress note dated (MONTH) 24, (YEAR) at 10:18 a.m., written by registered nurse (RN)-S indicated staff reported R1 had not eaten the prior day and only had one bite of cheese and sips of fluids for breakfast. RN-S indicated R1 fell out of bed on (MONTH) 19, (YEAR), with no injuries noted at the time. RN-S indicated after reviewing R1's prior progress notes R1 had complaints of left hip pain, and chronic right knee pain. RN-S indicated when she asked R1 about pain the resident did not respond. R1 had her eyes opened but she did not make eye contact. RN-S indicated R1's blood pressure was 200/102 with an adult cuff. RN-S contacted R1's family member and they decided to transfer R1 to the emergency room (ER) for evaluation. The undated transfer form signed by LPN-D sent with R1 to the hospital on (MONTH) 24, (YEAR), indicated R1 had decreased intake the day before and refused to eat breakfast or lunch. The form indicated that morning R1 only consumed two sips of fluid and a small piece of cheese, and was not verbally responsive. The form indicated on (MONTH) 19, (YEAR), R1 fell out of bed, and on (MONTH) 21, (YEAR), a LPN charted R1 complained of left hip pain. The form indicated R1 also complained of knee pain. A hospital nursing note, dated (MONTH) 24, (YEAR) at 11:46 a.m., indicated R1 grimaced in pain when turned and when staff touched her left hip and asked if it hurt, R1 answered Yes. A radiology report, dated (MONTH) 24, (YEAR) at 11:56 a.m., indicated R1 had a displaced femoral neck fracture, without dislocation. A hospital nursing note, dated (MONTH) 24, (YEAR) at 12:20 p.m., indicated R1 stated to staff she had hip pain. A hospital nursing note, dated (MONTH) 24, (YEAR) at 12:47 p.m., indicated when R1 arrived at the hospital ER she was initially unresponsive except to painful stimuli. R1's hospital physician note dated (MONTH) 24, (YEAR) at 5:32 p.m., indicated R1 was seen on (MONTH) 24, (YEAR) at 11:10 a.m. The physician indicated for the past three to four days R1 had not been eating and drinking adequately, had not been responsive as before, complained of left hip pain, and was found on the floor around five days ago. The physician indicated R1 was not brought to the ER for evaluation after the fall and her family was not aware of R1's fall on (MONTH) 19, (YEAR). As part of the facility investigation LPN-D wrote a statement (undated) which indicated she worked the day shift on (MONTH) 25, (YEAR). LPN-D indicated she overheard two NA's talking in the dining room during breakfast about R1's decreased appetite and unresponsiveness. LPN-D indicated the NA's were also discussing R1's fall and the residents increased signs of pain with transfers and repositioning. LPN-D indicated she worked the previous day and no staff reported R1 was having pain. LPN-D indicated she told the NA's to report their concerns to the RN on duty. LPN-D indicated she obtained R1's vital signs and the resident's blood pressure was elevated with multiple readings. LPN-D reported this to the RN and R1 was subsequently transferred to the emergency room for evaluation. On (MONTH) 26, (YEAR) at 7:16 a.m., a hospital physician completed a note regarding his visit with R1 on (MONTH) 25, (YEAR). In the note, the physician indicated when R1 was brought to the ER the resident was dehydrated and had a urinary tract infection. The physician indicated R1 complained of hip pain in the ER, a hip x-ray showed a new left femur fracture, and he would conservatively manage the fracture since R1 was non-ambulatory. On (MONTH) 26, (YEAR) at 11:55 a.m., the Administrator created a progress note indicating R1 rolled out of bed on (MONTH) 19, (YEAR) at 2:00 a.m. R1 intermittently reported knee and hip pain following the fall. The note indicated R1's level of consciousness declined and she was difficult to arouse for meals or activities. R1 was transferred to the ER for eval on 12/24/17. Documentation of the facilities internal investigation dated (MONTH) 26, (YEAR) and signed by an Administrator, indicated NA-A stated when they rolled R1 after her fall R1 placed her hand on her hip indicating she was having pain. The documentation indicated NA-A reported R1's pain to LPN-N, but NA-A was not sure if R1's pain was assessed by nursing. NA-A indicated for several days after her fall, R1 continued to have pain and the NA's continued to report R1's increase in pain to the nurses. As part of the internal investigation NA-G wrote a statement on (MONTH) 26, (YEAR) and indicated after R1's fall, NA-G and NA-A assisted R1 to turn in bed and R1 complained of pain her knee, however, NA-G indicated it seemed more like R1's hip was where the pain was coming from. NA-G stated when R1 fell she had assisted transferring R1 back into bed. R1 did not complain of pain at the time of the fall, however, when staff went into assist R1 several hours later, R1 complained of pain and it was reported to LPN-N. On (MONTH) 5, (YEAR) at 10:29 a.m., a hospital physician completed a note for his visit with R1 on (MONTH) 31, (YEAR). In the note, the physician indicated orthopedics did not plan to intervene for R1's fracture because R1 was a poor surgical candidate. A hospital physician's discharge note dated (MONTH) 10, (YEAR) at 9:43 a.m., indicated during her hospital stay R1 developed bilateral pneumonia and possible [MEDICAL CONDITION] embolism. R1 was discharged back to the facility. During interview on (MONTH) 10 (YEAR), at 11:36 a.m., NA-A stated when she came to R1's room after her fall, R1 was already in bed. NA-A stated when she and NA-G rolled R1 onto her right side, R1 moaned and guarded her left hip with her hand. NA-A stated the entire time they changed R1 she kept her hand over her left hip and tried to push staff away which was not normal behavior for the resident. NA-A stated the night of the fall when they assisted R1 after the fall, R1 expressed pain. NA-A stated normally when staff assisted R1 with cares she did not express pain, however, after the fall NA-A could tell R1 was uncomfortable and in pain. NA-A stated she and NA-G told LPN-N that R1 was in a lot of pain on (MONTH) 19, (YEAR). NA-A stated at morning shift change she also reported to the nurses that R1 had a fall and was having pain. NA-A stated she worked overnights on (MONTH) 19, 20, and 21st, and worked the day shift on (MONTH) 23 and 24. NA-A stated on (MONTH) 20 she assisted R1 with cares and R1 was having pain. NA-A stated she asked R1 if she was hurting and wanted pain medication, and R1 answered yes. NA-A stated about midnight on (MONTH) 20th she told LPN-D R1 was in a lot of pain and requested pain medication. NA-A stated R1 complained of pain, or showed signs of pain such as trying to push staff away, every time she assisted R1 after the fall. NA-A stated she and other NA's continued to tell the nurses R1 was in pain from (MONTH) 19 until she was sent to the emergency roiagnom on (MONTH) 24, (YEAR). NA-A stated on (MONTH) 23, (YEAR), she attempted to talk to R1 but the resident did not respond which was not normal for the resident. When interviewed on (MONTH) 10, (YEAR) at 12:32 p.m., NA-B stated the night before R1 went to the hospital she went into R1's room to check on her and R1 did not move, even as NA-B kept saying her name and touching her. NA-B stated R1 was sleeping and she did not get a response. NA-B stated reported this to the LPN on duty. During interview on (MONTH) 10, (YEAR) at 1:20 p.m., RN-C stated on (MONTH) 20, (YEAR) he recalled being told R1 was having knee pain. RN-C indicated around 9:30 or 10:00 a.m. R1 was sleeping and looked comfortable so he did not wake R1 to assess her. RN-C stated on (MONTH) 21, (YEAR), he recalled hearing R1 had knee pain and the night nurse applied Ben Gay which was effective. RN-C stated the director of nursing (DON) directed staff to do a pain assessment for R1. RN-C thought LPN-R did a pain assessment and R1 was not having any pain. After that, RN-C stated he never got any report that R1 was having hip pain, and LPN-R never reported any concerns about R1 having pain. RN-C stated staff had not reported to him any changes in R1's alertness, eating, drinking, or ability to take medications. When interviewed on (MONTH) 10, (YEAR) at 3:31 p.m., LPN-D stated R1 was complaining of knee pain on (MONTH) 20, (YEAR), and LPN-D applied Ben Gay to the resident's knee. LPN-D stated she did not complete a whole body pain assessment on R1 because the resident only complained of knee pain. LPN-D stated she was not aware R1 had a fall on (MONTH) 19, (YEAR), nor could she recall any staff notifying her R1 was having hip pain. LPN-D stated on the morning of (MONTH) 24, (YEAR), she heard NA-A and NA-G talking in the dining room about R1 not eating the last four meals and that R1 was having pain. LPN-D stated she told the NA's to report their concerns to RN. LPN-D stated she took R1 from the dining room to the nurse's station and obtained her vital signs. R1's blood pressure was around 200/100. LPN-D rechecked R1's blood pressure and continued to get elevated readings. LPN-D stated R1 was not responsive and was not acting like her normal self. LPN-D stated RN-S read the previous weeks nursing notes and saw a note from LPN-R about hip pain, however, there was no further pain assessment or monitoring implemented. LPN-D stated R1 had never complained of hip pain in the past, and although R1 continued to express pain after the fall, the facility lacked communication to ensure the residents pain was monitored and assessed. During interview on (MONTH) 10, (YEAR) at 4:18 p.m., PT-E stated she assessed R1's hips on (MONTH) 21, (YEAR) per request of a nursing assistant. PT-E stated when she assessed R1 the resident was awake, however, she was not alert and did not respond to questions. PT-E stated she assessed R1's legs and hips, and only saw R1 grimace when PT-E bent her right knee. PT-E stated R1 was petite and she could see R1's pelvic bones, but nothing looked abnormal. PT-E stated R1 grunted when her right knee was bent but did not respond when asked if she had pain. When interviewed on (MONTH) 10, (YEAR) at 4:46 p.m., NA-F stated she had reported to multiple nursing staff beginning on (MONTH) 20, (YEAR), that R1 was having pain and that the resident was not herself and something was wrong with her. NA-F stated she felt as though the nursing staff didn't listen to her concerns when she reported R1's pain. During an interview on (MONTH) 10, (YEAR) at 5:41 p.m., NA-G stated she and NA-A were doing rounds on (MONTH) 19, (YEAR) when she was called to R1's room by LPN-N. NA-G stated R1 requires a full body sling with a ceiling lift for transfers, however, she was instructed by LPN-N to pick up R1 under each arm, without using a gait belt, and put her on the bed. NA-G stated R1 said her right knee hurt, but she was also putting her hand over her hip and moving it, as if she was trying to keep things away from it. NA-G stated she changed R1 later that night and R1 was in a lot of pain and would not roll. NA-G stated she thought R1's hand movement indicated hip pain, but did not think R1 could verbalize the pain. NA-G stated R1 was fine with rolling prior to her fall, but after her fall she would say, that hurts, that hurts, and do the hand motion over her hip. NA-G stated the NA's reported R1's pain multiple times, including initially and after they did rounds at 5 a.m. on (MONTH) 19, (YEAR), when R1 was in a lot of pain. NA-G stated they told LPN-N about R1's pain. NA-G stated at morning shift change on (MONTH) 19, (YEAR), she reported to the two oncoming NA's R1 fell from a high bed, was not rolling well, and was in a lot of pain and guarding her left hip with her hand. NA-G stated she worked the following nights and R1 continued to complain of pain with repositioning. NA-G stated she continued to let nursing know R1 was having pain. When interviewed on (MONTH) 10, (YEAR) at 6:45 p.m., LPN-H stated when she did rounds with the provider on (MONTH) 21, she informed him R1 had fallen and she was unaware of any injuries, however, R1 was complaining of knee pain. LPN-H stated on the evening of (MONTH) 22, (YEAR) she tried to give R1 some medication and R1 had difficulty but was able to take some of the medications. LPN-H stated she thought R1 was sleepy and passed the information to the next shift. During interview on (MONTH) 10, (YEAR) at 7:13 p.m., NA-I stated on (MONTH) 20, (YEAR), R1 told her that her leg hurt and asked NA-I to please stop, when NA-I was attempting to roll R1 for cares. NA-I stated R1 did not normally complain of pain when being assisted with cares. NA-I stated she told the LPN on duty about R1's pain. During an interview on (MONTH) 12, (YEAR) at 1:32 p.m., family member (F)-K stated he was not aware R1 had a fall on (MONTH) 19, (YEAR), until staff called to notify him on (MONTH) 24, (YEAR) about transferring R1 to the hospital. F-K stated R1 could not always clearly articulate how much pain she was in; however, the hospital was able to communicate with R1 and determine the residents severity and location of pain. During an interview on (MONTH) 25, (YEAR) at 8:08 a.m., the physician stated he did not recall staff informing him that R1 had fallen on (MONTH) 19, (YEAR), nor was he informed R1 was having increased pain, and generally he would include information such as recent falls in his visit note. The physician stated he thought he learned about R1's fall when making rounds at the hospital and recognized R1's name. The physician stated when he rounds at the facility if residents are sleeping and there are no staff concerns he does not wake the resident. When interviewed on (MONTH) 25, (YEAR) at 2:56 p.m., LPN-N stated on (MONTH) 19, (YEAR), he heard a noise and went to check on R1 and she was on the floor. LPN-N stated he and another staff person chair-lifted R1 from the floor and onto her bed; meaning one staff grabbed R1's leg and under her arm, and the other staff member did the same on the other side, and they lifted the resident up and put her into bed. LPN-N stated R1's ROM was fine and complained of pain in her knee which was not abnormal. LPN-N stated after R1's fall he did not recall staff reporting R1 was having pain. A facility policy dated (MONTH) 3, (YEAR) and titled MALTREATMENT PROHIBITION POLICY, in part indicated, NEGLECT is the failure or refusal of a caregiver or other responsible person to provide for an elder's basic physical, emotional, or social needs, or failure to protect them from harm. The policy further indicated, Examples include: not providing adequate nutrition, hygiene, clothing, shelter, or access to necessary health care; or failure to prevent exposure to unsafe activities and environments. Did an incident (e.g. a fall) occur due to the failure to follow the care plan? A facility policy dated (MONTH) 23, (YEAR) and titled Notification of Changes, in part indicated, The Charge Nurse will immediately inform the resident; consult with the physician, and notify the resident representative (consistent with his or her authority), for the following situations: a. An accident involving the resident which results in injury and has the potential for requiring physician intervention. b. A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). The policy also indicated, Unless the resident specifies otherwise, even when a resident is mentally competent, his or her designated representative or family, as appropriate, will be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.

Based on observation, interview and document review, the facility failed to comprehensively assess nutritional status upon admission in order to implement consistent interventions for identified nutritional concerns due to pressure ulcers and weight loss for 1 of 3 residents (R27) who sustained severe weight loss. This resulted in actual harm for R27. Findings include: R27 was admitted to the facility 6/19/15. R27's undated, Resident Admission Record indicated R27 had [DIAGNOSES REDACTED]. R27's undated, Initial/Annual Nutritional Assessment which was to be completed upon admission, was incomplete. The blank fields included the following: -room number -physician -diagnosis -past medical history and pertinent medications -weight -ideal body weight (IBW) -usual body weight (UBW) -percentage IBW -percentage UBW and recent weight change -eating ability: type of feeding -dietary food preferences, food dislikes -food intake -calorie needs -protein needs -fluid needs -laboratory, medication and assessment. Review of R27's paper record, Matrix (current electronic medical record) and Momentum (previous electronic medical record) revealed R27's weight history was: 6/19/15: 102 pounds (lbs) (admission weight) 7/09/15: 81.5 lbs (20% weight loss) 7/16/15: 80.5 lbs (21% weight loss) 7/23/15: 75.5 lbs (26.5% weight loss) 7/30/15: 70 lbs (31.4% weight loss) 8/13/15: 69 lbs (32.4% weight loss) R27's undated, current care plan directed staff to weigh R27 weekly on bath day and as needed (PRN). The care plan also indicated R27 was to receive Ensure supplement three times daily at meal times. R27's admission Minimum Data Set ((MDS) dated [DATE], indicated R27 had severe cognitive impairment and required extensive assist of 2+ for bed mobility, transfer and walking in room. Extensive assist of 1 for dressing, toilet use and personal hygiene and required supervision with set up assistance for eating. The MDS also indicated R27's history of weight loss prior to admission was unknown and she did not have a swallowing disorder. The MDS further indicated R27's height to be 59 inches () and her weight to be 102 lbs. R27's nutrition Care Area Assessment (CAA) dated 6/30/15, indicated R27 had stage two and stage four pressure ulcers related to a [DIAGNOSES REDACTED]. The CAA indicated a plan of care would be created to reflect offering of Ensure (a nutritional supplement) three times daily at meal time to increase protein intake. Review of R27's nursing progress notes from 7/1/15, through 8/18/15, revealed the following regarding development of new pressure ulcer: -7/18/15 at 8:54 p.m. R27 has blister/pressure area on her right heel. -7/19/15 at 1:30 p.m. right inner heel has a mushy, dark area measuring 4.0 cm x 3.0 cm with a fluid filled blister over this area measuring 3.0 x 2.0 cm. Initiated treatment order of skin prep to area twice daily. Instructed staff and R27 to keep heels off bed and off each other. -7/27/15 at 1:42 p.m. right heel blister is now dry eschar. R27's Physician order [REDACTED]. R27's Resident Progress Note dated 8/18/15, identified as RD (registered dietitian) review, indicated R27 had undesirable weight loss and was below ideal body weight range of 95 +/- 5%. The RD recommended encouragement of Magic Cup (a nutritional supplement) trial three times per day to provide increased kilocalories (kcal)/fluid, whole milk, increased sauces, gravies to provide extra kcal to support weight stabilization. Goal indicated was to stabilize recommended weight. RD was to provide ongoing review due to weight, intake and skin integrity concerns. R27's Medications Administration History dated 08/01/15 - 08/20/15, identified an order for [REDACTED].>Refused or 0: 11 of 59 times 1-25%: 12 of 59 times 26-50%: 10 of 59 times 51-75%: 6 of 59 times 76-100%: 20 of 59 times On 8/19/2015, at 8:20 a.m. nursing assistant (NA)-C was observed to deliver a breakfast tray to R27's room and at 8:30 a.m. NA-C began to feed R27 the meal. R27 was observed to require total assistance to eat. -At 8:42 a.m. R27 finished eating her meal. She consumed 75% of hot cereal and drank sips of water. She consumed 0% scrambled egg, apple juice, coffee or milk. On 8/20/15, at 9:27 a.m. NA-E stated R27 needed more help with eating as she didn't feed herself anymore. NA-E stated R27 fed herself more often when up in the chair, however, she hadn't been up as much anymore. NA-E also stated R27 received Ensure for extra protein with meals. On 8/20/15, at 11:19 a.m. the support services coordinator (SSC) stated it was usual practice for new admissions to be assessed by the registered dietitian (RD) at the first RD visit after admission. The SSC indicated R27 was admitted after the RD's June visit and should have been seen at the July visit. However, the SSC stated the RD's July visit was not a routine visit therefore, the RD did not see residents that month. However, the SSC stated she had a phone discussion with the RD on 8/6/15, to discuss nutritionally at risk residents at which time R27's nutritional status was discussed. The SSC confirmed the RD did not see and assess R27 until the 8/17/15, visit. During this interview, the nutritional interventions for R27 were reviewed with the SSC who verified Ensure was ordered on [DATE], and 8 ounces of whole milk was added after the phone call on 8/6/15. The SSC indicated R27 was also started on a trial of a pureed diet as of 8/4/15, and all cereal for pureed diets were fortified. However, prior to the pureed diet, R27 received her menu choice. The SSC stated there was a period in July when R27 was refusing her supplements but had been doing better lately. The SSC confirmed R27's weight loss and stated they had not looked at alternative supplements and no further nutritional interventions were offered or implemented. On 8/20/15, at 12:08 p.m. the RD stated she did not see R27 or complete an assessment until 8/17/2015, and was first aware of R27's weight loss and being at nutritional risk during the phone call on 8/6/15. The RD confirmed no nutritional interventions other than Ensure were offered until 8/4/15, when R27 began receiving the pureed diet with fortified cereal. R27's meal intake monitoring was reviewed with both the RD and SSC who stated intake monitoring was only completed for newly admitted residents during the seven day MDS assessment period and for residents identified at nutritional risk. The RD stated intake for those residents who ate their meal in the dining room was tracked by dietary personnel on intake sheets which were monitored by the SSC and residents who ate their meals in their room were tracked by whomever picked up the tray. The RD stated If dietary personnel picked up the resident room tray, the intake was tracked on the intake sheets. The RD stated nursing staff did not document intake on the intake sheets. Intake sheets from 6/1/2015, through 8/19/2015, were reviewed. R27's intake was monitored on the intake sheet from 6/19/15, through 7/19/15, which was R27's initial MDS reference tracking period. The intake sheet indicated R27 consumed 0% of her meal 2 of 92 times, 25% of her meal 5 of 92 times, 50% of her meal 7 of 92 times, and 75% of her meal 3 of 92 times. The intake sheets were blank 67 of 92 times and R27 was in the hospital for 3 of 92 meals. R27's intake was not tracked on the dietary intake sheets after 7/19/15, despite current pressure ulcers and ongoing nutritional concerns. The SSC confirmed R27 was not identified at nutritional risk, therefore, did not have intake tracked or monitored. The RD stated R27 fell through the cracks and she wished they had caught the weight loss / nutritional risk sooner and intervened more aggressively. On 08/20/2015, at 12:30 p.m. the director of nursing (DON) confirmed R27 was not identified as a nutrition risk and nursing staff weren't consistently tracking intake of meals or supplements to determine effectiveness. The DON stated there was no formal system to document consumption of nutritional supplements prior to 8/1/2015. The Nutrition Risk Committee policy dated 11/1/13, indicated new admissions/readmissions and residents with significant weight changes or insidious weight loss would be discussed by the interdisciplinary team in the Nutrition at Risk meeting to discuss possible interventions as needed based on clinical condition and/or diagnosis.

Based on observation, interview and document review, the facility failed to assess and implement individualized interventions and/or provide appropriate wound treatment in order to prevent the development of, and/or enhance the healing of, pressure ulcers for 3 of 3 resident (R23, R27, R7) in the sample reviewed for pressure ulcers. The facility's failure to re-assess and provide individualized interventions resulted in actual harm for R23 due to the development and worsening of a pressure ulcer. Findings include: R23's pressure ulcer progressed to a stage 4 (full thickness ulcer to the bone) without adequate assessment and interventions implemented based on R23's individual needs. In addition, appropriate wound care was not provided to prevent the spread of infection to the pressure ulcer. R23's annual Minimum Data Set ((MDS) dated [DATE], indicated R23 was totally dependent on staff for all activities of daily living (ADL), had intact skin, was at risk for pressure ulcers, utilized a pressure redistribution cushion in the wheelchair and bed and was on a turning and repositioning program. R23's Pressure Ulcer Care Area Assessment (CAA) dated 3/14/15, indicated R23 had intact skin, was at risk for the development of pressure ulcers, was dependent on staff for mobility/turning and repositioning, required a regular turning schedule, spent majority of time in bed, required a special mattress or seat cushion to relieve pressure and had functional limitation in range of motion. The Analysis of Findings section of the CAA indicated R23 could not independently move self, staff must reposition her and the only the reason she doesn't have pressure ulcers is that we move her. The CAA further indicated R23's care plan would be reviewed and changes made that were applicable to keep R23 from developing pressure ulcers. R23's Skin Status Questionnaire dated 6/3/15, indicated R23 was non ambulatory, was intermittently up in the chair, was always incontinent of bowel and bladder, was at risk for developing a pressure ulcer, had intact skin upon admission and at present, utilized a pressure reducing device for chair and bed and was on a turning/repositioning program. R23's quarterly MDS dated [DATE], indicated R23 was diagnosed with [REDACTED]. The MDS indicated R23 had severe cognitive impairment, was totally dependent on two staff for all activities of daily living including bed mobility. The MDS also indicated R23 was at risk for the development of pressure ulcers, skin was intact and R23 utilized a pressure redistribution cushion in the wheelchair and bed and was on a turning a repositioning program. R23's Braden Scale for Prediction of Pressure Sore Risk (tool used to predict pressure ulcer risk) dated 8/12/15, indicated R23 was at high risk for the development of pressure ulcers. R23's care plan dated 6/10/15, indicated R23 was at risk for skin breakdown due to incontinence and decreased mobility. The goal was for R23's skin to remain intact. The plan directed staff to keep R23's skin clean and dry, keep linen clean, dry and wrinkle free, provide a pressure relief cushion on the chair and bed, provide incontinence care after each incontinent episode, turn and reposition R23 every two hours and to report any signs of skin breakdown. On 8/17/15, at 5:12 p.m. the director of nurses (DON) stated R23 had a stage two (partial thickness loss of dermis) pressure ulcer on her coccyx. On 8/18/15, at 12:00 p.m. the DON reported R23's pressure ulcer had worsened into a stage three (full thickness tissue loss) ulcer. The DON stated the facility had applied an air mattress to R23's bed and a pressure redistribution cushion to her Geri-chair. R23's progress notes revealed the following: - 7/6/15, indicated R23's skin was intact with no issues. - 7/18/15, indicated R23 had a red/open area on her coccyx and two open areas on each buttock. The note indicated [MEDICATION NAME] (transparent dressing) was applied to all three wounds. No measurements of the wounds was noted in the record. - 7/23/15, indicated R23 had a [MEDICATION NAME] to coccyx area to protect skin. The [MEDICATION NAME] caused a tear which measured 0.5 centimeters (cm) x 0.4 cm. The wound area was covered with an Allevyn (foam dressing). The wound did not produce an odor and the area was noted to have slight bleeding. - 7/27/15, indicated R23's Allevyn dressing was removed. The skin was no longer open. The coccyx was a dark, dusky red and blanchable. Will continue with Allevyn dressing. - 8/6/15, indicated R23's dressing on coccyx was changed due to old dressing having soaked through. The note further indicated R23's wound bed had yellow slough (dead tissue usually light in color, soft, moist and stringy) and an odor was noted. -8/7/15, indicated the DON observed R23's coccyx area. A new order was obtained to discontinue the Allevyn dressing and start Duoderm ([MEDICATION NAME], moisture-retentive wound dressing used for partial and full-thickness wounds with exudates) every seven days. - 8/11/15, indicated R23's Duoderm was changed due to the old dressing coming off. A foul odor was noted with a large amount of exudate (clear or pus like drainage). No measurements of the wound were noted. - 8/12/15, indicated a large amount of opaque, yellow exudate was seeping from underneath Duoderm dressing on coccyx. Dressing removed. Open area to coccyx measured 1.5 cm in length by 5 cm in width. Wound bed contained black eschar (dead tissue) with some white slough around the edges. Noted foul odor. NP (nurse practitioner) notified and new order to culture the wound and change dressing to wet to dry. - 8/13/15, indicated R23's wound continued to have a large amount of exudate and an order for [REDACTED]. The NP also ordered to change dressing to coccyx to [MEDICATION NAME] (calcium alginate dressing which when it comes in contact with the wound bed creates a soft [MEDICATION NAME] gel to protect against wound contamination) daily. - 8/14/15, indicated R23's wound had copious amounts of light, tan, drainage on her old dressing with a strong, foul odor noted from the wound. The new dressing was applied. - 8/18/15, Wound assessment: Coccyx wound measured 3.5 cm x 3.6 cm x 1.0 cm deep. There was a triangular piece of eschar which loosely covered the wound bed. A yellow, white slough covered the wound bed. Drainage is yellow, brown and odorous. There was undermining at the 9 and 1 o'clock positions. The NP was contacted. An order to change treatment to cleansing the wound with Dankins solution (antiseptic solution containing sodium hypochlorite and developed to treat infected wounds) and Mepelix Ag (foam dressing for medium exuding wounds) was received. An air mattress was applied to R23's bed and a pressure relief mattress was applied to R23's Geri chair. The note also indicated R23 was on a turning and repositioning schedule. R23's care plan updated on 8/18/15, indicated R23 was at risk for skin breakdown related to compromised mobility, incontinence and compromised intake of nutrients manifested by a stage three pressure ulcer on her coccyx. The plan directed staff to provide a nutritional supplement daily, wound care every other day with a Danskin cleanser and ABD dressing, keep skin clean and dry as possible, minimize skin exposure to moisture, keep linen clean, dry and wrinkle free, a pressure relief cushion to R23's Geri chair and an alternating air mattress to bed, report any signs of skin breakdown and to toilet and reposition R23 every two hours starting at 12:00 a.m., 2:00 a.m. and so forth. On 8/18/15, at 12:50 p.m. R23 was observed resting in bed on her right side. The bed was equipped with an alternating air mattress. On 8/19/15, at 7:05 a.m. R23 was observed in bed, fully dressed, sleeping on top of the air mattress. -At 8:00 a.m. nursing assistant (NA)-C and NA-E were observed to transfer R23 via a full body mechanical lift into the Geri-chair. R23's chair seat had a pressure redistribution pad on it. R23 was then wheeled to breakfast. -At 8:57 a.m. NA-E was observed to assist R23 back to bed via the mechanical lift. NA-E was observed to check R23's incontinent brief at which time, R23 was observed to have an ABD dressing which measured approximately 5.0 inched by 9.0 inches taped to her coccyx area. Approximately 75% of the dressing was observed saturated with tan drainage. NA-E stated the nurses would be changing the dressing soon. On 8/19/15, at 10:00 a.m. the DON and licensed practical nurse (LPN)-E entered R23's room to complete the dressing change. -At 10:05 a.m. the DON was observed to don a pair of gloves, remove the old dressing and pull a piece of dark, black foam dressing ([MEDICATION NAME]) from the wound bed. The DON proceeded to pick up a 6 cubic centimeter (cc) syringe with a small tip (slightly larger than a pencil lead) and filled it with normal saline. The DON placed the tip of the syringe under the skin/wound bed and rinsed the tunneling sections of the wound with the tip inside of the wound bed. The DON repeated the rinse with normal saline twice. With the same syringe, the DON twice filled the syringe with Dankins solution and again irrigated the inside of the wound. The wound bed was observed covered with a movable, soft, blackened tissue. The area around the wound was observed dark purple/black. With the same gloved hands, the DON measured the wound and reported the wound was 3.5 cm by 3.0 cm by 1.0 cm deep. A second smaller area was reported to measure 0.7 cm x 2.5 cm. The DON stated the second area had developed due to R23's reaction to tape. The DON stated she had changed to an alternative tape which was softer on R23's skin. -At 10:11 a.m. the DON removed the gloves and immediately donned a new pair. The DON proceeded to pack the wound with [MEDICATION NAME] foam dressing, covered it with a dressing and taped the dressing in place. The DON was not observed to wash her hands after removing the contaminated gloves and before applying clean ones. -At 10:17 a.m. the DON verified the wound was irrigated with a 6.0 cc syringe which had a small bore (small opening) and had the potential of causing increased pressure on the wound bed. This could result in further damage to the tissue in the pressure ulcer. On 8/19/15, at 11:31 a.m. the NP was interviewed. She stated the facility staff should not have irrigated R23's tunneling wound with a small bore syringe due to the potential to cause increased tissue damage. The NP stated she was aware of R23's wound rapidly worsening while at the facility. The NP stated she had not observed the wound. On 8/20/15, at 8:14 a.m. the DON stated initial concern related to R23's coccyx started on 7/18/15. She verified the facility had not implemented the alternating mattress nor the pressure redistribution cushion on the Geri chair until 8/17/15. The DON stated the facility had not completed a comprehensive re-assessment of R23's skin in order to determine if alternative interventions were needed based on R23's individual assessed needs. The DON also stated the facility only completed Braden Assessments quarterly and the staff were no longer completing individual resident tissue tolerance assessments (used to determine an individual's tolerance to pressure and to determine appropriate repositioning intervals) at the facility. She stated R23 was to be on a standard every two hour repositioning schedule. The DON stated R23 may have benefited from repositioning more frequently due to the condition of her skin at that time. The DON confirmed R23 should have had a new comprehensive skin assessment completed when she had developed the stage two ulcer on her coccyx and that the facility had missed this assessment. The DON stated the NP would be assessing R23's wound later in the afternoon. On 8/20/15, from 9:30 a.m. to 11:09 a.m. R23 was continuously observed resting in bed on her right side. -At 11:09 a.m. NA-F and NA-G were observed to reposition R23 onto her left side. -At 11:12 a.m. NA-F stated R23 was last assisted with repositioning at 9:00 a.m. a total of two hours earlier. She stated none of the residents were on a repositioning schedule which was less than every two hours. On 8/20/15, at 2:45 p.m. the wound was observed by NP, physical therapist-A and the DON. The DON reported the wound was debrided by the PT-A. R23's physical therapy note dated 8/20/15, at 2:45 p.m. indicated the wound was debrided and the eschar was removed. Documentation indicated the wound continued to have eschar present and may need further debridement. R23's NP documentation dated 8/21/15, read: Coccyx wound stage four measured 3.5 cm x 3.0 cm by 1.5 cm deep. The old dressing had copious amounts of yellow/brown foul smelling drainage. The wound bed had eschar present from the 7 o'clock position to the 12 o'clock position. The eschar was 1.0 cm wide. The wound had undermining at the 12 o'clock position which measured 1.0 cm. The 3 o'clock position had 1.0 cm of undermining. The 6 o'clock position had 2.0 cm of undermining. The 9 o'clock position had 3.0 cm of undermining. The wound edge was surrounded by dark, purple skin measuring up to 1.0 cm wide from the wound bed. A denuded area due to tape removal was also noted which measured 4.8 cm x 1.4 cm. The NP indicated R23 was started on an antibiotic for the wound based on culture results. R27 was not re-assessed when a new pressure ulcer to the right heel developed to determine appropriate individualized interventions. In addition, ongoing monitoring of the pressure ulcer was not conducted/documented, and inappropriate wound care was provided to prevent the spread of infection. R27's undated Resident Admission Record indicated R27 had [DIAGNOSES REDACTED]. R27's Comprehensive Evaluation of Skin Risk Factors dated 6/19/15, indicated R27 had a stage four pressure ulcer to the right hip and three stage two pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured blister) to the coccyx. No ulcers to the right heel were identified. R27's admission MDS dated [DATE], indicated R27 had severe cognitive impairment, required extensive assist of 2+ for bed mobility, transfer and walking in room and required extensive assist of 1 for dressing, toilet use and personal hygiene. The MDS also indicated R27 had three unhealed stage two and one stage four pressure ulcers present upon admission. The MDS indicated R27 was at risk of developing further pressure ulcers. R27's Pressure Ulcer CAA dated 7/2/15, indicated R27 had stage four and stage two pressure ulcers and the facility would care plan interventions in order to treat the ulcers and to help avoid the development of new ulcers. R27's Braden Scale for Predicting Pressure Sore Risk dated 7/10/15, indicated R27 was at risk. R27's Care Planning Report dated 8/20/15, indicated R27 had a stage four pressure ulcer on the right hip, stage two pressure ulcers on her coccyx and directed staff to avoid having R27 lay on her right side and to encourage R27 to move and change position as tolerated. The plan also directed staff to provide wound care for right hip, coccyx, left ear and right inner heel. The care plan further directed staff to keep both of R27's heels off the bed at all times and to position a pillow between her feet when lying on her side, every shift. The care plan did not provide direction regarding frequency of repositioning. The undated East Day and PM Team Toileting form directed staff to reposition R27 every 2 hours. Review of R27's nursing progress notes from 7/1/15, through 8/18/15, revealed the following: -7/18/15 at 8:54 p.m. R27 has blister/pressure area on her right heel. -7/19/15 at 1:30 p.m. right inner heel has a mushy, dark area measuring 4.0 cm x 3.0 cm with a fluid filled blister over this area measuring 3.0 x 2.0 cm. Initiated treatment order of skin prep to area twice daily. Instructed staff and R27 to keep heels off bed and off each other. -7/27/15 at 1:42 p.m. right heel blister is now dry eschar. The clinical record lacked any further documentation regarding monitoring of the right heel ulcer from 7/27 - 8/20/25. On 8/19/15, at 10:17 a.m. NA-E was observed to reposition R27 from her right side to her left side. R27's heels were observed raised off of the bed on a pillow with another pillow placed between her knees. An area of approximately 1.5 inches in diameter of black eschar was observed on R27's right heel. On 8/19/15, at 10:30 a.m. LPN-E and the DON were observed to enter R27's room. LPN-E stated R27 currently had pressure ulcers to her right hip, coccyx, right heel and between her 4th and 5th toes on her left foot. LPN-E stated R27 had also had a pressure area to her left ear that was now healed. LPN-E donned clean gloves. The DON washed her hands and donned clean gloves. LPN-E assisted R27 to turn onto her left side and the DON and removed the old dressing from R27's right hip. LPN-E removed the packing material from R27's right hip wound. Then she proceeded to cleanse the wound bed with gauze soaked with wound cleanser and measured the wound. The wound was observed to have undermining. Following the measurements, the DON removed and discarded her gloves and donned clean gloves without performing any hand hygiene. Using a swab, the DON packed the wound with 2x2 gauze pad soaked with normal saline, discarded the swab and covered the wound with 4 x 4 gauze and taped a dressing bandage on top. The DON discarded her gloves and applied hand sanitizer to hands and then applied skin prep and a [MEDICATION NAME] dressing to R27's [MEDICATION NAME] spine reddened areas. Following the application of the [MEDICATION NAME] dressing, the DON donned clean gloves and removed the old dressing from R27's coccyx and upper left buttock wounds, cleansed the skin around the open area on the coccyx with a peri wipe and then cleansed R27's rectal area. The peri wipe was observed to have fecal material after cleansing the rectum. The DON discarded her gloves and donned clean gloves without performing hand hygiene. The DON proceeded to measure the wounds, discard her gloves and donned clean gloves without performing hand hygiene and applied an Allevyn dressing to the coccyx and left upper buttock area. The DON then assessed R27's right heel and left foot toe wounds, repositioned R27 with LPN-E's assistance, bagged the garbage and washed her hands. On 8/19/15, at 11:00 a.m. the DON confirmed she had not performed hand hygiene between removing R27's soiled dressings and applying the clean dressings to R27's right hip and coccyx areas with her glove changes and should have done so. On 8/20/15, at 8:52 a.m. the DON stated R27's right heel ulcer developed in July 2015, and verified there was no comprehensive re-assessment completed at that time. The DON confirmed the ulcer developed in the facility. A new intervention to float (elevate off bed) R27's heels on a pillow was implemented after the development of the right heel ulcer, however, R27's skin tolerance to pressure was not reassessed to determine if the two hour repositioning schedule required revision based on R27's individual needs. The DON stated R27's every two hour repositioning schedule was implemented upon admission and was not based on assessment data, rather it was a standard intervention implemented for any resident identified with skin issues. The Wound Care policy dated 12/2010, indicated the Littlefork Medical Center had adopted the Pathway Health Services policy and procedures to ensure quality patient/resident care for those receiving wound care. The Pathway Health Services Dressing Change Policy and Procedure from the Wound Resource Manual, Fourth Edition, 2010, directed: 11. Loosen tape and remove dressing. Pull gloves over dressing and discard into appropriate plastic waste bag. 12. Wash hands thoroughly. Put on disposable gloves. 13. Irrigate/cleanse wound as ordered 14. Dry the skin surrounding the pressure ulcer by patting with a soft, clean 4 x 4. 15. Perform weekly wound measurements and observation when appropriate and per policy and procedure. 16. Apply skin sealant to surrounding intact skin as ordered. 17. Dress the pressure ulcer with the prescribed dressing. R7 was at risk for pressure ulcers and the facility failed to provide timely assistance with repositioning. R7's admission MDS dated [DATE], indicated R7 had moderate intellectual disabilities, required extensive assistance with bed mobility, total assistance to transfer, skin was intact and was at risk for developing pressure ulcers. R7's Pressure Ulcer CAA dated 6/26/15, indicated R7 was at risk for the development of pressure ulcers due to his size, cognition and immobility. R7's Skin Integrity Interventions dated 6/15/14, indicated R7 had a small friction rash on his buttocks and directed staff to use a barrier cream on his buttocks. R7's Braden Scale for Prediction Pressure Sore Risk dated 7/6/15, indicated R7 was at risk for the development of ulcers. R7's care plan dated 6/20/15, indicated R7 was at risk for skin breakdown related to sitting in a wheelchair for long periods of time. The plan directed staff to monitor R7's skin, report changes and to utilize a moisture barrier product on the perineal area. The care plan did not direct staff to utilize a pressure redistribution cushion on the wheelchair and it did not direct the staff on how often to assist R7 with repositioning. R7's progress notes revealed the following: - 6/16/15, R7 had two areas on the buttocks. The note had not described nor indicated measurements of the wounds. - 6/18/15, R7 had two scabs noted on his buttock area. Again the documentation did not describe the size or color of the wounds. - 6/30/15, R7 had a blister on the top of his left thigh. A [MEDICATION NAME] dressing was applied. The record lacked documentation of the size of the wound. - 7/1/15, R7's [MEDICATION NAME] was removed with approximately 2 milliliters of serosanguineous drainage noted under the wound. Area cleaned with wound cleanser, [MEDICATION NAME] and a Band-Aid was applied. The record lacked documentation of the wound size. - 7/27/15, R7 was noted to have a large area of friction/shear on his left buttock. Area measure 5.5 cm x 4.0 cm x 0.1 cm deep The middle of the wound was a reddish, purple and non blanchable. The surrounding tissue was blanchable, dusky red in color. Allevyn was applied after the skin was cleansed. The note also indicated a pressure relieving cushion was put into his wheelchair seat and the staff were to reposition R7 every two hours while in the chair. On 8/19/15, at 7:04 a.m. R7 was observed seated in a wheelchair next to the nurse's station. -At 7:42 a.m. R7 wheeled himself into the dining room for breakfast. -At 8:24 a.m. R7 wheeled from the dining room table to the activity room. R7 remained in the activity room until 9:22 a.m. at which time he wheeled himself back to the nurse's station. -At 9:30 a.m. R7 requested to use the rest room. -At 9:32 a.m. NA-F and NA-C were observed to wheel R7 into the bathroom. They were observed to transfer R7 from the wheelchair via a full body mechanical lift and onto the toilet. R7's wheelchair was observed to contain a pressure redistribution cushion. R7 was observed to have intact Duoderm dressings positioned on both sides of his coccyx. -At 9:35 a.m. NA-C stated R7 was assisted into the wheelchair at 6:30 a.m. a total of three hours earlier. She stated R7 was not on a repositioning schedule as he was able to notify staff when he needed to use the rest room. On 8/19/15, at 12:10 p.m. the DON stated R7's wounds on his buttocks were caused by an improper Geri-chair cushion. She stated she had removed the cushion and started the dressings to his buttocks. She confirmed R7 had developed the areas in house and he had not received a skin re-assessment after the development of the ulcers. She confirmed R7 did not have the ability to reposition himself, yet the facility had not competed a comprehensive skin assessment for R7 in order to identify and implement interventions based on R7's individual needs. On 8/19/15, at 1:30 p.m. R7 was observed in bed. The DON was observed to remove the Duoderm dressings. R7's skin was observed to be intact without any type of open areas. The DON stated she would discontinue the use of the Duoderm dressings and applied a barrier cream to R7's buttocks. On 8/20/15, at 8:40 a.m. the DON verified R7 did not have a re-assessment completed following the development of the two open areas on his buttocks and stated R7 should have had a new skin assessment completed at that time. The DON also stated any resident who was at risk for pressure ulcer development was to have an assessment which could determine if the resident required timed repositioning. The DON stated three hours was too long for R7 to sit in his wheelchair without assistance with repositioning. In addition, the DON confirmed R7's care plan should have been revised to include every two hour repositioning. The Wound Care policy dated 12/2010, indicated the Littlefork Medical Center had adopted the Pathway Health Services policy and procedures to ensure quality patient/resident care for those receiving wound care. The Pathway Health Services Prevention and treatment of [REDACTED]. A policy related to skin assessments was requested and none was provided.