Every finding on record at Lodge at Cypress Cove, The

Based on observation, record review, review of facility's policies and procedures, residents, resident's representatives and staff interviews, the facility failed to ensure adequate supervision to ensure safety and prevent falls for 3 (Residents #42, #8 and #206) of 3 residents reviewed for falls. The findings included: The facility policy Fall Review Program (revised 7/23) documented the facility strives to identify those residents at risk for falls, to provide a system of evaluation, reevaluation, and implementation of measures to reduce the potential for falls/additional falls. All residents will be reviewed for fall risk on admission/readmission and after an actual fall, and quarterly thereafter. For residents with 2 or more falls within the past 30 days will be placed on the Falling Star Program: A white round magnet with a red star will be placed on the residents door frame. The resident must not be left alone during toileting, grooming and bathing. Resident placement on the Falling Star program will be incorporated on the resident's care plan. Review of the clinical record for Resident #42 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, muscle weakness and difficulty walking. The Admission MDS (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 10/3/23 showed resident #42 had a Brief Interview for Mental Status score of 12 out of 15 which indicated moderate cognitive impairment. The care plan initiated on 9/25/23 showed Resident #42 was a high risk for falls related to gait/balance problems and a history of falls. The interventions included: encourage resident to rest in recliner before dinner initiated 1/15/24. Physical therapy (PT) eval: modify wheelchair (dropped) to promote safety, initiated 1/9/24. Clear indication made on remote to identify which button reclines initiated 10/23/2023. Encourage staff to communicate with resident when they are going to provide care initiated 10/25/2023. PT to treat as ordered initiated 11/6/2023. Dycem (non-slip mat) provided for wheelchair (w/c) placement to prevent sliding and promote safety initiated 11/29/2023. Dycem provided to recliner for placement to prevent sliding and promote safety initiated 12/28/2023. Therapy to assess w/c and cushion for recommendations to ensure safety initiated 1/4/2024. Call Don't Fall signs in resident room and bathroom as reminder to use call bell initiated 9/25/2023. Anticipate and meet the resident's needs initiated 9/25/2023. Ensure that the resident is wearing appropriate footwear i.e. brown leather shoes, non-skid socks etc.) when ambulating or mobilizing in w/c. Date initiated: 9/25/23. Falling Star Program initiated 10/23/2023. Keep bed in low position initiated 9/25/2023. Keep call light within reach-instruct on its use and remind/re-educate to use call light as needed initiated 9/25/2023. Resident should not be left alone during toileting, grooming, bathing. Staff should remain in the vicinity but do not have to be within arm's reach. On 1/17/24 at 12:18 p.m., in an interview Resident #42's wife said he falls all the time that is why he is here. He has Parkinson's and poor balance and in his mind he thinks he is still independent, but he is not. He also started sliding out of the wheelchair. He likes to be in the wheelchair so he can get around on his own. I have asked for therapy to try and work with him again and see if they can help him. Fall #1. Review of the facility Incident Report showed Resident #42 had a fall on 9/22/23 at 2:00 a.m. The incident report showed the resident was observed on the floor next to the wheelchair (w/c). The resident sustained a skin tear to the left elbow. The report documented the steps taken to prevent recurrence was increased rounding. Fall #2. Review of the facility Incident Report showed Resident #42 had a fall on 10/23/23 at 9:00 a.m. The incident report showed the resident was observed on the floor next to the wheelchair. The report documented the steps taken to prevent recurrence was increased rounding. Fall #3. Review of the facility Incident Report showed Resident #42 had a fall on 10/28/23 at 10:00 a.m. The incident report showed the resident was observed sitting on the floor next to his bed and wheelchair. The report documented the steps taken to prevent recurrence, was resident education. Fall #4. Review of the facility incident report showed Resident #42 had a fall on 11/28/23 at 6:00 p.m. The incident report showed the resident was found sitting on his bottom in the bedroom. He stated he fell off his wheelchair trying to pick up his remote off the floor with a grabber. The report documented the steps taken to prevent recurrence, was resident education. Fall #5. Review of the facility incident report showed Resident #42 had a fall on 12/23/23 at 11:00 a.m. The incident report showed the resident was in the lift chair and the chair started to raise/tilt forward, and he slid out of the chair and onto the floor. The report documented the steps taken to prevent recurrence, Assist with ambulation. Fall #6. Review of the facility incident report showed Resident #42 had a fall on 12/30/23 at 1:00 p.m. The incident report documented Resident was found on the floor while talking to his daughter. Resident stated he slid off his wheelchair because the cushion was pushed back due to him moving around. No injuries, no complaints of pain. The report documented the steps taken to prevent recurrence, resident education. Fall #7. Review of the facility incident report showed Resident #42 had a fall on 1/2/24 at 9:00 a.m. The incident report documented Resident was sitting on the floor by his bed, unlocked wheelchair close by him, alert, able to explain what happened, according with him he was trying to reposition himself in wheelchair, cushion was too far forward, ended up sitting on the floor. The report documented the steps taken to prevent recurrence, resident education. Fall #8. Review of the facility Incident Report showed Resident #42 had a fall on 1/4/24 at 4:00 p.m. The incident report documented Resident had a fall. Unwitnessed fall. Resident found sitting on floor next to wheelchair, said he slid out of wheelchair onto floor. The report documented the steps taken to prevent recurrence, resident education. Fall #9. Review of the facility incident report showed Resident #42 had a fall on 1/11/24 at 5:00 p.m. The incident report documented Resident found sitting on his bottom near the wheelchair. The resident stated, I was dozing and fell out of the chair. The report documented the steps taken to prevent recurrence, assist to recliner for naps. Fall #10. Review of the facility incident report showed Resident #42 had a fall on 1/14/24 at 2:00 a.m. The incident report documented Resident found on bathroom floor. The report documented the steps taken to prevent recurrence, assist with ambulation. On 1/16/24 at 3:14 p.m., the door to Resident #42's room was closed, there was a white circle with a red star on the door frame. On 1/16/24 at 3:45 p.m., in an interview Registered Nurse (RN) Supervisor Staff H said the red star on the door frame indicated the falling star program. Staff H said the Falling Star program meant the resident was not to be left alone in the bathroom. When asked what frequent rounding meant as a fall intervention she said, we round all the time, and we look in the rooms as we walk by but there was no documentation of the rounds. The RN said there was no schedule for the frequent rounding. On 1/17/24 at 9:04 a.m., in an interview RN Staff E said the star on the door frame indicated the falling Star program. Staff E said it meant the resident was a fall risk. She said, I do round all the time, and on the night shift the residents are checked every hour. On 1/17/24 at 9:22 a.m., in an interview Certified Nursing Assistant (CNA) Staff F said the falling star program meant a resident was a fall risk and you don't leave the resident alone in the bathroom. On 1/17/24 at 2:24 p.m., in an interview the Assistant Skilled Nursing Facility Administrator Risk Manager said, The process when a resident had a fall is we review the documentation, speak to the staff who may have seen or heard anything, and talk to the resident. We find the most applicable intervention and update the care plan, we put a new intervention in place. The Falling Star Program is used when someone has had more than 3 falls in 30 days. It means the resident is not to be left alone in the bathroom, that is the main part of the Falling Star program. When asked what else the staff are expected to do for someone on the falling star program, she said, I don't know. I will have to check on that. On 1/18/24 at 9:22 a.m., in an interview the Director of Nursing (DON), said the Falling Star program was initiated if the resident has had two or more falls within 30 days. It alerts the staff the resident is a fall risk. It alerts staff that the resident should not be left alone on the toilet or in an unsafe area alone. The staff are not to leave the resident alone when grooming, bathing, or sitting on the side of the bed. The DON said increased rounding meant the CNAs do every two-hour rounding and the nurses are encouraged to do every two hours rounds so someone is laying eyes on the resident every hour. The DON said there was no documentation of the increased rounding and no way of knowing if the increased rounding was effective or ineffective. She said on the incident report the nurse puts an intervention in place and then the Interdisciplinary Team goes over it and we see if the intervention is effective for the resident or needs to be changed. The DON said Resident #42 had not come to the realization that he needs help. It is very hard for him to come to us and ask for help. She said I would encourage him to watch TV in the day room, but he refuses. I spoke with his wife a week or so ago about having a companion to sit with him, but she won't pay for it. The DON said the resident's wife has a schedule for her visits and she can't come and sit with him more frequently. She said We just asked his wife to remind him over and over not to get up without using the call light. Our next intervention would have to be a 1-1 sitter at specific times. The DON agreed the current interventions were not effective in preventing falls for Resident #42. 41905 Review of the facility Falling Star Program revised June 2018 revealed After a resident sustains a second fall within a 30-day period, a red star will be placed on the doorframe of the resident's room. Interventions included: Not to be left unattended during toileting, grooming, bathing, sitting on the edge of the bed, and dressing; will be assisted with all transfers and ambulation. Review of the Caution and Fall Program revised February 2020, Residents at risk for falls will be identified to all staff members through a yellow dot on the doorframe. Residents should not be left completely unattended during toileting, grooming, bathing, and dressing. Staff should remain in the vicinity but do not have to be within arm's reach or within view of resident. Review of the medical record for Resident #206 revealed a fall and hospitalization prior to admission to the facility. Review of the hospital record revealed resident #206 suffered from dizziness for one year and multiple falls. His hemoglobin in the hospital was low and the resident suffered from delirium (episodes of confusion). The resident was admitted to the facility for rehabilitation. The facility's comprehensive assessment with a reference date of 12/1/23 revealed an elderly resident, admitted on [DATE] who required assistance for walking. The diagnoses included anemia (low red blood levels) and orthostatic hypotension (low blood pressure during position changes.) Review of the facility progress notes revealed Resident #206 fell 3 times at the facility: 11/18/23, 12/11/23, and 1/2/24. Review of the fall incident on 11/18/23 at 9:00 a.m. revealed the resident was alone in the bedroom when he fell . The resident tried to make a phone call and fell . The facility steps to prevent recurrence were apply lotion for skin hydration and place a Call Don't Fall sign in the bedroom and bathroom to remind the resident to use the call bell for assistance. Other interventions initiated on 11/20/23 to prevent falls were anticipating and meeting needs; caution program; ensure appropriate footwear while walking or using wheelchair; keep bed in low position; keep call light in reach, instruct on use and remind resident to use it; safe environment; slide personal items within reach; update fall risk review quarterly; assist resident with toileting and transfer using the wheelchair and walker. Review of the fall incident on 12/11/23 at 6:00 a.m. revealed the resident was alone in the bedroom when he fell . The resident lost his balance. The facility step to prevent recurrence was increased rounding. The care plan was updated to include placing a sign to remember to position foley bag (drainage bag from catheter inserted in the bladder) accordingly prior to ambulation. Review of the fall incident on 1/2/24 at 5:00 p.m. revealed the resident was alone in the bedroom when he fell . The resident stated he wanted to sit on the floor. After staff got him sitting on the bed, he started to slouch forward, so they laid him down quickly. After the resident returned to baseline, he started saying he fell off the bed. The staff noted this was switching stories. The steps taken to prevent a recurrence: assist with ambulation, which the resident was previously care planned for and labs ordered to rule out a urinary tract infection (UTI). Review of the facility progress notes from November 2023 - January 2024 revealed Resident #206 suffered periods of confusion and pulled out his urinary catheter twice while at the facility. The psychiatrist noted the resident suffered from dementia, impaired ability to remember, think or make decisions that interfere with doing everyday activities. Review of the care plans did not include increased supervision for the resident. Review of the facility progress notes from November 2023 - January 2024 revealed the resident suffered gait, balance, and wandering issues, sometimes wandering into the bedroom of others. The staff were to assist the resident as necessary for transferring. There were no directions for increased supervision of the resident. Review of the Standard of Care Agenda dated 1/4/2024 revealed the facility removed Resident #206 from the falling star program. He has had 1-3 falls in the last 30 days. The Resident is ambulating independently. Delirium seems to have cleared. On 1/16/24 at 10:32 a.m., during an interview with Resident #206 in his bedroom, he said he fell at home but did not recall any falls at the facility. The resident's room was the very last room at the end of the hall farthest from the nursing station. The call bell was in reach and the Call Don't Fall sign was on the wall near the bed. On 1/17/24 at 8:33 a.m., Resident #206 said his memory is not too good and he cannot remember some things that are said. He said he lived with his wife and wants to go home. He said he always gets up and uses the bathroom by himself with the walker if he remembers. He said he only falls when he trips on something. During the interview, the resident was lying in bed wearing street clothes and shoes. The resident's walker was in the doorway of the bathroom approximately 5-10 feet from the resident. The resident said he left the walker in the bathroom doorway. The wheelchair was in the room next to the credenza, but not in reach of the resident. He said he did not remember falling at the facility. He said if he needed to go to the bathroom he would just get up and use the walker and go himself and would not call the staff to help him. He said they don't come in and check on him very often. On 1/17/24 at 9:36 a.m., observed yellow dot on the doorframe of the resident's room. On 1/17/24 at 9:44 a.m., CNA Staff R said the yellow dot means the resident is a frequent faller and pulled out her instruction sheet. The sheet did not indicate how many times staff needed to check the resident. On 1/17/24 at 11:58 a.m., the Director of Rehab the resident has safety awareness issues and is not aware of his limitations. He said it does not matter how many signs you place in the room; the resident will get up and walk without calling for assistance. The director said the resident is not getting therapy. On 1/17/24 12:40 p.m., Resident #207 observed walking down hallway with walker. There were no staff in the area. On 1/17/24 12:59 p.m. CNA Staff T said she knows the resident is a fall risk and she should check on him. She said there is no special time or routine for checking. On 1/17/24 1:28 p.m., Licensed Practical Nurse (LPN) Staff O said staff should be checking resident every hour, but that is not written anywhere. She said the resident uses the call bell for toileting assistance and staff cannot leave until he is finished. She said there are no special instructions for supervision. On 1/18/24 at 8:46 a.m., observed resident in his room awake in bed. The Call Don't Fall sign was on the wall near the bed. The resident said you should call them on the phone before you do something where you may fall. The resident said he does not use the call bell, almost always uses the walker for ambulation unless he forgets. He said staff do not check on him. On 1/18/24 at 8:52 a.m., observed resident up in room walking without the walker. There were no staff in the room or in the hallway near the room. On 1/18/24 at 10:08 a.m., the MDS (Minimum Data Set) Coordinator said criteria for the Falling Star Program was two falls in one month. She said the resident had two falls in one month but was removed from the Falling Star Program. On 1/18/24 at 11:59 a.m., the Director of Nursing (DON) said Resident #206 was confused and was tripping over the urinary catheter bag when he was first admitted . The Assistant Nursing Home Administrator said they have safety concerns about the resident tripping when he goes home and that is why he is still at the facility. The Transitions of Care Coordinator said Resident #206 has short term memory deficits. The DON said the Resident #206 has no safety awareness. The DON said there has been no increase in supervision for Resident #206. She said between the CNAs and nurses they should be checking the resident every hour, but there are no specific instructions for that. 49527 Review of the clinical record for Resident #8 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE]. The assessment noted Resident #8 had a Brief Interview for Mental Status (BIMS) score of 02, which indicated severe cognitive impairment. The resident needed substantial/maximal assistance with all activities of daily living (ADLs). Review of Resident #8 care plan with a revision on 1/15/2024 after the fall was Therapy to evaluate wheelchair safety. Other interventions to prevent a fall in place 06/22/2023 Place Call don't fall signs in room, 7/05/2023 Ensure call light is easily within resident's sight while he is in bed, 2/17/2023 Keep call light within reach-instruct on its use and remind/re-educate to use call light as needed, and 8/10/2023 Falling Star program. Review of incident reports: Resident #8 unwitnessed fall out of wheelchair on 1/13/2024. Note states fall was unwitnessed at approximately 3:00 p.m. after the family left him. He slipped out of his wheelchair. No complaints of pain, no skin tears or major injuries noted. He stated he did not hit his head. Interventions in place at time of incident 1:1 supervision. The new intervention in place is to increase rounding. Note text: new intervention is for therapy to evaluate wheelchair safety. No new interventions to educate the family to notify staff when leaving so they can check on the resident, since his fall happened after the family left. On 1/16/24 at 10:15 a.m., Resident #8 was observed in a wheelchair at end of the bed with the call light out of reach on the bed. Resident stated he is to call for help when he needs to get up. Resident #8 was not able to reach for the call light upon request. Photographic evidence obtained. On 1/16/24 at 1:00 p.m., Resident #8's spouse stated Resident #8 fell out of his chair on 1/13/2024 but did not sustain any injuries. She felt that a wedge should be put on his wheelchair so that he doesn't have to always try and push himself back into the wheelchair. On 1/16/24 at 2:57 p.m., Resident #8 was observed asleep in bed with call light on the floor. Photographic evidence obtained. On 1/16/24 at 3:00 p.m., Licensed Practical Nurse Staff B said the resident used two call lights. She verified one of the call lights was on the floor and not within sight or reach of the resident. She pointed to a call light under the resident's pillow. The call light was not within the resident's sight as per the care plan dated 7/5/23. On 1/16/24 at 3:13 p.m., CNA Staff G, Said the yellow dot is fall risk on door. She said fall risk usually sit in hallway to have a set of eyes on the resident. She doesn't know what pink dot is. On 1/16/24 at 3:29 p.m., Registered Nurse (RN) Staff H Supervisor said it is on trust that the staff is increasing rounds on a resident. On 1/17/24 at 9:27 a.m., LPN Staff C stated pink means dnr, red is alarm, yellow is don't know, falling star at risk for fall. When is time to check on them she makes rounds every hour and CNAs are up and down the hall. There is no documentation that they round. The purpose of signs are to identify the resident issue. On 1/17/24 at 10:00 a.m. CNA Staff F said falling star means fall risk, do not leave them by themselves and no walk by themselves. On 1/18/24 at 9:22 a.m., in an interview the DON said increase rounding is: RN's and CNAs alternate rounds every two hours; they should increase to every 30 minutes. The DON confirmed there was no documentation of the increase rounds, they were just told to increase rounds

Based on record review and staff interview the facility failed to transmit Minimum Data Set (MDS) assessments in a timely manner for 16 residents (Residents #1, #2, #3. #6, #12, #17, #19, #20, #26, #29, #35, #37, #39, #40, #43 and #44) of 16 residents reviewed. The finding included: Record review for Resident #1's MDS assessments revealed the Quarterly MDS dated [DATE] was transmitted 1/16/24, 32 days after completion. The Annual MDS dated [DATE] was transmitted on 10/10/23, 26 days after completion. Record review for Resident #2's MDS assessments revealed the Quarterly MDS dated [DATE] was transmitted on 1/17/24, 49 days after completion. Record review for Resident #3's MDS assessments revealed an Admission assessment dated [DATE] was transmitted on 10/10/23, 28 days late. The Quarterly MDS dated [DATE] was transmitted and accepted on 1/16/24, which was 34 days late. Record review for Resident #6's MDS assessments revealed an Annual MDS dated [DATE] was export ready but still not transmitted as of 1/17/23 which was 56 days late. Record review for Resident #12's MDS assessments revealed a Quarterly MDS dated [DATE] was transmitted on 1/16/24, which was 44 days late. Record review for Resident #17's MDS assessments revealed a Quarterly assessment dated [DATE] was transmitted on 1/16/24, which was 46 days late. Record review for Resident #19's MDS assessments revealed a Significant Change MDS dated [DATE] was export ready but not transmitted as of 1/17/24, which was 86 days late. Record review for Resident #20's MDS assessments revealed a Quarterly MDS dated [DATE] was export ready but not transmitted as of 1/17/24, which was 54 days late. Record review for Resident #26's MDS assessments revealed a Discharge Return not anticipated MDS dated [DATE] was not transmitted as of 1/17/24, which was 125 days late. Record review for Resident #29's MDS assessments revealed a Quarterly MDS dated [DATE] was not transmitted as of 1/17/24, which was 54 days late. Record review for Resident #35's MDS assessments revealed a Quarterly MDS dated [DATE] was export ready but not transmitted from the facility as of 1/17/24, which was 56 days late. Record review for Resident #37's MDS assessments revealed a Quarterly MDS dated [DATE] was transmitted on 1/16/24, which was 47 days late. Record review for Resident #39's MDS assessments revealed an Annual MDS dated [DATE] was transmitted on 1/16/24, which was 32 days late. Record review for Resident #40's MDS assessments revealed a Quarterly MDS dated [DATE] was export ready but not transmitted as of 1/17/24, which was 55 days late. Record review for Resident #43's MDS assessments revealed a Quarterly MDS dated [DATE] was transmitted on 1/9/24, which was 33 days late. Record review for Resident #44's MDS assessments revealed an Admission MDS dated [DATE] was transmitted on 10/3/23, which was 19 days late. The Discharge MDS dated [DATE] was not transmitted and accepted until 1/9/24, which was 25 days late. On 1/17/24 at 1:11 p.m., in an interview MDS coordinator Staff L stated she started her position as MDS coordinator in July of 2023 and was still learning the regulations related to MDS assessments. On 1/17/24 at 1:36 p.m., in an interview the Director of Nursing verified the MDS assessments for Residents #1, #2, #3. #6, #12, #17, #19, #20, #26, #29, #35, #37, #39, #40, #43 and #44 had not been transmitted within the specified time frame in accordance with the Resident Assessment Instrument (RAI) manual. On 1/17/24 at 4:14 p.m., the Executive Director stated he expected MDS assessments to be completed and transmitted within the specified time frame.

Based on observation, review of facility policy and staff interviews, the facility failed to ensure expired medications were not retained longer than the expiration date in 1 of 2 medication storage rooms observed and 1) medication cart of 3 medication carts observed. This has the potential for expired medications to be administered to residents. The findings included: The facility policy and procedure Medication Storage (revised 8/23) documented All medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdates, defective or deteriorated medications with worn, illegible or missing labels. On 1/16/24 at 10:09 a.m., during an observation of the 2nd floor medication room with Licensed Practical Nurse (LPN) Staff B revealed an emergency insulin box located in the locked compartment of the medication refrigerator. The emergency insulin box contained 1 Humulin insulin injectable pen with an expiration date of 12/11/23. LPN staff B confirmed the insulin had expired. Photographic evidence obtained. On 1/16/24 at 10:29 a.m., during an observation of 2nd floor [NAME] Hall medication cart with LPN Staff C revealed a plastic pharmacy medication bag with 2 Albuterol AER/HFA inhalers. The expiration date on the inhalers was 12/23. LPN Staff C confirmed the inhalers had expired. Photographic evidence obtained. On 1/18/24 at 8:52 a.m., in an interview, the Pharmacy Consultant said he was at the facility monthly and checks the emergency drug kits including the insulin. The Pharmacy Consultant said he checked the emergency drug kits at his last visit on 12/20/23 and was not aware the Humulin insulin had expired on 12/11/23. On 1/18/24 at 5:15 p.m., the Director of Nursing said she had contacted the pharmacy to replace the emergency insulin box on 1/16/24 because the Humulin insulin had expired. She said she checks the medication refrigerators and the medications including the emergency drug box every day. The Humulin insulin had an expiration date of 12/11/23.

Based on observation, record review, and staff interview, the facility failed to provide care and services to prevent the decline in range of motion for 1 (Resident #29) of 2 sampled residents with functional limitation in range of motion. The findings included: A review of the Restorative Nursing Programs health care policy (R-12) revised June 2018 provided by the facility stated, Cypress Cove strives to provide maintenance and restorative services designed to maintain or improve a resident's ability to the highest practicable level. The procedure documented, Nursing personnel are training on basic, maintenance or restorative nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include maintaining proper positioning and body alignment, assisting residents with range of motion exercises, performing passive range of motion for residents unable to actively participate. Review of the clinical record for Resident #29 revealed an admitted [DATE]. Diagnoses included Dementia, and muscle weakness. The Admission minimum data set (MDS) assessment dated [DATE] noted the resident scored 00 on the Brief Interview for Mental Status, which indicated severe cognitive impairment. Resident #29 required the extensive assistance of two for bed mobility and was totally dependent on 2 persons for transferring, dressing, and bathing. Resident #29 had no impairment of upper extremities including shoulder, elbow, wrist, and hand. The Quarterly MDS assessment with a target date of 11/10/23 noted Resident #29 had impaired range of motion on both upper extremities (shoulder, elbow, wrist, hand). The care plan initiated on 12/6/20 and revised on 1/3/24 noted the resident had limited physical mobility related to contractures (chronic loss of joint mobility) in the upper and lower extremities. The interventions initiated on 12/6/20 included monitoring, documenting, and reporting as needed any signs and symptoms of immobility; contractures forming or worsening. A Social Service Progress note dated 4/26/2023 documented family in agreement for Occupational Therapy to evaluate for wheelchair positioning and contracture management. Team in agreement with plan of care. On 1/16/24 at 10:48 a.m., Resident #29 was observed in bed. Resident #29's right and left hands were closed in a fist. Resident #29 was not able to respond to attempt to interview. Resident #29 was not wearing any hand splints or devices. On 1/16/24 at 11:54 a.m., Resident #29 was observed sitting up in her Broda (specialized positioning) chair. Resident #29's left, and right hands remained closed in a fist. Resident #29 was not wearing any splints or devices to the hands. On 1/17/24 at 9:08 a.m., Certified Nursing Assistant (CNA) Staff F said, We used to put wash clothes in her hands. Resident #29 was observed in bed with her left and right hands closed in a fist. On 1/17/24 at 10:03 a.m., Resident #29 was observed with Licensed Practical Nurse (LPN) Staff C. Resident #29's left, and right hands were closed in a fist. The resident was not wearing any splint or devices to the hands. Staff C said, sometimes we roll towels for her hands. On 1/17/24 12:01 p.m., Resident #29 was observed with her right and left hands closed in a fist. The resident was not wearing hand splints or rolled towels in her hands. On 1/18/24 at 8:22 a.m., CNA Staff M said, We roll the wash clothes to put in her hands whenever we remember. On 1/18/24 at 9:00 a.m., Registered Nurse (RN) Staff L said the specific care plan interventions for Resident #29 related to the contractures were resident is dependent on staff for feeding, dressing, and transfers. Therapy will reassess quarterly and as needed if there is a change or weakness. On 1/18/24 at 9:14 a.m., the Director of Rehab (DOR) said all residents are screened quarterly or more often if there is a referral from nursing. Residents will remain on the restorative program as long as needed. Once discharged they are monitored weekly for functional changes. All quarterly screenings are documented in the screening book. On 1/18/24 at 9:30 a.m., review of the screening book provided by the DOR failed to reveal quarterly therapy screenings for Resident #29 for the year 2023 or 2024. On 1/18/24 at 10:11 a.m., the Director of Restorative Services said Resident #29 was not on a restorative program. She confirmed there were no interventions in place addressing the resident's contractures. She said nursing staff should do light range of motion and keep the resident's nails trimmed. She said, I would think there should be specific interventions. We have had others with foam rolls, cones, but I don't see anything in place in this care plan. On 1/18/24 at 11:04 a.m., the DOR verified the lack of screening for Resident #29. The DOR said the resident should have been screened in July 2023, October 2023, and January 2024. On 1/18/24 at 11:43 a.m., the Occupational Therapist said she had not seen Resident #29 for quarterly screenings or restorative programming, and the nurse should have sent a referral. The Occupational Therapist said Resident #29 would benefit from custom or prefabricated splints for her hands. On 1/18/24 at 12:00 p.m., the MDS coordinator verified there were no specific interventions in the care plan related to Resident #29's contractures other than basic skin care. On 1/18/24 at 12:24 p.m., The DON said she would expect to see care plan interventions such as hand strengthening exercise, massage and wash cloth rolls for Resident #29. On 1/18/24 at 12:42 p.m., the Occupational Therapist verified Resident #29 was not receiving services for the hand contractures.

Based on observation, record review, and interview, the facility failed to develop and implement an individualized care plan to prevent decline in range of motion for 1 (Resident #29) of 2 residents reviewed with limited range of motion. The findings included: The facility policy, Plan of Care revised July 2023 noted, It is the policy of Cypress Cove to develop and implement a comprehensive person-centered care plan for each resident . that are identified in the resident's comprehensive assessment . Review of the clinical record for Resident #29 revealed an admitted [DATE] with diagnoses including Dementia and muscle weakness. The Admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 00. The Quarterly MDS assessment with a target date of 11/10/23 noted Resident #29 had functional limitation of upper extremities on both sides. Resident #29 had contractures (chronic loss of joint mobility), multiple sites. The care plan with an effective date of 12/6/2020 and revised on 12/8/22 noted the resident had limited physical mobility related to contractures in the upper and lower extremities. The interventions with an effective date of 12/6/20 included monitoring, documenting, and reporting as needed any signs or symptoms of immobility, contractures forming or worsening. The care plan did not list interventions to prevent further decline in range of motion. On 1/16/24 at 10:48 a.m., Resident #29 was observed in bed. Both hands were contracted, closed in a fist. Resident #29 was not wearing any splints or hand rolls to prevent further decline in range of motion of the resident's hands. On 1/16/24 at 11:54 a.m., Resident #29 was observed sitting up in her Broda (specialized positioning) chair with both hands closed in a fist. There were no splints, positioning devices or hand rolls visible in the room. On 1/17/24 at 9:08 a.m., Resident #29 was observed in bed with her hands tightly closed. In an interview, Certified Nursing Assistant (CNA) Staff F said, we used to put wash clothes in her hands. On 1/17/24 at 10:03 a.m., and 12:01 p.m., Resident #29 was observed with Licensed Practical Nurse (LPN) Staff C. Resident #29's hands remained in a closed fist. The resident had no rolls or splints in either hand. Staff C said, sometimes we roll towels for her hands. On 1/18/24 at 8:22 a.m., CNA Staff M said, We roll wash clothes to put in her hands whenever we remember. On 1/18/24 at 9:00 a.m., Staff L, Registered Nurse (RN) said the specific care plan interventions for Resident #29 related to the contractures were resident is dependent on staff for feeding, dressing, and transfers. Therapy will reassess quarterly and as needed if there is a change or weakness. On 1/18/24 at 12:00 p.m., the MDS coordinator said the care plan says all they were doing was monitoring for worsening skin breakdown and notify staff she has upper and lower extremity contractures. Hoping there are no complications like skin breakdown, thrombus and reporting to the doctor. On 1/18/24 at 12:24 p.m., the Director of Nursing (DON) said she would expect to see hand strengthening exercise, massage, wash cloth rolls in the comprehensive care plan.

Based on observation, interview, and review of the facility's medication storage policy the facility failed to appropriately manage expired drugs and biologicals for 2 of 2 med cart reviews. The findings included: Policies and procedures-Pharmacy Services for Nursing Facilities 2006 American Society of Consultant Pharmacists and MED-PASS, INC. (Revised January 2018) When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (Note: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be (30) days unless the manufacturer recommends another date or regulations/guidelines require different dating. 2. The nurse will check the expiration date of each medication before administering it. 3. No expired medication will be administered to a resident. 4. All expired medications will be removed from active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. 1. On 9/9/20 at 10:47 a.m., a side by side review of the medication cart in the Green Unit was conducted with Registered Nurse Staff B on the Green Unit. There was an opened bottle of Pro-Stat Liquid Protein- Nutrition Management (Concentrated protein for wound care) opened on 9/8/20, with an expiration date of 6/26/20. 2. On 9/9/20 at 1:25 p.m., a side by side review of cart in Tan Unit was conducted with Licensed Practical Nurse Staff C on the Tan Unit. There was an opened bottle of Geri-[MEDICATION NAME] DM (a cough suppressant [MEDICATION NAME]), with an expiration date of 4/20. On 9/10/20 at 10:53 a.m., an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing who confirmed the findings.

Based on observation, record review, resident and staff interview the facility failed to complete an assessment to determine the ability to self-administer medications for 1 (Resident #28) of 1 resident observed with unsecured medication at the bedside. The facility also failed to promote the resident's right and assess the resident's ability to self-administer medications for 1 (Resident #28) of 1 resident who requested to self-administer medications. The findings included: Review of the policy and procedure titled Self-Administration of Medication issued 11/1/01, last revised 6/2018 showed: Policy It is the policy of Cypress Cove to provide guidelines allowing residents to self-administer drugs safely and correctly when they request unless such practice is deemed unsafe. Residents may self-administer physician ordered bedside drugs after the interdisciplinary team has determined that this practice is safe. Guidelines: 1. If the resident requests to self-administer drugs, the nurse will notify the Director of Nursing or designee. The Director of Nursing or designee will complete the 'Self-Medication' form, and explain to the resident that the form will be reviewed by members of the interdisciplinary team. On 9/8/20 at 9:37 a.m., an unsecured bottle of [MEDICATION NAME] tablets (medication used to treat episodes of chest pain) was observed on Resident #28's dresser. He said the cardiologist prescribed the medication and told him to carry it at all times in case he experienced chest pain. Resident #28 said the nurses at the facility managed his medications and they were aware he carried the [MEDICATION NAME]. Resident #28 said no one gave him a locked box to safeguard the medication. On 9/8/20 at 9:40 a.m., during an interview Licensed Practical Nurse Staff D verified the observation and said Resident #28 did not have an evaluation for self-administration of medications. She said the [MEDICATION NAME] was not included in the physician's orders [REDACTED]. On 9/10/20 at 10:55 a.m., during an interview Resident #28 said he'd been carrying his [MEDICATION NAME] for the past [AGE] years but the nurse suddenly took it away from him and said it was against the rules to have it with him. He said the nurse told him to ask for the medication when he wanted it. Resident #28 said It doesn't make sense. Whatever happened to common sense? I leave the facility to go get [MEDICAL CONDITION] for [MEDICAL CONDITION]. If I have chest pain and I need a nitro when I am away from the facility I would have to call here and wait for the nurse to bring it to me. Resident #28 also said he was supposed to [MEDICATION NAME] each meal and had to ask for it. He said he'd asked the nurse several times to let him carry [MEDICATION NAME] he can take it when he was away from the facility, but they had refused.[MEDICATION NAME] a prescription medicine used to treat people who could not digest food normally because their pancreas did not make enough enzymes. Resident #28 said if he knew they would take his medications and not allow him to carry them, he would have hidden them. Resident #28 said when he went to the treatment center, he was away from the facility for 4 to 5 hours and ate at the treatment center, but he did not get the Creon. Review of the Medication Administration Record [REDACTED]. Review of the MAR for 9/2020 revealed on 9/2/20 and 9/9/20 at 11:00 a.m., the nurse documented the resident was absent from the facility without medications. On 9/10/20 at 11:30 a.m., during an interview the Director of Nursing said she was not aware the resident wanted to self-administer his medications. She said when he left the facility and he's going to be gone for a long time the facility sent a lunch with him. She verified the resident did not receive [MEDICATION NAME] ordered when he left the facility to go to the treatment center. On 9/10/20 at 12:20 p.m., during an interview the Dietary Manager said when Resident #28 left the facility for his treatments they generally sent a sandwich with him. On 9/10/20 at 1:15 p.m., the Director of Nursing said the facility did not have a plan in place to ensure Resident #28 received the [MEDICATION NAME] ordered with his lunch meal when he was away from the facility at lunch time for his [MEDICAL CONDITION]. She said the facility did not notify the physician that Resident #28 had not been receiving the medication as ordered.

Based on record review and resident and staff interview the consultant pharmacist failed to make recommendation for medication omission during the monthly drug regimen review for 1 (Resident #28) of 6 residents reviewed for unnecessary medications. The findings included: The facility's policy and procedure for Quality Reporting: Drug Regimen Review issued on 9/25/18 showed The pharmacy consultant will review the medical record for documentation that supports that a drug regimen review was conducted, and that any clinically significant medication issues identified were addressed in a timely manner. On 9/10/20 at 10:55 a.m., during an interview Resident #28 said he was supposed to [MEDICATION NAME] each meal and had to ask for it.[MEDICATION NAME] a prescription medicine used to treat people who could not digest food normally because their pancreas did not make enough enzymes. He said he'd asked the nurse several times to let him carry [MEDICATION NAME] he can take it when he was away from the facility, but they had refused. Resident #28 said when he went to the treatment center for [MEDICAL CONDITION], he was away from the facility for 4 to 5 hours. He ate at the treatment center but, he did not get the Creon. Review of the Medication Administration Record [REDACTED]. Review of the MAR for 9/2020 revealed on 9/2/20 and 9/9/20 at 11:00 a.m., the nurse documented the resident was absent from the facility without medications. On 9/10/20 at 11:30 a.m., during an interview the Director of Nursing said she was not aware the resident wanted to self-administer his medications. She said when he left the facility and he's going to be gone for a long time the facility sent a lunch with him. She stated, I've seen it myself. She verified on the MAR indicated [REDACTED]. On 9/10/20 at 12:20 p.m., during an interview with the Dietary Manager she said when Resident #28 left the facility for his treatments they gave him a lunch to take with him. she said generally it's a sandwich. On 9/10/20 at 1:15 p.m., the Director of Nursing said the facility did not have a plan in place to ensure Resident #28 received the [MEDICATION NAME] ordered with his lunch meal when he was away from the facility at lunch time for his [MEDICAL CONDITION]. She said the facility did not notify the physician Resident #28 had not been receiving the medication as ordered. Review of the Consultant Pharmacist's Medication Regimen Review for 8/2020 revealed no recommendation for Resident #28. On 9/10/20 at 1:30 p.m., during an interview the Consultant Pharmacist said if she had noticed they were not giving the medication when he went to [MEDICAL CONDITION] center, then she would have made the recommendation for him to receive it. On 9/10/20 at 2:10 p.m., during a second telephone interview the Consultant Pharmacist said she reviewed Resident #28's MARs but did not notice the omissions. She said if she had she would have certainly said something to the facility. The Consultant Pharmacist said she reviewed the clinical record and did not see documentation that Resident #28 suffered from any gastrointestinal symptoms. She also reviewed the medication insert and it says they cannot double the next dose to make up for the missed dose of medication. She repeated she did not notice the missed doses [MEDICATION NAME] would have made a recommendation if she had seen it. Although, she did say she did not think the few omissions were significant.

Based on observation, record review, resident and staff interviews, the facility failed to ensure 3 (Resident's #6, #13 and #22) of 6 residents reviewed for accident hazards received appropriate alternative interventions and informed consent was obtained prior to the use of side rails. Failure to ensure side rails were appropriate put the residents at potential risk of entrapment or injury. The findings included: Review of facilities policies and procedures side rail (quarter) screen issued 2/2009 and revised on 10/2018: It is the policy of Cypress Cove to provide a tool to screen those residents who require or request use of quarter side rails. All residents will be screened upon admission/readmission to determine necessity for quarter rails. A licensed nurse will screen the resident to determine the need for quarter side rails. The side rail screen in Point Click Care will be completed within 24 hours of admission. Resident consent and physician order [REDACTED]. 1. Observation on 2/18/19 at 11:30 a.m., Resident #13 was lying in his bed with a quarter bed rail raised on both sides of the bed and a scoop mattress (a mattress with inflatable side rails) was on the bed. The resident said the rails were already on the bed when he arrived at the facility and he did not feel he needed them. Review of Resident #13's medical record revealed he was admitted on [DATE]. The side rail consent form was signed by the resident on 11/12/18. The physician ordered the quarter side rails on 11/12/18. The side rail evaluation form was completed on 5/9/18 and reveals the resident required quarter side rails to serve as enabler to promote independence as needed. The evaluation indicated the resident had expressed a desire not to have the rails raised while in bed. There was no evidence of other interventions attempted prior to the use of the side rails. 2. Observation on 2/18/19 at 10:51 a.m., Resident #22 was in a high back wheel chair and the quarter side rails were in the up position on both sides of the bed. On 2/19/19 at 2:00 p.m., Resident #22 was in her bed and quarter side rails are up on both sides of the bed. Review of Resident #22's medical record revealed on 11/14/18, the Physician ordered quarter side rails to be used for mobility, positioning and comfort. The side rail assessment was completed on 5/26/17 and the resident had expressed a desire to have the quarter raised when in bed. There was no documentation of interventions attempted prior to the use of the side rails. In an interview on 2/20/19 at 1:23 p.m., with the Maintenance Supervisor, he said maintenance monitored the side rails for repair and routine maintenance, but the side rails were already on all of the beds. Maintenance did not apply the side rails to the beds. On 2/20/19 at 1:43 p.m., measurement of side rail gaps: length 6 1/2 inches, width 7 3/4 inches, diagonal 14 inches. There were no gaps between the mattress and the side rails. There were no gaps between the head or foot board and the mattress. In an interview on 2/20/19 at 3:57 p.m., the Director of Nursing said there was no documentation available instructing the staff to provide other interventions prior to the use of side rails. She said the side rail assessments were completed by the nursing staff and there was no instructions in the facility side rail policy and procedure as to how the assessment should be completed. 3. Observation on 2/19/19 at 1:47 p.m., Resident #6 was lying in her bed on her left side a pillow was placed between her and bedrail and the quarter bed rail raised on both sides of the bed. Review of Resident #6's medical record revealed she was admitted on [DATE]. Resident's side rail assessment was dated 11/10/15 and indicated the resident required quarter side rails to serve as enabler to promote independence as needed. No update or reassessment was documented in the electronic or hard chart in 3 years. Resident care plan recorded that resident required assistance of 2 staff members to turn and reposition in bed. The side rail consent form was signed by the resident but had no date. The side rail consent form recorded that it was the policy of the facility to use bedrails only after attempts at using alternatives have proven inadequate or inappropriate. There was no evidence of other interventions attempted prior to the use of the side rails. **Photos on File**

Based on observation, clinical record review and staff interview the facility failed to provide the prescribed diet ordered by the physician for 1 (Resident #22) of 2 residents reviewed. This had the potential to cause the resident to have continued weight loss. The findings included: During observations on 2/18/19 at 12:39 p.m., Resident #22 was being assisted with her noon meal by the facility nurse. The resident had a regular diet with ground meat. Observation on 2/19/19 at 1:13 p.m., Resident #22 was being assisted with her lunch and was eating a regular diet with ground meat. The resident's meal ticket listed the resident's diet as a mechanical soft diet. A review of Resident #22's medical record reveals a physician order dated 12/28/17 for a regular texture diet, thin consistency, and finger foods. The resident's care plan initiated 9/12/18 identified that Resident #22 had a problem of weight loss related to a fluctuating intake, advanced dementia and the need for assistance at meals. The care plan identified Resident #22's diet as a regular diet. A review of the facilities Dining Services Policy and Procedures, step 1. All residents must have a diet order on admission that shall be recorded in the resident's record. Step 2. All diet orders and changes in diet, will be communicated via the dietary communication form in the resident's electronic record. In an interview on 2/19/19 at 1:14 p.m., Licensed Practical Nurse Staff A said Resident #22's diet was a mechanical soft diet. A review of the facilities Dietary Communication form dated 6/7/18 for Resident #22, listed the diet as mechanical soft with ground meat. During an interview on 2/20/19 at 9:15 a.m., the Registered Dietician said the nursing staff would write the diet order received from the physician and then send a communication form to the dietary staff. She verified that there was no physician order for [REDACTED].>

Based on staff interview and record review, the facility failed to ensure 7 (Resident #1, #141, #136, #6, #293, #28, and #294) of 10 residents sampled had the admission comprehensive minimum data set (MDS) assessment completed within 14 days of being admitted to the facility as required by regulation. This lack of assessment has the ability to affect care planning and the care provided to residents. The findings included: On 3/13/18, record review of Resident #1 revealed an admission date of [DATE]. Further review revealed the admission comprehensive MDS assessment was still in progress, 25 days after admission. On 3/13/18, record review of Resident #141 revealed an admission date of [DATE]. Further review revealed the admission comprehensive MDS assessment was still in progress, 25 days after admission. On 3/13/18, record review of Resident #136 revealed an admission date of [DATE]. Further review revealed the admission comprehensive MDS assessment was still in progress, 28 days after admission. On 3/13/18, record review of Resident #6 revealed an admission date of [DATE]. Further review revealed the admission comprehensive MDS assessment was still in progress, 20 days after admission. On 3/13/18, record review of Resident#293 revealed an admission date of [DATE]. Further review revealed the admission comprehensive MDS assessment was still in progress, 18 days after admission. On 3/13/18, record review of Resident #28 revealed an admission date of [DATE]. Further review revealed the admission comprehensive MDS assessment was still in progress, 16 days after admission. On 3/13/18, record review of Resident #294 revealed an admission date of [DATE]. Further review revealed the admission comprehensive MDS assessment was still in progress, 15 days after admission. On 3/14/18 at approximately 1:30 p.m., the facility MDS Coordinator confirmed the admission comprehensive assessment for Resident (#1, #141, #136, #6, #293, #28, and #294) had not been completed within 14 days of admission as required by regulation.

Based on observation, record review, staff interview, review of the Nurse Practice Act and the facility's policy and procedures for wound management, nursing staff failed to accurately assess the skin condition for 1 (Resident #11) of 2 residents reviewed with skin issues. The failure to accurately assess the resident's skin could contribute to the lack of identifying a significant change in the resident's condition and worsening of wounds. The findings included: 1. Review of the Nurse Practice Act for Registered Nurses (RN's): Florida Statute 464.003 included: (20) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b) The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (c) The supervision and teaching of other personnel in the theory and performance of any of the acts described in this subsection .(22) Registered nurse means any person licensed in this state to practice professional nursing .(18) Nursing treatment means the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health. Review of the Nurse Practice Act for Licensed Practical Nurse (LPN's): Florida Statute 464.003 included: (19) Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. A practical nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing .(16) Licensed practical nurse means any person licensed in this state to practice practical nursing. Review of the facility's policy and procedures titled, Skin-Wound Management Program, revised 3/2016, included: .ON-GOING SURVEILLANCE: RN/LPN Weekly Skin Assessment-Head to toe assessment will be completed on a weekly basis Monday-Sunday by the designated 7-3 or 3-11 Licensed Nurse .SKIN CONDITION FORM-All wounds, regardless of etiology (surgical, skin tears, abrasions, pressure, vascular), will be documented using the 'Skin Conditions' . The policy included the LPN in the assessment process which was not in accordance with Florida Nursing Practice act. The policy did not define how the nurses were to complete the head to toe weekly skin assessment and did not delineate the process between skin assessment and 'skin checks'. 2. On 3/12/18 at 12:22 p.m., LPN Staff A said Resident #11 was treated for [REDACTED]. On 3/13/18 at 1:33 p.m., Staff A entered Resident #11's room and assisted the resident to a right side-lying position. Staff A said when she did a skin check, she was looking for open areas, skin tears, and then said, Well, just about everything. Staff A removed a blue boot from Resident #11's right foot and while holding up her foot said there were no wounds on the heel. Staff A did not see a small, deep reddish-purple area on the Achilles portion of the right heel. A cluster of deep reddish-purple areas was observed on the right anterior shin. Staff A said she did a skin check earlier in the morning and the resident's skin was clear. Staff A said she would notify her supervisor. On 3/13/18 at 1:41 p.m., RN Supervisor (RNS) Staff B removed the right heel boot and measured the wound on Resident #11's heel and said the wound was an unstageable pressure sore. Staff B observed the cluster of deep reddish purple areas on the anterior right leg. Staff B said Resident #11 developed bleeds under her skin. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the skin observation tool completed by Staff A dated 3/13/18 at 11:50 a.m., approximately 1 1/2 hours earlier, found no skin issues and documented the resident's skin was intact. Review of the skin observations tools and daily/weekly skilled and long term charting completed by Staff A for the dates of 2/6/18, 2/13/18, 2/20/18, and 2/27/18 documented Resident #11's skin as intact and without any identified concerns. On 3/14/18 at 8:44 a.m., the Director of Nurses (DON) said when doing skin checks, she expected her nurses to go in and with the resident undressed, observe the resident from head to toe and visually inspect the resident's body. She said they (nurses) were to document what they saw on the weekly skin documentation areas. The DON did not comment when informed of the newly discovered pressure wound on right Achilles and cluster of reddish-purple areas on the resident's right anterior shin. On 3/14/18 at 10:54 a.m., LPN Staff A confirmed she completed the skin observation tool on Resident #11. She admitted when she did her skin observation (on 3/13/18), Resident #11 was wearing a gown and she did not remove the gown during her head to toe skin check. Staff A said she did not remove the resident's clothing when doing skin checks.

Based on observation, record reviews, staff interviews, and review of Do Not Resuscitate Orders (DNROs) and advanced directives, the facility failed to honor the advanced directives of 2 (Resident #9 and #12) of 2 residents reviewed for DNRO's and advanced care planning. This failure could impact quality care at the end of life for the residents. The findings included: 1. On 3/13/18 at 1:30 p.m., Resident #9 was observed in her room in bed. She was awake and could answer simple questions when asked. Review of the quarterly Minimum Data Set with a reference date of 12/19/17 showed Resident #9 was unable to participate in a review for mental status. Review of the advanced directives section of the chart found a Do Not Resuscitate Order (DNRO) dated 11/20/17 and signed by Resident #9's spouse as the surrogate and durable power of attorney. Record review showed a document signed and dated 5/27/15 by Resident #9 entitled, Comprehensive Advanced Directive which designated Resident #9's spouse as the health care surrogate in the event Resident #9 should become incapacitated. Within this document was a Living Will that included: .if at any time I am incapacitated, and if one or more of the following conditions applies to me: (1) I have a terminal condition; (2) I have an end-stage condition .(3) I am in a persistent vegetative state .I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I should be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or alleviate pain . Also included in this Comprehensive Advanced Directive, page 6 of 6, found the following: .Pursuant to Florida Statue 765.204(2), if a principals' capacity to make health care decisions for himself or provide informed consent is in question, the attending physician shall evaluate the principal's capacity, and if the physician concludes that the principal lacks such capacity, (the attending physician shall) enter that evaluation in the principal's medical record . Record review failed to show Resident #9 was deemed incapacitated to make healthcare decisions. The record failed to show the resident was diagnosed with [REDACTED]. The record failed to show any social service notes related to advanced care planning since (MONTH) (YEAR). (Advance care planning is a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions.) On 3/13/18 at 3:01 p.m., the Transitions of Care Manager (TCM) admitted she could not find the incapacity statement for Resident #9 and did not know why any of her notes were not in the record. The TCM said Resident #9 was on their comfort care program and her spouse did not want Resident #9 hospitalized . The TCM confirmed neither a terminal or end-stage [DIAGNOSES REDACTED].#9 was not in a vegetative state. The TCM said she would request a psychiatrist who was not the physician for the resident and the primary physician to evaluate Resident #9's capacity to make decisions and have her spouse re-sign a valid DNRO. 2. Review of the quarterly Minimum Data Set assessment with a reference date of 12/27/17 documented Resident #12 with severely impaired decision making skills and could not participate in the interview for mental status. Record review found no care plan addressed Resident #12's advanced directives. Review of the advanced directives section of the clinical record showed a DNRO signed and dated 12/31/15 by Resident #12's son as the Durable Power of Attorney. Review of the document titled Declaration to Withhold Life-Sustaining Treatment (California Health and Safety code .) dated 7/30/1992 included: .If I should have an incurable and irreversible condition that has been diagnosed by two physicians and that will result in my death within a relatively short time .and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Natural Death Act of California, to withhold or withdraw treatment . A Durable Power of Attorney for Health care (California Civil Code .), unsigned and undated, included: .3. General Statement of Authority Granted .If I become incapable of making informed health care decisions, I grant my Agent full power and authority to make health care decisions for me, to the same extent that I could make such decisions for myself, if I had the capacity to do so, subject to the limitations set forth in this document . A Designation of Health Care Surrogate (HCS) signed and dated 4/20/15 by Resident #12 included: .In the event that I have been determined to be incapacitated to provide informed consent for medical treatment and surgical diagnostic procedures, I wish to designate as my surrogate for health care decisions: (spouse) . Record review failed to show Resident #12 was deemed incapacitated to make healthcare decisions. On 3/14/18 at 12:30 p.m., the TCM said the current DNRO for Resident #12 was signed by a physician and her son while Resident #12 was in the hospital. She confirmed she did not have an incapacity statement from Resident #12's primary physician and said there should've been an incapacity statement in place in accordance with Resident #12's advanced directives in order to ensure her HCS could sign the DNRO as valid.

Based on record review and staff interview, the facility failed to ensure as needed (PRN) [MEDICAL CONDITION] medications (medications that affect a person's mental state) were not extended beyond 14 days without being reordered and documenting the rationale and duration for the PRN order for 1 (Residents #23) of 6 Residents reviewed. This has the potential to lead to administration of unnecessary medication. The findings included: Review of the facility policy titled: Use of Antipsychotic Drugs, revised on (MONTH) 20, (YEAR), revealed as needed (prn) orders for [MEDICAL CONDITION] drugs were limited to 14 days except as provided if the attending physician or prescribing practitioner believed that it was appropriate for the prn order to be extended beyond 14 days. He or she should document their rationale in the resident's medical record and indicate the duration for prn order. On 3/14/18 record review of Resident #23 revealed an order for [REDACTED]. On 3/14/18 a review of the Medication Administration Record [REDACTED]. On 3/14/18 at 3:43 p.m., the Director of Nursing confirmed the PRN [MEDICAL CONDITION] medication use exceeded the 14 day limit without being reordered for Resident #23. There was no specified duration or documentation of a rationale to support the continued use of the prn [MEDICAL CONDITION] medication.

Based on observation, record review, and staff interviews, the facility failed to provide care to a resident with dementia in a manner to prevent the resident from becoming injured when being resistive to care. The facility failed to assess, plan care and provide individualized interventions to prevent and minimize distress when approached for care for 1 (Resident #23) of 3 residents reviewed for dementia care. The findings included: On 3/12/18 at 12:11 p.m., Resident #23 was observed sitting in a wheelchair in the day room watching television (TV). The resident was observed to have a healing skin tear on her right knuckle approximately 1.5 centimeter (cm) in length. The surrounding skin was reddish/purple in color. A dressing was noted to the right elbow area and the surrounding skin was also reddish/purple in color. The resident was confused and unable to answer any questions. Resident #23's clinical record revealed a [DIAGNOSES REDACTED]. Behavior flow records were reviewed from 2/1/18 through 3/12/18 and indicated the resident had exhibited combative behaviors on 14 of the 40 days reviewed. These behaviors occurred mostly on the evening shift. Nursing notes were reviewed and showed on 1/24/18 at 9:59 p.m., the nurse noted the resident was combative during transfer from the wheelchair to her bed and sustained a skin tear 2.0 cm by 0.5 cm to her right elbow. On 2/8/18 at 9:28 p.m., the nurse noted the resident became combative during care and hit her right hand resulting in a skin tear measuring 1.2 cm in length. On 3/9/18 at 9:35 p.m., the nurse noted when 2 Certified Nursing Assistants (CNAs) were transferring Resident #23 to bed with a mechanical lift, the resident was kicking, hitting, and trying to bite staff. The resident hit her right arm on the lift and sustained a skin tear near her right elbow. On 3/13/18 at 12:27 p.m., Licensed Practical Nurse (LPN) Staff A said Resident #23 could be very combative, angry, strike out, yell at staff, and was resistive to care. Staff A said sometimes the dining room was too much stimulation and when the resident was angry she put her in the TV room. Staff A said the resident was usually receptive to care during the day but did get tired and angrier in the evening. On 3/13/18 at 12:48 p.m., CNA Staff C said she routinely took care of Resident #23 on the day shift. She said the resident sometimes was in a mood and would be upset. She said this occurred usually when you bother her for care. Staff C said she did not attend any care plan meetings and did not know of any written planned approaches to use when the resident was upset. On 3/13/18 at 2:58 p.m., Registered Nurse Staff E said she took care of Resident #23 on the evening shift and she was frequently combative and resistive to care. Staff E said triggers for the behavior were transfers with the lift, showers, and any attempts at moving her. On 3/13/18 at 3:11 p.m., CNA Staff F said she took care of the resident 4 to 5 days a week. She said the resident did have behaviors, yelled, and hit when approached for care. This occurred usually when staff had to use the lift to give her care. She said it did take 2 staff to give care and the resident had injured herself from being combative. Staff F said there were no care instructions in regards to the resident's behaviors. There was no evidence of any assessment of the resident's behaviors to include stressors causing the resident to exhibit these behaviors in the resident's clinical record. The interdisciplinary care plan was reviewed on 3/14/18 and did not address the resident's combative/resistive behavior which had resulted in injury on several occasions. There was no systematic process directed towards preventing, relieving and/or accommodating the resident's distress when approached for care to include individualized approaches for staff to use. On 3/14/18 at 2:33 p.m., the LPN Care Plan Coordinator said nursing staff were welcome to attend care plan meetings but did not schedule direct care staff any time from their duties so they could attend. The Care Plan Coordinator said she was aware the resident had sustained skin tears from being resistive to care and confirmed there was no care plan developed to address this problem to included approaches for staff to use to minimize resident injuries and distress.

Based on observation, record review, and staff interview, the facility QAA (Quality assessment and assurance) committee failed to develop and implement an appropriate plan of action to correct previously identified quality deficiencies regarding skin assessments. The findings included: 1. On 5/16/18 at 1:28 p.m., during QAA meeting with the Director of Nursing (DON), she reported she had an education day on 4/4/18 and facility staff were required to sign in. The sign in sheet contained 26 nurses, 12 of whom did not sign in and 11 of the 12 nurses were Licensed Practical Nurses (LPN's). The DON reported the staff who did not sign in for the education day were supposed to meet with her to receive their education, but she could not remember who came to see her. 2. Record review of facility policy and procedure for skin wound care management program revised 4/2018 revealed: On-going Surveillance: RN/LPN Weekly Skin Assessment. Head to toe skin check will be completed on a weekly basis Monday-Sunday by the designated 7-3 or 3-11 licensed nurse. Resident will be assessed from head to toe while clothing is removed to ensure all body areas are able to be visually inspected. The policy did not define the difference between skin assessment and 'skin checks' and included the LPN in the on-going surveillance weekly skin assessment process. On 5/16/18 at 8:45 a.m., interview with the DON revealed the policy should have been updated to read skin check not skin assessment. The DON reported on 5/16/18 at 2:10 p.m., the policy should have been changed to On-going surveillance for RN/LPN skin observation. 3. Record review of staff meeting agenda for: Nursing Staff Meeting - State Survey and Plan of Correction dated 4/4/18. Under heading F Tag 684 -Quality of Care heading listed: 1 resident's Skin assessment did not include discoloration noted to bilateral legs. Skin assessment completed to include discoloration to bilateral legs. Staff Education. Policy updated to delineate between LPN and RN duties. Record review of LPN's documentation of skin revealed they documented assessments. During QAA meeting on 5/16/18 at 1:28 p.m., the DON reported she never educated the LPN's on not using the word assessment for their documentation of skin observation.

Based on observation, record review, and staff interview, the facility QAA (Quality assessment and assurance) committee failed to develop and implement an appropriate plan of action to correct previously identified quality deficiencies regarding skin assessments. The findings included: 1. On 5/16/18 at 1:28 p.m., during QAA meeting with the Director of Nursing (DON), she reported she had an education day on 4/4/18 and facility staff were required to sign in. The sign in sheet contained 26 nurses, 12 of whom did not sign in and 11 of the 12 nurses were Licensed Practical Nurses (LPN's). The DON reported the staff who did not sign in for the education day were supposed to meet with her to receive their education, but she could not remember who came to see her. 2. Record review of facility policy and procedure for skin wound care management program revised 4/2018 revealed: On-going Surveillance: RN/LPN Weekly Skin Assessment. Head to toe skin check will be completed on a weekly basis Monday-Sunday by the designated 7-3 or 3-11 licensed nurse. Resident will be assessed from head to toe while clothing is removed to ensure all body areas are able to be visually inspected. The policy did not define the difference between skin assessment and 'skin checks' and included the LPN in the on-going surveillance weekly skin assessment process. On 5/16/18 at 8:45 a.m., interview with the DON revealed the policy should have been updated to read skin check not skin assessment. The DON reported on 5/16/18 at 2:10 p.m., the policy should have been changed to On-going surveillance for RN/LPN skin observation. 3. Record review of staff meeting agenda for: Nursing Staff Meeting - State Survey and Plan of Correction dated 4/4/18. Under heading F Tag 684 -Quality of Care heading listed: 1 resident's Skin assessment did not include discoloration noted to bilateral legs. Skin assessment completed to include discoloration to bilateral legs. Staff Education. Policy updated to delineate between LPN and RN duties. Record review of LPN's documentation of skin revealed they documented assessments. During QAA meeting on 5/16/18 at 1:28 p.m., the DON reported she never educated the LPN's on not using the word assessment for their documentation of skin observation.

Based on record reviews, and interviews, the facility failed to ensure qualified professionals completed assessments in accordance with professional standards for 3 (Residents #4, #2, and #1) of 4 residents at risk for developing, or worsening pressure ulcers. Pressure ulcer assessments were not completed in accordance to the Florida Board of Nursing, Nurse Practice Act, or with current standards of practice as outlined by the National Pressure Ulcer Advisory Panel. The findings included: According to the Florida Board of Nursing, the performance of an assessment was a function of a Registered Nurse (RN) and was not within the scope of practice for a Licensed Practical Nurse (LPN). The Florida Board of Nursing, Nurse Practice Act Chapter 464 Florida Statutes; 464.003 Definitions, (3) (a) 1. Practice of professional nursing (RN); was defined as The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care . Under section 3. (b) Practice of Practical Nursing (LPN) meant the performance of selected acts, including the administration of treatments and medications . Current standard of practice for pressure ulcer assessments were outlined in the National Pressure Ulcer Advisory Panel (NPUAP) (web site at http://www.npuap.org) on page 11, pressure ulcer assessment: Assess the pressure ulcer initially and re-assess it at least weekly, documenting findings. 1. On 2/25/16 at 11:24 a.m., Staff C, RN Supervisor, (facility's wound care nurse), said Resident #4 had a stage 2 pressure ulcer on her coccyx present on admission on 2/16/16. On 2/25/16 at 12:02 p.m., the Advanced Registered Nurse Practitioner (ARNP) said she worked with Staff C, RN, and looked at any wounds weekly. The ARNP said Resident #4 had a pressure ulcer on her sacrum area present on admission. She said the wound was a stage 2, improving, and there was nothing complicated about it. Resident #4's clinical record indicated the resident was admitted on [DATE]. The hospital discharge information noted the resident had a stage 3 pressure ulcer on her sacrum/coccyx. (The NPUAP defines stage 3 as full thickness skin loss and slough may be present in the wound). A skin assessment form completed by Staff A, LPN, on 2/17/16, indicated Resident #4 had a stage 3 pressure ulcer, and there was slough (yellow [MEDICATION NAME] tissue) in the wound bed. The wound measured 2.4 centimeters (cm) x 0.8 cm in size x 0.2 cm in depth. Staff A noted the surrounding skin was dark. On 2/17/16, the ARNP documented in a progress note Resident #4 had an open wound to her coccyx. The ARNP did not describe or note a stage for the wound. On 2/22/16, Staff C, RN, completed a skin assessment form and noted the resident had a stage 2 pressure ulcer measured at 1.8 cm x 1.0 cm in size. Staff C indicated there was no slough in the wound bed. On 2/25/16 at 1:57 a.m., Staff B, LPN, noted on a skin assessment form, the tissue in the wound had no slough and measured 1.7 cm x 1.0 cm in size. Staff B noted there was purulent drainage (associated with infection) and under stage: Further Assessment Required. On 2/25/16 at 1:40 p.m., after obtaining Resident #4's consent, her pressure ulcer was observed along with Staff C, RN, and Staff D, LPN. The foam dressing was removed and a stage 3 pressure ulcer was observed on the resident's coccyx. A small amount of yellow-colored drainage was on the dressing. The center of the wound had an area of slough 0.5 cm x 0.25 cm in size and the overall size of the wound was 1.0 cm x 0.75 cm. On 2/25/16 at 2:00 p.m., Staff C, RN, confirmed the initial assessment of Resident #4's pressure ulcer had been done by an LPN. She said neither she nor the ARNP looked at the wound on 2/17/16. Staff C said the facility allowed the LPN staff to do the initial assessments of the wounds, including staging them. Staff C said she had not been made aware of any slough in the wound and the slough was not present when she did her assessment on 2/22/16. Staff C acknowledged the wound was a stage 3 and would alert the ARNP. 2. Resident #1 was admitted to the facility on [DATE]. The MDS of 10/21/15 and 10/27/15 (discharge) documented the resident had 2 unstageable pressure ulcers with suspected deep tissue injury in evolution were present on admission, a foley catheter and frequent bowel incontinence. A comprehensive care plan of 10/15/15 identified deep tissue injury to the sacrum and right heel. Interventions included assess and measure wound weekly and as needed, dietary consult, off load heels, heel protectors in bed, wheel chair cushion for wheel chair, check every 2 hours for incontinence. Review of the medical record revealed a Skin Assessment Form was completed by a LPN as follows: On 10/14/15 - beefy red open area to sacrum/buttocks, no drainage noted 7.5 cm x 8.5 cm. Pressure area noted to right heel, red with small purple area unblanchable. On 10/15/15 - Dressing change to sacral suspected deep tissue injury, writer assisted by Director of Nursing (DON) to assess wound and recommendation is to continue treatment until ARNP can assess sacral area. (There were no measurements documented and no signature of the DON.) On 10/16/15 - Deep tissue injury on right heel purple small intact 0.2 x 1.0. On 10/18/15 - Partial Thickness Wound, pinpoint area right heel 0.2 x 1.0 and Partial Thickness Wound red/blackish area, draining serosanganous drainage on sacrum 7.5 cm x 8.2 cm. On 10/24/15 - Sacrum, area on left upper buttocks black foul odor circular with redness around wound 7 cm x 7.5 cm, necrotic/eschar, time physician notified 0.0 (no documentation that physician was notified of the change of condition of the pressure ulcer); right heel purple intact 0.2 cm x 1 cm. (necrotic/eschar is dead tissue) The ARNP performed a History and Physical (H&P) on 10/16/15 (signed by physician on 10/20/15) and identified sacral hematoma and sacral, heel and left leg wounds with blisters, will observe. This H&P also said the resident was continent of bowel and bladder. On 10/19/15, the ARNP stated, Pain Rounds, she complains of pain in lower right leg preventing her from moving around in bed or getting out of bed. She has a wound on her heel and sacrum and on her left hip there are blisters. She is s/p (status [REDACTED]. Plan is to get her out of bed tomorrow. Wounds - Allevyn (non-medicated dressing) on heel. Will observe left hip and sacrum. The ARNP notes documented: On 10/20/15, draining blisters left leg - C&S (Culture and Sensitivity) awaiting results, Wounds - deep tissue to sacrum and right heel. Inactivity, will try to control pain. Instructed in pain control. On 10/21/15, Wounds: sacrum dark red deep tissue, right heel, small healing deep tissue closed. On 10/23/15, Sacral wound, continue same treatment. On 10/26/15, Sacral wound measured 7 cm x 7.5 cm area of black eschar with redness surrounding site, foul smelling, serous drainage, localized warmth and tenderness. Sacral wound - [MEDICATION NAME] and bacroban bid to site with allevyn cover. Wound consultation. (See above for LPN note of 10/24/15 documented the same information.) Record review revealed a physician note dated 10/21/15, No complications, Patient has complaints of pain today. No pressure ulcers were identified by the physician. On 2/25/16 at 12:48 p.m., the ARNP said the resident developed the sacral pressure sore when she fell at home and laid on the floor for 4 days. She was admitted to the hospital and then to this facility. The resident was nutritionally comprised and admitted for after care for left hip open reduction, internal fixation on 10/12/15 secondary to the fall. The ARNP stated We realized that the sacral wound was very severe and was not responding to treatment and sent her back to the hospital within a few days. I talked to the family on many occasions to keep them up to date regarding the wound and the care the resident was receiving and notified them regarding the decision to send the resident to the hospital for wound care. On 2/25/16 at 2:00 p.m., Staff C, RN, confirmed the initial and subsequent assessments of Resident #1's pressure ulcers had been done by an LPN. Staff C said the facility allowed the LPN staff to do the assessments of the wounds, including staging them. On 2/25/16 at 5:00 p.m., during exit interview, the DON acknowledged assessment was not within the LPN's scope of practice. 3. Review of the medical record for Resident #2 revealed the Skin Assessment Form was completed by LPN's as follows: On 11/24/15 - slit in gluteal crease with maceration 1cm x 0.2 cm treatment of [REDACTED]. On 12/1/15 - upper buttocks reddened continue current treatment of [REDACTED]. On 12/8/15 - reddened and cracked upper buttocks On 12/12/15 left buttock small open area due to friction 2.5 x 1.0 cm Allevyn dressing (non-medicated dressing) no bag balm. On 12/15/15 - Allevyn dressing discontinued and bag balm restarted. On 12/17/15 - open small area to right buttocks .9 cm x .2 cm, left buttock 4 cm x .5 cm. On 12/22/15 - excoriated areas to both sides of buttocks. On 12/29/15 - buttocks red, blanchable. On 1/5/16 - right buttocks small superficial open area, left buttock 2 small superficial open areas. On 1/12/16 - buttocks red continue bag balm no open areas. On 1/19/16 - large reddened area on both buttocks and 2 small open areas on both buttocks. On 1/17/16 - Allevyn dressing started and discontinued on 1/18/16 and bag balm restarted. On 1/22/16 - changed to bag balm to buttocks and [MEDICATION NAME] to any macerated or reddened areas on buttocks. On 2/2/16 - reddened buttocks with open areas (no measurements). On 2/4/15 - left buttocks small open area from moisture and stool, edges white, pink center, oblong shape .2 cm x .5cm. On 2/9/16 - redness noted to buttocks continue bag balm/[MEDICATION NAME]. On 2/16/16 - very small open area on left buttocks not measurable. On 2/23/16 - pinpoint opening to left buttocks and right buttocks. On 2/25/16 at 12:48 p.m., the ARNP said she tried to see all residents with wounds, at least weekly. She said she also worked with the Staff C, RN Nursing Supervisor, who monitored all residents with wounds and said Staff C was furthering her education in this regard. The ARNP said she observed Resident #2's wound on 2/25/16 and it was rashy and somewhat yeasty and fungal in nature; and the treatment was being changed. She also said she was ordering a nutritional consult and the resident had a history of [REDACTED]. On 2/25/16 at 2:00 p.m., Staff C, RN, confirmed the initial and subsequent assessments of Resident #2's pressure ulcers had been done by an LPN. Staff C said the facility allowed the LPN staff to do the assessments of the wounds, including staging them. On 2/25/16 at 5:00 p.m., during exit interview, the DON acknowledged assessment was not within the LPN's scope of practice.

Based on observation, record review and interviews, the facility failed to accurately assess, comprehensively plan for and consistently monitor 3 (Resident #4, #1, and #2) of 4 sampled residents with pressure sores to ensure they received the necessary treatment and services to promote healing, prevent infection and worsening of the pressure sore. The findings included: According to the Florida Board of Nursing, the performance of an assessment was a function of a Registered Nurse (RN) and was not within the scope of practice for a Licensed Practical Nurse (LPN). The Florida Board of Nursing, Nurse Practice Act Chapter 464 Florida Statutes; 464.003 Definitions, (3) (a) 1. Practice of professional nursing (RN); was defined as The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care . Under section 3. (b) Practice of Practical Nursing (LPN) meant the performance of selected acts, including the administration of treatments and medications . Current standard of practice for pressure ulcer assessments were outlined in the National Pressure Ulcer Advisory Panel (NPUAP) (web site at http://www.npuap.org) on page 11, pressure ulcer assessment: Assess the pressure ulcer initially and re-assess it at least weekly, documenting findings. Assess and document physical characteristics including; location, Category/Stage, size, tissue type, color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate and odor. 1. On 2/25/16 at 11:24 a.m., RN Supervisor Staff C (facility's wound care nurse), said Resident #4 had a stage 2 pressure ulcer on her coccyx present on admission. On 2/25/16 at 12:02 p.m., the Advanced Registered Nurse Practitioner (ARNP) said she worked with Staff C and looked at any wounds weekly. The ARNP said Resident #4 had a pressure ulcer on her sacrum area present on admission. She said the wound was a stage 2, improving, and there was nothing complicated about it. Resident #4's clinical record indicated the resident was admitted on [DATE]. The hospital discharge information noted the resident had a stage 3 pressure ulcer on her sacrum/coccyx. (The NPUAP defines stage 3 as full thickness skin loss and slough may be present in the wound). A skin assessment form completed by LPN Staff A on 2/17/16, indicated Resident #4 had a stage 3 pressure ulcer, and there was slough (yellow [MEDICATION NAME] tissue) in the wound bed. The wound measured 2.4 centimeters (cm) x 0.8 cm in size x 0.2 cm in depth. Staff A noted the surrounding skin was dark. The ARNP did not describe or note a stage for the wound. On 2/22/16, RN Staff C completed a skin assessment form and noted the resident had a stage 2 pressure ulcer measured at 1.8 cm x 1.0 cm in size. Staff C indicated there was no slough in the wound bed. On 2/25/16 at 1:57 a.m., LPN Staff B noted on a skin assessment form, the tissue in the wound had no slough and measured 1.7 cm x 1.0 cm in size. Staff B noted there was purulent drainage (associated with infection) and under stage: Further Assessment Required. On 2/25/16 at 1:40 p.m., after obtaining Resident #4's consent, her pressure ulcer was observed along with RN Staff C and LPN Staff D. The foam dressing was removed and a stage 3 pressure ulcer was observed on the resident's coccyx. A small amount of yellow-colored drainage was on the dressing. The center of the wound had an area of slough 0.5 cm x 0.25 cm in size and the overall size of the wound was 1.0 cm x 0.75 cm. On 2/25/16 at 2:00 p.m., RN Staff C confirmed the initial assessment of Resident #4's pressure ulcer had been done by an LPN. She said neither she nor the ARNP looked at the wound on 2/17/16. Staff C said the facility allowed the LPN staff to do the initial assessments of the wounds, including staging them. Staff C said she had not been made aware of any slough in the wound and the slough was not present when she did her assessment on 2/22/16. Staff C acknowledged the wound was a stage 3 and would alert the ARNP. On 2/25/16 at 5:00 p.m., the Administrator and Director of Nursing (DON) said the facility's practice of allowing LPN staff to perform assessments and evaluate care in regards to the pressure ulcers was reviewed. The DON acknowledged the concern with the lack of initial assessment, identification and communication with the ARNP, so that care may be evaluated, in regards to Resident #4's wound. 2. Resident #1 was admitted to the facility on [DATE]. A Minimum Data Set (MDS) assessment of 10/21/15 (5 day) documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS of 10/21/15 and 10/27/15 (discharge) documented the resident had 2 unstageable pressure ulcers with suspected deep tissue injury in evolution were present on admission, a Foley catheter and frequent bowel incontinence. A Comprehensive Care Plan of 10/15/15 identified deep tissue injury to the sacrum and right heel. Interventions included assess and measure wound weekly and as needed, dietary consult, off load heels, heel protectors in bed, wheel chair cushion for wheel chair, check every 2 hours for incontinence. Review of the medical record revealed aSkin Assessment Form was completed by a LPN as follows: On 10/14/15 - beefy red open area to sacrum/buttocks, no drainage noted 7.5 cm x 8.5 cm. Pressure area noted to right heel, red with small purple area unblanchable. On 10/15/15 - Dressing change to sacral suspected deep tissue injury, writer assisted by DON to assess wound and recommendation is to continue treatment until ARNP can assess sacral area. (There were no measurements documented and no signature of the DON.) On 10/16/15 - Deep tissue injury on right heel purple small intact 0.2 x 1.0. On 10/18/15 - Partial Thickness Wound, pinpoint area right heel 0.2 x 1.0 and Partial Thickness Wound red/blackish area, draining serosanganous drainage on sacrum 7.5 cm x 8.2 cm. On 10/24/15 - Sacrum, area on left upper buttocks black foul odor circular with redness around wound 7 cm x 7.5 cm, necrotic/eschar, time physician notified 0.0 (no documentation that physician was notified of the change of condition of the pressure ulcer); right heel purple intact 0.2 cm x 1 cm. The ARNP performed a History and Physical (H&P) on 10/16/15 (signed by physician on 10/20/15) and identified sacral hematoma and sacral, heel and left leg wounds with blisters, will observe. This H&P also stated that the resident was continent of bowel and bladder. ARNP notes stated on 10/19/15: Pain Rounds, she complains of pain in lower right leg preventing her from moving around in bed or getting out of bed. She has a wound on her heel and sacrum and on her left hip there are blisters. She is s/p (status [REDACTED]. Plan is to get her out of bed tomorrow. Wounds - Allevyn (non-medicated dressing) on heel. Will observe left hip and sacrum. The ARNP documented: On 10/20/15 - draining blisters left leg - C&S awaiting results, Wounds - deep tissue to sacrum and right heel. Inactivity, will try to control pain. Instructed in pain control. On 10/21/15 - Wounds: sacrum dark red deep tissue, right heel, small healing deep tissue closed. On 10/23/15 - Sacral wound, continue same treatment. On 10/26/15 - Sacral wound measured 7 cm x 7.5 cm area of black eschar with redness surrounding site, foul smelling, serous drainage, localized warmth and tenderness. Sacral wound - [MEDICATION NAME] and bacroban bid to site with allevyn cover. Wound consultation. (See above for LPN note of 10/24/15 that documents the same information.) A physician note dated 10/21/15 stated No complications, Patient has complaints of pain today. No pressure ulcers were identified by the physician. On 2/25/16 at 12:48 p.m., the ARNP revealed the resident developed the sacral pressure sore when she fell at home and laid on the floor for 4 days. She was admitted to the hospital and then to this facility. The resident was nutritionally comprised and admitted for after care for left hip open reduction, internal fixation on 10/12/15 secondary to the fall. The ARNP stated We realized that the sacral wound was very severe and was not responding to treatment and sent her back to the hospital within a few days. I talked to the family on many occasions to keep them up to date regarding the wound and the care the resident was receiving and notified them regarding the decision to send the resident to the hospital for wound care. On 2/25/16 at 2:00 p.m., Staff C, RN, confirmed the initial and subsequent assessments of Resident #1's pressure ulcers had been done by an LPN. Staff C said the facility allowed the LPN staff to do the assessments of the wounds, including staging them. On 2/25/16 at 5:00 p.m., during exit interview, the DON acknowledged the assessment was not within the LPN's scope of practice. Resident #1's discharge note, from the hospital, on 10/14/15 stated, Sacral deep tissue pressure injury in evolution, pressure threatened to right heel. Plan: maximal offloading with Clinitron bed (specilty air mattress) and foam wedge propping. Bilateral waffleboots. Frequent position change. [MEDICATION NAME] ointment to sacral/buttock injured skin followed by [MEDICATION NAME] Sacrum Border outer dressing. The area of deep tissue injury will need to be observed over time. If it does not recover it will evolve into eschar needing surgical debridement. Follow up (name) Wound Clinic. Review of the care plan/physician orders [REDACTED]. Bacroban was not ordered until 10/22/15, 9 days after admission. A physician order [REDACTED]. Check placement every shift. In addition, the facility also failed to notify the physician regarding a change of condition, in the status of the sacral pressure ulcer, when it occurred on 10/24/15. 3. Review of the medical record for Resident #2 revealed the Skin Assessment Form was completed by LPN's as follows: On 11/24/15 - slit in gluteal crease with maceration 1 cm x 0.2 cm treatment of [REDACTED]. On 12/1/15 - upper buttocks reddened continue current treatment of [REDACTED]. On 12/8/15 - reddened and cracked upper buttocks, 12/12/15 left buttock small open area due to friction 2.5 x 1.0 cm Allevyn dressing (non-medicated dressing) no bag balm. On 12/15/15 - Allevyn dressing discontinued and bag balm restarted. On 12/17/15 - open small area to right buttocks .9 cm x .2 cm, left buttock 4 cm x .5 cm. On 12/22/15 - excoriated areas to both sides of buttocks. On 12/29/15 - buttocks red, blanchable. On 1/5/16 - right buttocks small superficial open area, left buttock 2 small superficial open areas. On 1/12/16 - buttocks red continue bag balm no open areas. On 1/19/16 - large reddened area on both buttocks and 2 small open areas on both buttocks. On 1/17/16 - Allevyn dressing started and discontinue on 1/18/16 and bag balm restarted. On 1/22/16 - changed to bag balm to buttocks and [MEDICATION NAME] to any macerated or reddened areas on buttocks. On 2/2/16 - reddened buttocks with open areas (no measurements). On 2/4/15 - left buttocks small open area from moisture and stool, edges white, pink center, oblong shape .2 cm x .5cm. On 2/9/16 - redness noted to buttocks continue bag balm/[MEDICATION NAME]. On 2/16/16 - very small open area on left buttocks not measurable. On 2/23/16 - pinpoint opening to left buttocks and right buttocks. Further review of the clinical record revealed physician orders [REDACTED].#2 on 2/25/16 stated, start Dislucan 200 mg (milligrams) 1 tab (tablet) today (antifungal) and [MEDICATION NAME] powder (antifungal) apply lightly to buttocks for 10 days. There had been no change in the bag balm order, to the buttocks, since 11/24/15 in spite of a lack of response to the treatment. In addition, the label for this ointment stated the bag balm had been the farmer's friend helping to keep dairy cows from becoming chapped. Special Directions only include use for pets and cows. The label also warned Discontinue use if rash or irritation occurs. Documentation since 11/24/15 noted maceration, excoriation and redness. On 2/25/16 at 12:48 p.m., the ARNP said she tried to see all residents with wounds, at least weekly. She said she also worked with the nursing supervisor Staff C who monitored all residents with wounds and said Staff C was furthering her education in this regard. The ARNP said she observed Resident #2's wound on 2/25/16 and it was rashy and somewhat yeasty and fungal in nature; and the treatment was being changed. She also said she was ordering a nutritional consult and the resident had a history of [REDACTED]. On 2/25/16 at 2:00 p.m., RN Staff C confirmed the initial and subsequent assessments of Resident #2's pressure ulcers had been done by an LPN. Staff C said the facility allowed the LPN staff to do the assessments of the wounds, including staging them. On 2/25/16 at 5:00 p.m., during exit interview, the DON acknowledged assessment was not within the LPN's scope of practice. Further review of the clinical record revealed physician orders [REDACTED].#2 on 2/25/16 stated, start Dislucan 200 mg (milligrams) 1 tab (tablet) today (antifungal) and [MEDICATION NAME] powder (antifungal) apply lightly to buttocks for 10 days. There was no change in the bag balm order, to the buttocks, since 11/24/15 in spite of a lack of response to the treatment. In addition, the label for this ointment stated the bag balm had been the farmer's friend helping to keep dairy cows from becoming chapped. Special Directions only include use for pets and cows. The label also warned Discontinue use if rash or irritation occurs. Documentation since 11/24/15 noted maceration, excoriation and redness.

Based on record review, observation and interview the facility failed to develop a care plan for hospice services for 1 (Resident #16) of 1 sampled residents. The findings included: On 1/26/16 a review of the hospice care plan had documentation of an aide task list with one intervention. The facility care plan had the intervention of Resident is on Hope Hospice. The hospice aide's intervention was not on the facility care plan. On 1/26/16 a review of Resident #16's hospice aide task list dated 1/5/16 documented patient care services to socialize with patient 2 times a week, either outside or inside. On 1/26/16 a review of the care plan meetings sign in sheet for Resident #16 documented meetings were held on 4/2/15, 4/9/15, 7/7/15, 10/6/15, and 1/5/16. The hospice nurse Staff D only signed in as attending the meeting on 10/6/15. On 1/26/16 at 1:50 p.m., Certified Nursing Assistant (CNA) Staff A said the resident received therapy and exercise with restorative therapy for walking. She liked to go to the music activity and get her hair done. She said a companion came to visit her 2 days a week for 2 hours each visit. The companion sat with her, fixed the clothes in the closet, and did Resident #16's laundry. Staff A said the companion started 2 weeks ago but she didn't remember the companion ' s name. On 1/26/16 at 2:00 p.m., companion, Staff B said she fixed Resident #16's clothes and spent time with the resident. She said she came 1 day a week and the resident decided which day she came. She said usually it was Tuesday, but last week the resident had a doctor's appointment on Friday, so she came Friday and went to the appointment with her. On 1/26/16 at 2:00 p.m., companion Staff B was observed in the facility interacting with Resident #16. At 2:30 p.m., she was observed arranging clothing in the resident's closet. On 1/26/16 at 2:30 p.m., Licensed Practical Nurse Staff C said Resident #16 had an aide from hospice. She said she thought the hospice aide came twice a week. The hospice aide would straighten up the residents clothes in the closet. The hospice aide might take Resident #16 to the bank, to mail a letter, or assist in contacting a doctor. She said those are the things she knew about, she didn't know every detail of what the hospice aide did. She said the hospice aide didn't tell her what she had done, but she would tell her if she was taking her off the unit. If she rubbed lotion on the resident, she might say she did that. She said there was a care plan in there, pointing to the hospice binder, so she would assume those were things she was supposed to do. On 1/26/16 at 2:45 p.m., Care Plan Coordinator/Licensed Practical Nurse (CPC/LPN) Staff G said she had the hospice care plan in a drawer, in her desk. She removed it from the drawer and made a copy for Resident #16's medical record. On 1/26/16 at 2:50 p.m., Nursing Supervisor Staff H explained hospice provided a copy of the hospice care plan for the CPC and one copy for the chart. The hospice Social Worker (HSW) or hospice nurse attended the facility care plan meetings. The HSW Staff E had attended the last two care plan meetings. Staff H said she didn't know what the hospice aide duties were. Staff H reviewed the hospice care plan which said the hospice CNA will socialize with the patient 2 times a week, either inside or outside. She confirmed there was no order for the hospice aide visits on the facility care plan. She reviewed the facility copy of the hospice care plan. She said the nursing interventions identified on the hospice care plan were listed under each correlating area of the facility care plan. Staff H said the hospice care plan was on resident #16's chart. She confirmed the one intervention listed on the hospice care plan for the aide was not on the facility care plan. She looked for the hospice care plan on Resident #16's chart, and was not able to locate one. She reviewed the facility care plan and confirmed the hospice nursing interventions were listed as resident is on Hope Hospice. On 1/27/16 at 3:35 p.m., the facility social worker (FSW) Staff F said she periodically communicated with and met with the HSW, Staff E. She said Staff E attended the facility care plan meetings. The FSW said the hospice nurse met with the nurse on the unit. She was not able to provide any documentation to show the communication. She said she was unaware if anyone from hospice was here yesterday. She said she had no contact with the hospice staff yesterday. The FSW said she believed the hospice nurse was required to come every 2 weeks. As for the CNA, Resident #16 had refused personal care from hospice and wanted the facility aides to take care of her. The hospice aide takes her outside, will fix up her closet, assist with special laundry needs, and any other personal things. The HSW Staff E discussed this with Resident #16 at the care plan meeting. She confirmed the facility did not update the effectiveness of the hospice care plan for Resident #16. On 1/27/16 at 4:15 p.m., the Director of Nursing (DON) said the hospice CNA told her the facility CNA provided the residents personal care so the hospice aide could sit with her outside. The DON said the resident had somebody who took her to her appointments, but didn't know how frequently. The DON said she didn't know who the person was, or what else she did for the resident She said the hospice schedule was not up to date. There were residents on the hospice list that have passed away. She said she didn't know how often the hospice nurse or aide visited. After reviewing the hospice care plan she said, looking at the progress notes the hospice nurse Staff D, came quarterly. She said she didn't know how often they were scheduled to come. She said there should be orders documenting when they visit. She said Staff D should be here once or twice a week for 8 weeks, and there was no order for Staff I, only an intervention. Under the intervention the aide should be here twice a week. The sign in sheet showed the last time Staff I visited was 11/24/15 and the visit prior to that was 7/28/15. The DON confirmed Staff I's notes dated 11/24, 12/3, 12/8, 12/11 and 1/5 located in the hospice binder and confirmed it did not appear Staff I had visited twice a week. On 1/28/16 at 8:45 a.m., Resident #16 said her companion Staff B goes to her doctor's appointments with her, does some laundry and arranges the clothes in her closets. She said once her closet was set, Staff B spends time with her outside talking or inside talking. She said Staff I from hospice visited her too. She said Staff I visited sometimes on Tuesday or Thursday, she never knew in advance. She said there was nothing set up on a regular basis, she came once a week. When she came, Staff I would go with her to the bank in the other building. Resident #16 said she was not quite sure what Staff I was supposed to be doing. She said she wouldn't mind if Staff I gave her a shower. She said she had seen the hospice nurse Staff D a couple of times. She didn't remember when the last time was. On 1/28/16 at 8:55 a.m., hospice aide Staff I said she came on Tuesday and Thursdays. She said the last Tuesday she was here and she took the resident to activities. She said she was here at 9:00 a.m., on Tuesday. Resident #16 said when Staff I came they just socialized. Staff I said she had a schedule up front at the nurse's station. She said her visits were usually 1 to 1 1/2 hours. Staff I said she put the aide task forms in the book today and her nurse would need to sign them. She said the only way the facility CNA would know what she had done was by looking to see if the sheet was in the book. She said she didn't talk to the CNA or nurse to tell them what she had done with the resident on each day. She said she didn't need to sign the resident out to go to the bank because it's in the other building. On 1/28/16 at 9:15 a.m., Staff H and the DON both confirmed the hospice care plan was not on the resident's chart. The DON said she asked the CPC Staff G why it wasn't on Resident #16's chart and she didn't know. Staff H told the DON she looked for the hospice care plan in Resident #16's medical record on Tuesday and the care plan was not on the chart.