Every finding on record at Manor of the Plains

The facility reported a census of 32 residents. The facility identified five Certified Nurse Aides (CNA) employed over the 12 the month period. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for two of the five CNA reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. Findings included:- Review of CNA personnel files revealed the following:CNA II, hired on 06/20/24, lacked an annual performance evaluation. Certified Medication Aide (CMA) R hired 11/17/23lacked an annual performance evaluation. During an interview on 09/11/25 at 12:09 PM, Administrative Staff A reported she expected 100 percent compliance to have the annual performance evaluations completed annually. The facility did not provide a policy on annual performance evaluations.

The facility reported a census of 32 residents, one main kitchen and one satellite kitchen. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. Findings included:- During a second tour of the satellite kitchen on 09/10/25 at 04:40 PM, observation revealed Dietary Staff DD removed a container of lettuce from the refrigerator with gloved hands. Wearing the same gloves, Dietary Staff DD opened a cabinet door, removed bowls from the shelf, and closed the door. With the same soiled gloves, Dietary Staff DD removed the lid from the lettuce container and grabbed a handful of lettuce from the container twice to fill two bowls with lettuce, then turned on the faucet handle, rinsed the lettuce off under water, and shut the faucet handle off. Still wearing the same gloves, Dietary Staff DD squeezed the lettuce and placed it back into each bowl. Dietary Staff DD removed the gloves and applied a new pair of gloves without performing hand hygiene. Dietary Staff DD then opened a drawer, removed a small black plastic container from the drawer, opened the bag of shredded cheese, placed the small black container into the bag, and scooped out the shredded cheese. Dietary Staff poured salad dressing into a small black plastic container from a measuring cup, rinsed out the container in the sink, removed her gloves, and applied a new pair of gloves without performing hand hygiene.During an observation on 09/10/25 at 04:50 PM, Dietary Staff DD removed tomatoes and a jar of pickles from the refrigerator using gloved hands. She removed her gloves and applied new gloves without performing hand hygiene. Dietary Staff DD cut up tomatoes, removed the lid from the pickles, and reached into the pickle jar with the same gloved hand and removed several sliced pickles and placed them on the plate with the tomatoes. Additionally, Dietary Staff DD removed the lid from the lettuce container, grabbed a handful of lettuce with her gloved hand, turned on the faucet, rinsed the lettuce, shut off the faucet, squeezed the lettuce of excess water, and placed the lettuce on the plate with tomatoes and pickles. Dietary Staff DD then removed her gloves and applied a new pair of gloves without performing hand hygiene.During an interview on 09/10/25 at 05:10 PM, Dietary Staff DD reported that she usually used hand sanitizer when she removed her gloves and confirmed she had not washed her hands or used hand sanitizer when she removed her gloves. Dietary Staff DD reported she would normally use a utensil to remove the food items from the containers.During an interview on 09/10/25 at 05:20 PM, Certified Dietary Manager BB stated that she expected staff to perform hand hygiene every time gloves were removed from the hands and to utilize utensils when removing food from containers. Additionally, Certified Dietary Manager BB stated that she expected staff not to use the same gloves that touched surfaces of the kitchen to touch food.During an interview on 09/11/25 at 12:24 PM, Administrative Staff A stated she expected the kitchen staff to serve all food in a sanitary manner.The facility's policy Use of Gloves dated 03/2020, documented to wash hands thoroughly prior to putting on gloves and when changing into a fresh pair of gloves. Gloves are to be changed when changing from one task to another.

The facility reported a census of 32 residents. Five Certified Nurse Aide (CNA) staff who worked in the facility for more than 12 months were reviewed for the required in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for CNA staff with the required topics and no less than 12 hours per year. Findings included:- Review of CNA personnel files revealed the following:CNA P, who was hired for the facility on 09/13/22, lacked abuse, neglect, and exploitation (ANE), social media training, and dementia (progressive mental disorder characterized by failing memory, confusion) training. CNA P's total hours were not calculated for the 12 hours required.CNA Q, who was hired 02/14/24, lacked ANE and social media training. CNA Q's total hours were not calculated for the 12 hours required.CNA II, who was hired 06/20/24, lacked ANE and social media training. CNA II's total hours were not calculated for the 12 hours required.During an interview on 09/11/25 at 12:09 PM, Administrative Staff A reported he expected the staff to have the required education and the required 12 hours annually.The facility did not provide a policy for CNA staff required for in-service and annual training hours.

The facility reported a census of 32 residents; 12 residents were sampled for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed to ensure two resident's advanced directives were thoroughly completed when Resident (R) 38 had a do not resuscitate (DNR- or no code, a legal document or order that means the person does not desire resuscitative measures) order but not signed DNR form. Additionally, R4's DNR lacked a witness signature. Findings included:- Review of R4's Physician Order in the Electronic Medical Record (EMR) recorded an order for DNR, date ordered 11/04/24.Review of R4's EMR on 09/09/2025 at 12:45 PM, DNR signed by R4 on 11/01/24 and by the physician on 10/31/24. The DNR form lacked a witness signature. R38's Physician Order in the EMR recorded an order for DNR, date ordered 09/05/25.R38's EMR lacked a signed DNR form.During an observation on 09/11/25 at 09:40 AM, a red dot was noted on the name tag of R38's room.During an observation on 09/11/25 at 09:45 AM, a red dot was noted on the name tag of R4's room.During an interview on 09/11/25 at 09:35 AM, Administrative Nurse F reported that Social Service Designee (SSD) X would complete the advanced directive forms, and a nurse would place the order in the EMR, once the advanced directive paperwork was completed. Administrative Nurse F reported a red dot on any resident's name plate outside of their room meant the resident was a DNR. Administrative Nurse D confirmed R38 did not have a completed DNR form.During an interview on 09/11/25 at 10:15 AM, SSD X reported R4's DNR form was incomplete as it did not have a witness signature. SSD X stated she thought R38 had a DNR, but confirmed she could not locate a signed DNR form for R38 in a file or in EMR.The facility's Advanced Directive, dated 10/11/21, documented residents at all levels of living are provided with written information to exercise their legal rights: to make health care decisions, to refuse treatment, and to make Advance Directives. Advance Directives and Physician Orders will be reviewed by the resident/representative and the care plan team at least annually.

The facility reported a census of 32 residents. There were 12 residents selected for review which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 21's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had the required 14-day stop date or a specified duration with a physician's rationale to support the extended use. Findings included:- R21's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R21's 09/26/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS recorded R21 had behaviors, including refusal of care for one day. The MDS documented R21 required total assistance with most activities of daily living (ADL). The MDS recorded R21 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood disorders), and antianxiety (a class of medications that calm and relax people) medications. The 09/27/24 Psychotropic Drug Use Care Area Assessment (CAA) documented R21 triggered secondary to the use of psychotropic med to manage a psychiatric condition. A licensed nurse would monitor side effects every shift, and the physician would be notified of any abnormal findings. A pharmacist consultant would review medications monthly, and the physician would review medications with each visit. Contributing factors included a history of depression. Risk factors included increased falls, impaired balance, and potential for adverse effects of medication. The care plan would be reviewed to monitor the effectiveness of psychotropic medication and any adverse effects of the medication.R21's 06/26/25 Quarterly MDS documented a BIMS score of zero, which indicated severely impaired cognition. The MDS recorded R21 had no depression or behaviors during the lookback period. The MDS documented R21 received antipsychotic, antianxiety, and antidepressant medications. R21's Care Plan instructed staff R21 would receive PRN lorazepam (antianxiety medication) cream for agitation, dated 11/14/24. R21's Physician's Orders documented an order for lorazepam cream 1 milligram (mg)/ 1 milliliter; give 2 mg/ 2 ml topically to the wrist every four hours PRN for dementia with agitation dated 11/01/24. The order lacked a stop date.R21's Medication Regimen Review (MRR) dated 08/11/25 documented there was no stop date for the PRN Ativan (lorazepam) noted.R21's Medication Administration Record (MAR), dated 04/01/25 through 04/30/25, had a documented order as needed psychotropic medication - physician communication review required for as needed compound lorazepam cream every 6 months. Last completed 04/09/24. Notify both Administrative Nurse D and Administrative Nurse E by email that this is due for review. For unspecified dementia of unspecified severity with agitation. Due on 04/10/2025 in the morning every 6 months starting on the 10th. The MAR lacked the initials indicating it was completed.R21's Concern and Assessment dated 04/07/25, documented by the practitioner, noted R21 was on compounded lorazepam cream 1mg/1ml every four hours as needed for unspecified dementia and reoccurred behaviors, which required a 14-day review, separate from the actual prescription. An extended end date can be chosen if you perform the review and document the rationale for the extended use, and notate the end date. Rationale for extended use progressive dementia with behaviors. Review every six months.During an observation on 09/09/25 at 03:58 PM, a nurse assisted R21 to the lobby area. R21 received a cookie and a drink from the staff. During an interview on 09/10/25 at 12:03 PM, Certified Nurse Aide (CNA) N reported R21 could be resistant to care at times and said staff would reapproach her as needed.During an interview on 09/11/25 at 08:43 AM, Consultant Pharmacist JJ reported that he would review the residents' EHR to verify a stop date for PRN psychotropic medications. Consultant Pharmacist JJ reported that Administrative Nurse F would handle all the stop dates that were required for PRN psychotropic medications, and that is why he did not document on the Monthly Medication Regimes. He also stated he had not realized there was no stop date for the PRN compound lorazepam until he reviewed the EHR during the interview. During an interview on 09/11/25 at 09:10 AM, Administrative Nurse F reported that R21's compound lorazepam had a stop date in the last EHR, but confirmed there was no stop date in the current EHR that the facility started to use on 11/01/24. She reported that she would keep a binder of all PRN psychotropic medications, which was reviewed every six months. Administrative Nurse F said the review dates would be the stop date.The facility's policy Psychoactive Psychopharmacological Medications dated 02/03/25, documented psychotropic medications used on as needed basis must have a diagnosed specific condition and indication for as needed use documented in the resident's medical record and is subject to the limitations as noted: As needed orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days.

The facility reported a census of 32 residents. The sample included 12 residents with one resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to offer and provide assistance with grooming of facial hair for Resident (R) 25, who participated in her hygiene activities but needed staff assistance. Findings included:- R25's Electronic Health Record (EHR) revealed diagnoses of macular edema (swelling in a part of the retina that causes blurry or wavy vision, dull colors, and vision loss) and Meniere's disease (a chronic progressive disease of the inner ear, characterized by recurrent episodes of dizziness, progressive hearing loss, and ringing of the ears).R25's 01/20/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R25 required maximal assistance with most AD, which included transfer, bathing, dressing, and footwear. The MDS documented R25 required supervision with personal hygiene.The 01/27/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented the CAA triggered secondary to R25's assistance required in ADLs, impaired balance and transition during transfers, and functional impairment in activity. The CAA noted contributing factors included generalized weakness and decreased safety awareness, and risk factors included further ADL decline. The care plan would be initiated and reviewed to improve and maintain the current ADL status and functional ability.R25's 07/17/25 Quarterly MDS documented a BIMS score of 10, which indicated moderately impaired cognition. The MDS documented R25 was independent with all ADLs, except she required supervision with ambulation.R25's Care Plan, revised on 05/28/25, directed staff to provide one-person assistance with bathing and showering.R25's Care Plan lacked any documentation for personal hygiene assistance or preferences for R25.R25's Personal Hygiene Task reviewed from 08/09/25 through 09/09/25 documented R25 was independent with the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands.During an observation and interview on 09/09/25 at 02:00 PM, R25 was in her room, self-propelling around in her wheelchair. She had several long facial hairs on her face, approximately one-half inch long. R25 reported that she did not know that she had long facial hairs and stated she did not like having facial hair. R25 seemed a bit confused and repeated the same questions three times. R25 reported she completed her own care, and the staff did not need to do anything for her.During an observation on 09/10/2025 at 10:05 AM, R25 was in activity doing morning exercise. She still had several long facial hairs on her face.During an interview on 09/11/25 at 10:15 AM, Social Service Designee (SSD) X reported the residents would let the facility staff know their preference for facial hair removal. SSD X reported if a resident had impaired cognition, the family member or responsible party would give that preference information to the facility staff, and all preferences would be care planned.During an interview on 09/11/2025 at 10:43 AM, Administrative Nurse E stated he expected the staff to assist residents with facial hair removal and address this on scheduled bath days. Administrative Nurse E reported facial hair preferences would be on the care plan, and R25 really would not refuse showers. Administrative Nurse E reported that R25 believed she would be more independent than she really was.During an interview on 09/11/2025 at 01:16 PM, Certified Nurse Aide (CNA) S reported R25 received her showers on Monday and Thursday during second shift and reported R25 might refuse to have facial hair removed, it depended on the approach. CNA S reported that R25 could not see well, which is why she wore her glasses and head visor when she was not in her room.During an interview on 09/11/2025 01:22 PM, Administrative Nurse D stated she expected staff to remove unwanted facial hair on shower days or as needed, and it should be care planned. The facility did not provide a policy for ADLs.

The facility reported a census of 32 residents; the sample included 12 residents with four residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to follow the care planned interventions to prevent falls for Resident (R) 1 and R7. Findings included:- R1's Electronic Medical Records (EMR) documented diagnoses that included right femur (thigh bone) fracture, hypertension (HTN-elevated blood pressure), and narcolepsy (a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes of muscle weakness). R1's 03/06/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS documented R1 had falls and a fall that resulted in a fracture within the last month prior to admission.R1's 03/06/25 Falls Care Area Assessment (CAA) documented R1 required assistance for activities of daily living (ADLs) and impaired balance during transfers. The CAA noted contributing factors included generalized weakness and decreased safety awareness, and risk factors include further ADL decline, falls, and pain. R1's 06/06/25 Quarterly MDS documented R1 had a BIMS score of 15, indicating intact cognition. The MDS documented R1 had two or more noninjury falls. The MDS documented R1 was dependent on staff assistance with wheelchair mobility; R1 did not walk and required substantial to maximal assistance with transfers. R1's Care Plan dated 05/29/25 documented that R1 was at risk for falls due to walking and balance problems. The care plan was updated following a fall during a transfer on 06/16/25, and instructed staff to use two staff members for all transfers. R1's Care Plan was updated following a fall on 07/10/25 for staff to use a body pillow on the bed to prevent falls. R1's Incident Note on 07/19/25 at 10:45 PM, documented R1 had a fall off the bed onto the floor. The note documented R1's body pillow was not in use as it was on the other bed in the room. During an interview on 09/09/25 at 10:53 AM, R1 reported he fell out of bed several times due to being restless and tossing and turning when he slept.On 09/11/25 at 9:00 AM, Certified Nurse Aide (CNA) M assisted R1 to his room and removed the foot pedals from the wheelchair. CNA M locked the wheelchair, applied the gait belt around R1's waist, retrieved the walker, and placed it in front of him. CNA M removed the arm from the wheelchair and stood in front of the walker, then pulled R1 forward to help him stand. R1 stood with his knees bent, and CNA M encouraged him several times to stand straight and to turn. R1 was unsteady but was able to slide his feet a small bit to turn a little. R1 began falling, and staff assisted R1 to turn a bit more and plop into his recliner. CNA M then assisted R1 to sit properly in the recliner. On 09/11/25 at 9:08 AM, CNA M stated R1 was at risk for falls and had been found on the floor several times at night. CNA M said R1 also had several falls from staff not transferring him properly. CNA M said she was not aware of any special instructions on the care plan for transferring R1. CNA M reported staff follow the care plan to know how to take care of the residents, and when someone falls, their care plan was updated by the MDS nurse. On 09/11/25 at 01:48 PM, Administrative Nurse D stated that when there was a fall, the administrative staff sat down as a group the following morning and investigated the fall to come up with an appropriate intervention. Administrative Nurse D said the MDS nurse put the intervention into the care plan and communicated it to the staff, and the staff were expected to follow the care plan.The facility's policy Falls dated 11/01/24, documented the residents will be identified for risks of falls and interventions implemented to reduce the risk of falls. The quality assurance nurse will review fall interventions and update as needed.- R7's Electronic Medical Records (EMR) documented diagnoses that included vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), generalized muscle weakness, and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). R7's 03/16/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. The MDS documented R7 had two or more noninjury falls and one fall with an injury that was not severe.R7's 03/16/25 Falls Care Area Assessment (CAA) documented R7 required assistance for activities of daily living (ADLs) and impaired balance during transfers. The CAA noted contributing factors included generalized weakness and decreased safety awareness, and risk factors included further ADL decline, falls, and pain. R7's 06/16/25 Quarterly MDS documented R7 had a BIMS score of seven, indicating severe cognitive impairment. The MDS documented R7 had no falls. The MDS documented R7 required substantial to maximal assistance for wheelchair mobility. R7's Care Plan dated 11/19/24 documented R7 was at risk for falls due to her age, dementia, balance problems, and history of falling. The plan instructed staff to ensure her four-wheeled walker was in her reach. The plan was updated following a fall on 12/06/24 to include placing a Dycem (a non-slip mat used for stabilization and gripping to prevent slipping) in R7's chair and wheelchair. On 09/10/25 at 12:55 PM, Certified Nurse Aide (CNA) N and CNA O assisted R7 to her room in her wheelchair. They removed the wheelchair pedals and applied a gait belt around R7's waist. The two staff, one on each side, lifted R7 to a standing position, and she slowly moved her feet with difficulty. CNA N and CNA O assisted R7 to turn and lowered her into her recliner. They moved the wheelchair against the wall on the other side of the room. The walker was against another wall. Observation revealed the recliner, and the wheelchair did not have a Dycem in it. On 09/10/25 at 12:59 PM, CNA O reported that staff follow the care plan for all R7's care, and if there was a new intervention, staff can look at the profile that pulls from the care plan. CNA O said she was aware the R7 was a fall risk and stated that staff put the wheelchair away for R7, so she does not attempt to get up; staff listen for her to call and do frequent checks on her. CNA O said she was not aware that the care plan documented a Dycem should be in the wheelchair and the recliner, or that staff should keep R7's walker within reach. On 09/11/25 at 09:08 AM, CNA M reported staff follow the care plan to know how to take care of the residents. CNA M said when someone falls the care plan was updated by the MDS nurse and the MDS nurse told the charge nurse what the update was, and the charge nurse told the other staff. On 09/11/25 at 01:48 PM, Administrative Nurse D stated that when there was a fall, the administrative staff sat down as a group the following morning and investigated the fall to come up with an appropriate intervention. Administrative Nurse D said the MDS nurse put the intervention into the care plan and communicated it to the staff, and the staff were expected to follow the care plan.The facility's policy Falls dated 11/01/24, documented the residents will be identified for risks of falls and interventions implemented to reduce the risk of falls. The quality assurance nurse will review fall interventions and update as needed.

The facility reported a census of 32 residents; the sample included 12 residents with one resident reviewed for tube feeding (administration of nutritionally balanced liquefied foods or nutrients though a tube). Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 38,a resident who did not eat or drink, had a physician's order for the type of enteral feed formula to be administered through R38's gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) and/or assessment and direction from the Registered Dietician (RD) until six days after admission.Findings included:- R38's Electronic Health Record (EHR) documented diagnoses which included partial intestinal obstruction, malignant neoplasm of colon (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer), and severe calorie protein nutrition.R38's 09/08/25 admission Minimum Data Set (MDS) not completed at time of survey but included a 09/09/25 Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition.R38's 09/03/25 Base Line Care Plan documented staff were to provide tube feeding of Jevity 1.5 (liquid nutrition with fiber providing complete nutrition).R38's Hospital Discharge Orders dated 09/03/25 lacked a tube feeding/diet order.The Physician Order documented enteral feed order every night shift, open system container or gravity feeding - change feeding administration set daily; label the formula container, syringe and administration set with resident's name, date, time, and nurse's initials, date ordered 09/03/25 and date discontinued 09/09/25.R38's Physician Orders lacked an order for Jevity 1.5 or any enteral feeding solution.The Physician Orders dated 09/03/25 lacked nothing per mouth order (NPO).R38's Department of Clinical Nutrition: Nutrition Assessment dated 09/09/25 at 01:32 PM by the RD documented a diet order for enteral feedings; 45 milliliter (ml)/hour gravity, Jevity 1.5. The assessment noted R38 was NPO, and receiving tube feedings via gravity.During an observation on 09/09/25 at 11:10 AM, R38 was in her bed. She reported she had just returned from a appointment with her doctor. Observation revealed a tube feeding bag connected to a feeding pump, the bag was labeled with a date and time the enteral feeding was hung. No other information was written on the enteral feeding bag. R38 reported she did not know how much of the enteral feeding she would receive and reported the nurse would be back soon to reconnect her feeding to her feeding tube.During an observation on 09/09/25 at 11:45 AM, R38 had the enteral tube feeding connected to her feeding tube: the rate of the enteral feed was set a 45ml/hr.During an interview on 09/10/25 at 08:54 AM, Licensed Nurse (LN) G reported that the physician order would let the nurses know what type of enteral feed was to be administered when the feed was via the pump. LN g reviewed the discontinued order in EHR and reported the order did not state what type of enteral feed or amount to be administered. LN G reported that the night shift nurse would start the tube feeding as it was continuous. During an interview on 09/10/25 at 04:00 PM Administrative Nurse D reported that questions regarding the 09/09/25 assessment should be directed to the Registered Dietician. Administrative Nurse D reported she realized on 09/09/25 that R38's tube feeding orders were missing the type and amount of feeding to be administered and R38's orders had changed to a bolus feeding so all the orders are correct now.During an interview on 09/11/25 at 10:00 AM, Consultant RD KK reported that she expected a nutritional assessment to be completed within 72 hours after a resident admitted with a tube feeding.During an interview on 09/11/25 at 12:28 PM, Administrative Staff A stated she expected the nutritional assessment for R38's tube feeding to be completed before R38 was admitted and reported that she had sent the Registered Dietician emails that contained the nutritional notes from the hospital.The facility's policy Clinical Nutrition Department Responsibilities dated 01/2025 documented the Registered Dietitian Nutritionist (RDN) would assess the nutritional status of those patients/residents identified at risk, and will communicate information that impacts care to the health care team.

The facility identified a census of 32 residents. The sample included 12 residents including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the facility failed to act upon blood sugar monitoring for Resident (R) 7 when staff administered insulin (a hormone that lowers the level of glucose in the blood) that should have been held per physician ordered parameters. Findings included:- R7's Electronic Medical Record (EMR) revealed a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R7's 03/16/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. The MDS documented R7 had a diagnosis of diabetes and took insulin every day. R7's 06/16/25 Quarterly MDS documented R7 had a BIMS score of seven, indicating severe cognitive impairment. The MDS documented R7 had a diagnosis of diabetes and took insulin every day.R7's Physician's Order noted an order for Humalog (fast-acting insulin); inject eight units after meals related to diabetes mellitus. Notify the physician for blood sugar over 350 milligrams(mg) per deciliter(dl) or less than 60 mg/dl. Hold Humalog for blood sugars under 100 mg/dl or for refusal of meals; ordered 03/14/25. R7's Physician's Order noted an order to check blood sugar fasting and two hours after meals; start date 11/01/24. R7's August 2025 Medication Administration Record (MAR) revealed the following dates when R7's blood sugar was below 100 mg/dl, but the Humalog insulin was administered:08/01/25, R7's fasting blood sugar was 94 mg/dl, Humalog was given after breakfast. 08/09/25, R7's 01:00 PM blood sugar was 91 mg/dl, Humalog was given after supper. 08/10/25, R7's fasting blood sugar was 92 mg/dl, Humalog was given after breakfast. 08/12/25, R7's 10:00 AM blood sugar was 88 mg/dl, Humalog was given after lunch. 08/18/25, R7's fasting blood sugar was 99 mg/dl, Humalog was given after breakfast. 08/25/25, R7's fasting blood sugar was 97 mg/dl; Humalog was given after breakfast. 08/28/25, R7's 10:00 AM blood sugar was 98 mg/dl, Humalog was given after lunch. On 09/11/25 at 09:48 AM, Administrative Nurse F stated R7's blood sugars are taken fasting at around 07:30 and two hours after meals, and staff use those blood sugar readings to determine if they would hold or give the insulin after R7 ate. Administrative Nurse F said staff would follow the parameters given by the doctor. On 09/11/25 at 01:48 PM, Administrative Nurse D stated that she expected staff to take the blood sugar fasting and two hours after meals as ordered, and after the meal, the nurse was to give or hold the insulin according to the parameters in the order.The facility's Medication Administration policy reviewed 02/03/25 documented medications are administered as prescribed in accordance with good nursing principles and practices.

The facility reported a census of 32 residents. Based on interview and record review, the facility failed to electronically submit accurate staffing information through Payroll-Based Journaling (PBJ). Findings included:- The PBJ Staffing Data Report for Fiscal Year (FY) 2025 Quarter 1 (October 1 - December 31) documented the facility did not have Licensed Nurse (LN) coverage 24 hours a day on the following dates:10/13/24, 1020/24, 12/1/24, 12/08/24 and 12/24/24Review of the Daily Nurse Staffing Form and Payroll Data Sheets indicated the days listed above were covered with the required LN coverage 24 hours each day. On 09/11/25 at 10:14 AM, Administrative Staff A reported the Regional Human Resources people would compete the PBJ report. Administrative Staff A said she expected the PBJ to be reported accuratelyThe facility did not provide a policy for Payroll Based Journal

The facility census totaled 29 residents with 12 included in the sample with five reviewed for medications. Based on observation, interview, and record review, the facility failed to follow the physician orders directing the nursing staff to notify the physician for blood sugars (BS) below 70 and above 350, for Resident (R)24. Findings included: - R24's signed physician orders dated 07/31/23, revealed the following diagnoses: diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin) and chronic kidney disease (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. The resident received insulin during the 7-day observation period. The Quarterly MDS dated [DATE] revealed a BIMS of four, indicating severe cognitive impairment. The resident received insulin during the observation period. Review of the care plan dated 05/23/23, revealed R24 had the potential for hypo/hyper glycemia (low or high blood sugar) due to diabetes. Staff were to observe for any signs/symptoms of hypo/hyper glycemia such as altered level of consciousness, confusion, dry mouth, excessive sweating, irritability, thirst, hunger, sweet odor on breath, headache, nausea, vomiting, etc. Notify the physician as needed (PRN). Administer the insulin per the physician's order. R24 frequently fluctuated to extreme blood sugar values and experienced changes in alertness when blood sugar was high or low. Staff were to check the resident's blood sugar as ordered and notify the physician per orders. Review of the Physician Order dated 07/31/23, revealed an order for Accuchecks (a way of testing blood sugar) four times a day, fasting, and post prandial (after meal). If R24's fasting BS in the morning was less than 100, the Licensed Nurse (LN) was to notify the physician. For all other accuchecks, staff was to notify the physician of BS less than 70 and more than 350. Review of the Medication Administration Record from 08/01/23 thru 09/19/23, revealed 200 opportunities for blood sugars. Of those 200 blood sugars taken, 54 of those results were above the ordered parameters of 350. Of those 54 blood sugars, 38 were not reported to the physician, as ordered. The blood sugars that were reported were faxed to the physician office and not called to the physician. Observation on 09/18/23 at 10:00 AM revealed the resident sat in her room watching out the window. The resident was able to carry on short conversations and answered questions with not always appropriate questions. Observation on 09/19/23 at 3:00 PM revealed the resident lying in bed resting with eyes closed. On 09/20/23 at 11:00 AM, Certified Nursing Assistant (CNA) N reported the resident would come out early to the dining room to eat and go back to her room. The resident was cooperative with her care. During an interview on 09/20/23 at 11:30 AM, Licensed Nurse G reported she just sent a fax to the physician about the resident's blood sugars. Sometimes he would answer and most times he did not. Staff had a sliding scale the physician ordered, but the blood sugars had not changed that much even with the sliding scale. On 09/20/23 at 10:40 AM, Administrative Nurse D reported she would expect the nurses to be calling the physician when the blood sugars got high and out of the physician ordered parameters. Review of the facility's policy for Notification of Parameters- Primary Care Providers dated 10/13/21, revealed notification of primary care physicians in a timely, efficient, and effective manner can be accomplished when the facility had developed a specific system which is consistently followed by licensed nursing staff. Licensed nurses have the responsibility of contacting a physician any time a resident has developed a clinical problem requiring physician intervention. The facility failed to follow the physician orders directing the nursing staff to notify the physician for blood sugars (BS) below 70 and above 350.

The facility reported a census of 29 residents with 12 residents included in the sample, that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consulting Pharmacist identified and reported blood sugars out of parameters ordered by the physician for Resident (R)24, and the lack of an end date for as needed (PRN) psychotropic medications administered past the 14-day regulatory requirement for R1. Findings included: - R24's signed physician orders dated 07/31/23, revealed the following diagnoses: diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin) and chronic kidney disease (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. The resident received insulin during the 7-day observation period. The Quarterly MDS dated [DATE] revealed a BIMS of four, indicating severe cognitive impairment. The resident received insulin during the observation period. Review of the care plan dated 05/23/23, revealed R24 had the potential for hypo/hyper glycemia (low or high blood sugar) due to diabetes. Staff were to observe for any signs/symptoms of hypo/hyper glycemia such as altered level of consciousness, confusion, dry mouth, excessive sweating, irritability, thirst, hunger, sweet odor on breath, headache, nausea, vomiting, etc. Notify the physician as needed (PRN). Administer the insulin per the physician's order. R24 frequently fluctuated to extreme blood sugar values and experienced changes in alertness when blood sugar was high or low. Staff were to check the resident's blood sugar as ordered and notify the physician per orders. Review of the Physician Order dated 07/31/23, revealed an order for Accuchecks (a way of testing blood sugar) four times a day, fasting, and post prandial (after meal). If R24's fasting BS in the morning was less than 100, the Licensed Nurse (LN) was to notify the physician. For all other Accuchecks, staff was to notify the physician of BS less than 70 and more than 350. Review of the Medication Administration Record from 05/01/23 through 08/06/23 revealed 424 opportunities for Accuchecks. Of those 424 opportunities 57 readings were above the 350 parameter ordered by the physician. Review of the Consulting Pharmacist Monthly Medication Review revealed: On 05/04/23- No recommendations. On 06/02/23- No recommendations. On 07/03/23- No recommendations. On 08/06/23- No recommendations. The Pharmacist failed to identify the blood sugars being out of the parameters ordered by the physician. Observation on 09/18/23 at 10:00 AM revealed the resident sat in her room watching out the window. She had two bird feeders and a corn feeder for the squirrel. The resident was able to carry on short conversations and answered questions with not always appropriate questions. On 09/20/23 at 10:40 AM Administrative Nurse D reported the pharmacist should be noting the blood sugars on his monthly report when he reviewed the resident's medication record. She reviewed the reports every month and the resident blood sugars were not mentioned on any of the reports. On 09/21/23 attempts made to contact the Consulting Pharmacist and unable to get a response. The facility failed to provide a policy regarding the consulting pharmacist. The facility failed to ensure the Consulting pharmacist identified and reported blood sugars out of parameters ordered by the physician. - Resident R1's signed physician orders dated 03/14/23 revealed the following diagnoses: chronic obstructive pulmonary disease- COPD (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (elevated blood pressure), and chronic pulmonary edema (accumulation of extravascular fluid in the lung tissues). The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The resident required limited assistance with all daily cares. R1 received pain medication on schedule and on an as needed (PRN) basis. The resident had shortness of air and received oxygen (O2) therapy. Medications included antipsychotic, antianxiety, antidepressant, medications seven days of the 7-day observation period. The Quarterly MDS dated [DATE] revealed no changes in cognition, ADL's and added a hypnotic and diuretic medication to the daily medication regimen. The Psychotropic drug use Care Area Assessment (CAA) dated 03/21/23 revealed the resident received scheduled administration of antipsychotic medication, scheduled administration of antidepressant medication and PRN use of anxiolytics (anxiety medications). A license nurse should monitor for signs and symptoms of adverse effects of psychotropic medications. A pharmacist would review medications monthly and the physician would review medications with each visit and more often if needed. Review of the Care Plan dated 06/21/23, revealed the resident had a history of depression and had the potential for anxiety. R1 received Ativan 0.5 milligrams (mg), (anti-anxiety medication) every six hours, as needed for anxiety. Monitor for side effects. When the resident was anxious, staff to encourage R1 to focus on her breathing, because when she would experience being anxious, she became short of breath. Review of the physician orders dated 03/23/23, revealed an order for Ativan 0.5 mg, every six hours PRN. The order lacked a 14 day stop date. Review of the Medication Administration Record revealed the resident received the medication almost daily. Review of the Consulting Pharmacist Medication Regimen review revealed: 1. On 04/02/23, the consulting pharmacist documented the facility needed a 14-day end date for Ativan 0.5 mg PO PRN. No response from the physician and resident continues with order ongoing. 2. On 05/04/23, the consulting pharmacist documented the facility needed a 14-day end date for clonidine HCL ordered PRN Ativan 0.5 mg PO PRN- No response from physician and resident continues with order ongoing. No further recommendation documented for the Ativan and the 14- day stop date. Observation on 09/19/23 at 10:10 AM revealed the resident sat in her recliner. The resident visited to a staff person with no visible signs of distress or problems breathing. On 09/19/23 at 1:30 PM, Certified Nursing Assistant (CNA) M reported the resident required extensive assistance with cares. She required the use of O2 continuous, or she would get anxious if she thought she could not breath. On 09/20/23 at 11:00 AM, CNA N reported the resident spent much time in her room. She did go to the dining room (DR) for meals and exercise class before the noon meal but that was about all. She had to always have her O2 with her and would become anxious if she felt she could not get her breath. CNA N would report that to the nurse, and she would give her something to calm down. On 09/20/23 at 11:10 AM, Licensed Nurse G reported the resident requested her Ativan a lot if she was winded. She would want an Ativan when she walked from the dining room to her room. On 09/20 23 at 11:28 AM, Administrative Nurse D reported the medical records staff member kept a book of all medications requiring an extension when the medication had an automatic end date, such as the Ativan that should have a 14 day stop date. She sent the form to the physician by fax to have him sign to extend the order another 14 days. But when Administrative Nurse D checked the book, she reported there was no sheet to update the resident's Ativan. The medication had no 14-day stop date with resident receiving it daily. She reported the medical records staff missed it because they were questioning the order, then forgot to send the form to the physician. On 09/21/23 attempts made to contact the Consulting Pharmacist and unable to get a response. The facility failed to provide a policy regarding the consulting pharmacist. The facility failed to ensure the Consulting Pharmacist identified and reported the lack of an end date for as needed (PRN) psychotropic medications administered past the 14-day regulatory requirement.

The facility census totaled 29 residents with 12 included in the sample, that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to have an appropriate end date for as needed anti-anxiety medication administered past the 14-day regulatory requirements for Resident (R1). Findings included: - Resident R1's signed physician orders dated 03/14/23 revealed the following diagnoses: chronic obstructive pulmonary disease- COPD (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (elevated blood pressure), and chronic pulmonary edema (accumulation of extravascular fluid in the lung tissues). The Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The resident required limited assistance with all daily care. R1 received pain medication on schedule and on an as needed (PRN) basis. The resident had shortness of air and received oxygen (O2) therapy. Medications included antipsychotic, antianxiety, antidepressant, medications seven days of the 7-day observation period. The Quarterly MDS dated [DATE] revealed no changes in cognition or ADL's and added a hypnotic and diuretic medication to the daily medication regimen. The Psychotropic Drug Use Care Area Assessment (CAA) dated 03/21/23 revealed the resident had scheduled administration of antipsychotic medication, scheduled administration of antidepressant medication, and as needed (PRN) use of anxiolytics (anxiety medications). A license nurse was to monitor for signs and symptoms of adverse effects of psychotropic medication. A pharmacist reviewed medications monthly and the physician would review medications with each visit and more often if needed. Review of the Care Plan dated 06/21/23, revealed the resident had a history of depression and had the potential for anxiety. R1 received Ativan 0.5 milligrams (mg) (anti-anxiety medication) every 6 hours, as needed for anxiety. Staff were to monitor for side effects. When the resident became anxious, staff were to encourage R1 to focus on her breathing, because when she would become anxious, she became short of breath. Review of the physician orders dated 03/23/23, revealed an order for Ativan 0.5 mg, every six hours. The order lacked a 14-day stop date. Review of the Medication Administration Record, from 03/23/23 -08/31/23 revealed daily use of the medication. Observation on 09/19/23 at 10:10 AM revealed the resident sat in her recliner. The resident visited with an unidentified staff and displayed no signs of anxiety or difficulties breathing. On 09/20/23 at 11:00 AM, Certified Nursing Assistant (CNA) N reported the resident spent much time in her room. She had to always have her O2 with her and would become anxious if she felt she could not get her breath. On 09/20/23 at 11:10 AM, Licensed Nurse G reported the resident requested her Ativan a lot if she was winded. She would want an Ativan when she walked from the dining room to her room. On 09/20 23 at 11:28 AM Administrative Nurse D reported the medical records staff member kept a book of all medications requiring an extension when the medication had an automatic end date, such as the Ativan that should have had a 14 day stop date. She sent the form to the physician by fax to have him sign to extend the order another 14 days. But when Administrative Nurse D checked the book, she reported there was no sheet to update the resident's Ativan. The medication had no 14-day stop date with resident receiving it daily. She reported the medical records staff missed it because they were questioning the order then forgot to send the form to the physician. Review of the facility policy named Psychoactive Medications dated 07/05/22 revealed PRN psychotropic medications limited to 14-days. The prescribing physician must evaluate the resident before writing a new order for a psychotropic medication. The facility failed to have an appropriate end date for as needed anti-anxiety medication administered past the 14-day regulatory requirements for Resident (R1), which increased the risk for unnecessary psychotropic medications administered.

The facility census totaled 29 residents with 12 included in the sample. Based on observation, interview, and record review, the facility failed to ensure a clean sanitary environment for residents of the facility by the failure to change gloves when going from dirty to clean, and the lack of hand hygiene while assisting an incontinent resident to use the toilet for Resident (R) 20. Findings included: - On 09/19/23 at 10:00 AM, Certified Nursing Assistant (CNA) M placed a gait belt on the resident and assisted Resident (R)20 to stand up and then assisted her to sit in the wheelchair. Staff took the resident to her bathroom and instructed the resident to grab the bar to assist with transfer to the toilet. While the resident stood, CNA M pulled her pants down and removed the soiled brief. The resident then sat on the toilet and voided. While wearing the same gloves, CNA M left the bathroom, went to the resident's closet, and retrieved a clean brief. She then proceeded to put the brief on the resident. She then removed her gloves with no hand hygiene done prior to donning clean gloves. CNA M then did peri-care on the resident using wet wipes and the clean brief and pants were pulled up in place. CNA M removed her gloves and assisted the resident out of the bathroom and out of her room. CNA M failed to clean her hands. On 09/19/23 at 10:10 AM, CNA M acknowledged she should have changed gloves and cleaned her hands during toileting the resident. On 09/20/23 at 01:00 PM, Administrative Nurse D reported she expected the staff to have clean gloves and to clean hands when gloves removed. The facility's policy for Hand Hygiene dated 09/22, revealed staff were to wear gloves when in contact with body fluids. Change gloves during elder care if moving from a contaminated body site to clean body site. Wash hands after removing gloves. The facility failed to ensure a clean sanitary environment for residents by the failure to change gloves when going from dirty to clean and the lack of hand hygiene while assisting an incontinent resident to use the toilet.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ,) when the facility failed to submit staffing hourly data for all nursing personnel by the required deadline. Findings included: - Review of the fiscal year (FY)- Quarter 3, 2022 (April 1 - June 30) revealed the following concerns: The facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following dates: On 05/15/22, Sunday (SU), 05/29/22, (SU), 06/04/22, Saturday (SA),06/25/22 (SA),06/26/22, (SA). Review of FY- Quarter 4, 2022 (July 1 - September 30): The facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following dates: On 07/10/22, (SU), 08/06/22, (SA), 08/07/22 (SU), 08/14/22, (SU), 08/21/22, (SU), 09/24/22, (SA). Review of FY Quarter 1, 2022 (October 1 - December 31) The facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following dates: 10/08 Saturday (SA); 10/13 Thursday (TH); 10/23 Sunday (SU); 10/25 Tuesday (TU); 10/26 Wednesday (WE); 10/30 (SU) 11/05 (SA); 11/20 (SU); 11/26 (SA); 11/27 (SU) 12/11 (SU); 12/17 (SA); 12/24 (SA) Review of FY Quarter 2, 2023 (January 1 - March 31) The facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following dates: 01/14 (SA), 02/05 (SU); 02/26 (SU), 03/18 (SA); 03/19 (SU). Review of the nursing schedule and clocking sheets for the above dates revealed adequate hours to account for 24-hour nursing coverage, however the review of the PBJ documented the facility lacked those entered hours. Interview on 09/19/23 at 04:20 PM, Administrative Staff A reported the facility was having the corporate office report the facility hours for the PBJ. They have realized they were not reporting the licensed nursing hours accurately. After the discovery, the facility reports their own hours and have not had any more errors reported. Review of the Electronic Staffing Data Submission Payroll-Based Journal for Long Term Care Facility dated 06/22, revealed long term care facilities must electronically submit to Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable date in a uniform format according to specifications established by CMS. The facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hourly data for all nursing personnel by the required deadline.

The facility census totaled 30 residents, which included seven residents who required a mechanically altered diet (foods that can be safely and successfully swallowed by being whipped, blended, ground, chopped or mashed). Based on observation, interview, and record review the facility failed to provide the appropriate mechanically altered diet to Resident (R) 82, who subsequently developed aspiration pneumonia (an [CONDITION(S)] condition of the lungs caused by inhaling foreign material or vomit) and admitted to the hospital, requiring oxygen on 12/14/21 (after the noon meal) which she did not require prior to this incident. R82 underwent an esophagogastroduodenoscopy (EGD, a procedure to examine the throat, stomach and small intestine) to remove a piece of pork. This placed the resident in immediate jeopardy for choking and at risk for potential death or brain damage due to lack of oxygen through choking. Findings included: - Resident (R) 82's pertinent diagnoses from 11/23/21 Physician's Orders in the Electronic Medical Record (EMR) revealed unspecified non-displaced fracture of second cervical vertebrae (break of the second bone in the neck; required a neck brace to prevent movement). The 11/29/21 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R82 required limited one-person assistance with eating meals. R82 had no history of choking or swallowing issues. The Nutrition Care Area Assessment (CAA) dated 11/29/21 documented R82 received a pureed diet (a smooth, creamy substance made of liquidized or crushed food items) with thin liquids (normal consistency drinks). R82 required set up with her meals and preferred to eat in her room. The Physician Orders documented on 11/23/21, that R82 had a diet order for pureed foods. On 12/14/21 at 03:48 PM, the orders directed staff to discontinue the pureed diet. The 12/04/21 Care Plan documented R82 was on a dysphagia (difficulty swallowing) level 1 diet (pureed diet) due to the cervical fracture and Speech Therapy would evaluate her for swallow function. The Speech Language Pathologist Note written on 12/13/21 by Speech Therapist I documented R82 wanted to increase her diet consistency from pureed to the most appropriate diet consistency. R82 did not exhibit any deficits if her diet consistency was changed from pureed to mechanical soft. R82 had to wear her neck collar/brace but had no additional cautions for swallowing. The Therapy Communication Form written by Speech Therapist I on 12/13/21, recommended R82 be moved up to a mechanical soft diet with ground meat and extra gravy. Administrative Nurse J noted the form as seen on 12/14/21. The Lunch Menu for 12/14/21 documented pork chops, stewed tomatoes, rice, and cheesecake. Further investigation revealed for a dysphagia 1 diet, the dietary staff were expected to puree the pork chops, tomatoes, and cheesecake, and would not serve the rice. The Meal Ticket (used by dietary staff to identify the type of diet each resident had, with the resident's meal order) for R82 dated 12/15/21 documented R82 with a diet of pureed, but the word pureed was scratched out and ground was written in by hand. Observation of R82 on 12/14/21 at 04:00 PM found R82 coughing and spitting up clear phlegm ([MEDICATION(S)] coughed up from the lungs) into a basin. Licensed Nurse (LN) M was at the bedside to complete an assessment and inquired if R82 was ok. R82 denied pain and discomfort. The Nursing Progress Note written on 12/14/21 at 04:31 PM by LN M, documented R82 had no complaints of shortness of breath and was not using supplemental oxygen. R82 complained of a nasal drip and coughed up a lot of clear phlegm after lunch. The Nursing Progress Note written on 12/14/21 at 05:45 PM by LN M, documented R82 continued to cough up clear phlegm out of her nose and mouth with no complaints of shortness of breath. The staff notified R82's family of the lunch incident. LN M noted at approximately 05:00 PM, Occupational Therapist O notified her that R82 was vomiting a darker tinged color, out of her mouth and nose, and was unable to stop. LN M assessed R82 and noted the resident complained of shortness of breath, stated she felt like something was stuck at the top of her throat, had a headache, and she could not keep anything down. LN M notified Administrative Nurse B, notified R82's family, and received consent to send R82 to the emergency room for an evaluation. The facility's Investigation documented R82 admitted to the facility on [DATE] on a pureed diet. On 12/13/21 speech therapy evaluated R82 because she did not like her pureed diet. After the evaluation, speech therapy recommended R82 be moved up to a mechanical soft diet of ground meat and extra gravy. It was also recommended that R82 have ice in her liquids to help stimulate muscle action within the oral cavity and to help execute a safe swallow. The diet orders were changed after lunch on 12/14/21 to a mechanical soft diet of ground meat and extra gravy. R28 received a regular diet tray at lunch. R28 experienced a choking episode with lunch and did not report it to nursing staff right away, but later in the afternoon reported choking on the meat to physical therapy staff. R28 began experiencing vomiting and nasal drainage. The facility sent R28 to the emergency department for further evaluation. All diet cards were reviewed for correct consistency. All staff were educated on verifying meal served with diet card. All dietary staff were educated on serving correct diet and following diet cards. All residents on altered diets were evaluated for safety on eating further meals in their rooms. The 12/16/21 Emergency Department Record documented R82 was on a pureed diet for the last two weeks but was given a piece of [pork] at lunch and was unable to drink anything since that time. R82 felt that she had something stuck in her throat. R82 was given a small amount of water in the emergency room (ER) but could not swallow it. The ER staff called the on-call general surgeon to assess R82. The EGD found the [pork] stuck in R82's throat and removed it. The hospital kept R82 overnight in the hospital for observation. A Witness Statement dated 12/15/21 by Dietary Staff N documented R82 was missing a tray on the first meal pass. Dietary Staff N made a plate for R82 with pureed food and placed it on the cart to be delivered. Dietary Staff N documented that she told the [unnamed] nurse aide to ensure R82 received the correct tray as the trays did not have (meal) tickets on them. Interview on 12/20/21 at 08:27 AM with Certified Nurse Aide (CNA) O revealed she was behind that afternoon and had the [unnamed] Certified Medication Aide (CMA) take the lunch orders from each resident. CNA O was given R82's lunch tray to deliver to her room. When CNA O gave R82 the lunch tray, R82 looked over the food and said it looked right. CNA O stated that R82's name was on the meal ticket, but stated that she could not remember if the diet was written on the ticket or not. CNA O picked up R82's tray after lunch and noted that R82 was coughing a little bit. CNA O stated that R82 told her I did not swallow my food right and that she did not eat well because of this. CNA O offered R82 a drink of water which did not stop the coughing. CNA O stated that R82 did not appear to have difficulty breathing, was not short of breath and was not using supplemental oxygen. R82 requested to see the nurse, so CNA O notified the [unnamed] LN on duty. Interview on 12/15/21 at 09:40 AM with Executive Chef F revealed the dietary staff were not to plate any food other than what was documented on the diet ticket, even if the nurse told the dietary staff differently. He stated the only valid way to have a diet order changed was to have it in writing, signed by the physician, and faxed to the kitchen manager. He said, prior to 12/15/21, meal tickets were printed on a weekly basis, so all the meal tickets for R82 documented puree. Executive Chef F verified he had not received written confirmation from a physician that R82's diet changed, and dietary staff should have given R82 a pureed meal. He expected all dietary staff to verify each meal tray for accuracy before being given to the residents. Interview on 12/15/21 at 10:06 AM with LN E revealed dietary staff would plate all food for residents and then bring the trays to the nurses' station to be delivered to the residents who eat in their rooms. The CNAs would then deliver the meal trays to the residents in their rooms. LN E stated all CNAs should open the lid to ensure the food plated matched the meal ticket. If the food did not match the ticket, the LN would notify the kitchen, and have it corrected. To change a diet for a resident, the LN would obtain an order from the physician and then send the written order to the kitchen manager Just before LN E left at 02:00 PM on 12/14/21, R82 told LN E that it felt like something was stuck in her throat, but she did not complain of anything else. She said R82 then went to therapy. Interview on 12/15/21 at 02:30 PM with Occupational Therapist (OT) G stated she worked with R82 after lunch around 01:30 PM or 02:00 PM. R82 was coughing and OT G noticed a small basin filled with spit. R82 stated she did not eat much lunch because she choked on something. OT G notified [LN M] and LN M completed an assessment. R82 still wanted to work with OT G, so the two of them walked the hall a short distance before returning to R82's room. R82 was not in distress or short of breath, but R82 did sound wheezy. R82 complained of a headache and staff offered fluids. Interview on 12/15/21 at 03:30 PM with Administrative Nurse J revealed R82 requested to eat regular food the week prior because she did not like the pureed diet. Administrative Nurse J obtained an order from the physician for R82 to have a swallow evaluation completed by Speech Therapy. Speech Therapist I and Physical Therapist H completed the swallow evaluation on 12/13/21 via facetime on the phone Administrative Nurse J stated R82 passed the evaluation with no concerns by the therapy team. Speech Therapist I recommended R82 be advanced to a mechanical soft diet with ground meat and extra gravy. Administrative Nurse J received the Therapy Communication Form written by Speech Therapist I and faxed it to the physician, requesting a new diet order and placed a copy of the form in R82's chart. Administrative Nurse J also placed a copy of the form on the dietary manager's desk and emailed him as well as the Dietician. LN M notified Administrative Nurse J that [LN M] had concerns about R82's swallowing. Administrative Nurse J told LN M to notify Administrative Nurse B of the concern and that R82 received the wrong tray at lunch. Administrative Nurse J spoke with Kitchen Manager P about the incorrect plate served to R82 and Kitchen Manager P stated R82 was never changed off the pureed diet and should have received the puree diet tray for lunch. Interview on 12/15/21 at 05:23 PM with Physical Therapist (PT) H revealed that she assisted Speech Therapist I on 12/13/21 with a swallow evaluation via facetime. PT H stated she and Speech Therapist I told R82 that she would be upgraded to a mechanical soft diet with ground meat and extra gravy. PT H stated that the mechanical soft diet with ground meat and extra gravy should start on 12/15/21 with the evening meal and that R82 should have received a pureed meal for both breakfast and lunch on 12/15/21. On 12/15/21, she worked with R82 between 04:00 PM and 05:00 PM. R82 stated she felt like something was stuck in her throat and started vomiting. R82 vomited a total of three times before PT H was able to get nursing assistance. R82 vomited again once the [unnamed] LN came into the room. PT H stated that the vomit was pink-tinged and coming out of her mouth and nose, and that Administrative Nurse B came to the room. R82 vomited for the fifth time and pointed to her throat with the collar in place. PT H stated that R82 was not on oxygen and did not appear to be short of breath, but that R82 did have a gurgling sound coming from her throat. Administrative Nurse B left the room and told [unnamed LN] to call Emergency Medical Services (EMS). R82 was then sent to the ER. Interview on 12/16/21 at 02:59 PM with Speech Therapist I revealed R82 did not like the pureed diet and requested to be placed on a regular diet with real food. PT H assisted with the swallow evaluation of R82, which R82 passed. Speech Therapist I recommended that R82 be elevated to a mechanical soft diet with ground meat and extra gravy to prevent choking. Speech Therapist I and PT H discussed the meaning of the new diet with R82, which R82 responded she understood. Speech Therapist I stated that PT H brought the Therapy Communication Form to Administrative Nurse J and presented the information at the morning meeting on 12/14/21. Speech Therapist I stated that once she made a diet recommendation, it needed to be approved by the physician before the resident could have that diet. R82 was to receive the pureed diet until her physician approved the elevated diet of ground meat. Interview on 12/15/21 at 11:30 AM with Administrative Nurse B and Administrative Nurse D revealed they completed one-on-one education with both kitchen/dietary staff and nursing staff about following diet orders. They also discovered CNA O was the staff member who delivered the lunch meal tray to R82. They stated all resident orders were checked and verified with the most current order from the physician and all meals would be supervised by a member of the management team to ensure the meal order was being read and plated correctly. They further stated, only the cook would plate the food, the dietary aides would verify the tray with the supervisor and serve to the residents in the dining room or place the meal tray on the cart to be delivered. The nursing staff would be serving to the residents in their rooms and would be expected to verify the tray prior to delivery. The 03/2020 Meal Identification policy documented a meal ticket would be used to identify each resident's meal to ensure the resident received the correct meal. The meal ticket would include the resident name, room/location, and diet order as prescribed by the physician in the medical records. The facility failed to provide the appropriate mechanically altered diet to R82, who subsequently developed aspiration pneumonia and admitted to the hospital, requiring oxygen on 12/14/21 (after the noon meal) and she did not require oxygen prior to this incident. R82 underwent an EGD to remove a piece of pork. This placed the resident in immediate jeopardy for choking and at risk for potential death or brain damage due to lack of oxygen through choking. On 12/15/21 at 05:09 PM, the facility provided an acceptable plan for removal of the immediate jeopardy, when the facility implemented the following: 1. The facility immediately identified the event and the need for staff education for accurate diet textures served to residents. 2. The facility completed an audit of diet orders. 3. An audit of diets for all residents at mealtimes by dietary and nursing and audits were taken to morning meeting to follow up with any other clinical/dietary needs. 4. Supervising all meals being plated during meal times. The surveyor verified the implementation of the removal of the immediacy onsite on 12/16/21. The deficient practice remained at a G scope and severity following removal of the immediate jeopardy.

The facility reported a census of 30 residents. Based on observation, interview, and record review the facility failed to store food in a safe, sanitary manner and in accordance with professional standards for food service safety. The facility failed to monitor the refrigerator and freezer temperatures to ensure proper food storage and temperatures, failed to monitor the quaternary (chemical used to clean and sanitize surfaces) levels to ensure efficacy of the sanitizer used to clean tables and surfaces, and failed to monitor food temperatures to ensure all foods were prepared/cooked to the safe temperatures. This had the potential to affect all residents. Findings included: - On [DATE] at 10:00 AM, during the initial tour of the main kitchen, the following items were noted to be expired: 57.5 dozen eggs (expired between [DATE] through [DATE]) in the walk-in refrigerator, four packaged avocado halves (expired on [DATE]) in the walk-in refrigerator, and four packages of Instant Potato mix (expired between June and September of 2021) in the pantry. In addition, the pantry stored the following items which did not have an expiration date listed: 14 MedPass drinks, one (35 oz) bag of Cheerios, four (35 oz) bags of Frosted Shredded Wheat, two (35 oz) bags of Chex, and four (35 oz) bags of Rice Krispies. The pantry also stored an open (unsealed) and undated bag of spaghetti, without an open date. The walk-in refrigerator contained two (eight pack) containers of strawberry yogurt that were leaking yogurt and 20 very mushy/soft whole avocados in the walk-in refrigerator. On [DATE] at 10:00 AM, during the initial tour of the main kitchen the refrigerators and freezers lacked documentation/logs of temperature monitoring. The quaternary strips (tests the concentration of the quaternary chemical) available in the kitchen, were expired (expiration date [DATE]) and the kitchen lacked documentation/logs of monitoring or evidence of daily checks of the sanitizer to ensure adequate dilution of the chemical. In addition, no temperature documentation/logs were found to ensure the staff checked the cooked and prepared foods to ensure the safe temperature (to ensure the food is hot enough to kill harmful germs that cause food poisoning) and checked cold served foods to ensure a safe temperature, prior to being served to residents for meals. Interview on [DATE] at 10:15 AM with Registered Dietician K, Certified Dietary Manager (CDM) L, and Executive Chef F revealed [DATE] was their first day on the job, as the facility had hired their company to take over management of the kitchen and dietary services. They stated they were in the process of organizing everything in the kitchen. They also completed inventory of the food items in the kitchen and in storage but did not realize some food was expired or unlabeled. They agreed the temperatures of the freezers and refrigerators should be checked at least daily or twice a day and expected the staff to check the quaternary solution three times a day. Registered Dietician K, CDM L, and Executive Chef F stated all food items should have been checked at each meal and they did not know why these were not being completed. They stated they would be completing education with the dietary staff and providing logs for the dietary staff to complete daily. The 2011 Health Technologies Refrigerator/Freezer Temperatures policy documented that the refrigerators were to be kept at 41 degrees Fahrenheit (F) or lower and the freezers were to be kept at zero degrees F or lower. The dietary staff were responsible for taking the temperatures on all kitchen and nourishment room refrigerators and freezers, and recording temperatures on temperature report logs daily, during each shift. The 2011 Health Technologies Steam Table Serving Temperatures for Hot and Cold Foods policy documented the cook would take the temperatures of all hot and cold items using approved food thermometers prior to each meal service and recorded. The 2020 Health Technologies Sanitizing and Disinfectant Solutions policy documented employees would prepare the sanitizer solution in accordance with manufacture guidelines and would test the concentration level at least daily before use. The facility failed to store food in accordance with professional standards for food service safety to prevent the outbreak of foodborne illness when observations revealed expired food in the kitchen, lack of temperature logs for the refrigerators and freezers, lack of quaternary solution checks, and lack of temperature logs for prepared food.

The facility reported a census totaling 30 residents. Based on observation and interview, the facility failed to maintain all mechanical care equipment in safe operating condition, when the kitchen tour revealed a three-tub sink and a garbage disposal in a separate sink did not work, putting residents at risk for unsanitary conditions. Findings included: - On 12/13/21 at 10:00 AM, during the initial tour of the main kitchen, the surveyor observed the three-tub sink did not work. The plumbing was turned off and the sinks were not being used by staff. There was no sign present noting the sinks did not work. In addition, the garbage disposal located in a separate sink in the kitchen did not work. This sink was taped off with a pan upside down to prevent dietary staff from using the sink. Interview on 12/13/21 at 10:15 AM with Registered Dietician K, Certified Dietary Manager (CDM) L and Executive Chef F revealed that 12/13/21 was their first day on the job, as the facility had hired their company to take over management of the kitchen and dietary services. They stated that a new three-tub sink and garbage disposal were ordered and would be replaced the following week. Interview on 12/14/21 at 11:20 AM with Executive Chef F and Kitchen Manager P revealed a company (Ecolab) would be replacing the three-tub sink the following week, and that maintenance was notified of the non-working garbage disposal in the separate kitchen sink and ordered a new part. They stated the separate sink would not be operational until the disposal was fixed. The facility did not provide a policy related to maintaining equipment in a safe operating condition. The facility failed to maintain all mechanical care equipment in safe operating condition.

The facility reported a census of 30 residents, with 12 sampled, including five for unnecessary medications. Based on interview and record review, the facility failed to ensure the physician responded to the multiple consultant pharmacist's recommendations for Resident (R)15. Findings included: - R15's Electronic Health Record dated 07/01/20 included a diagnosis of major depressive disorder (MDD; major mood disorder). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R15 received scheduled pain medication and pain medication as needed (PRN). R15 also received six out of the seven-day observation period of antipsychotics (class of medications used to treat [CONDITION(S)] and other mental and emotional conditions) and antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression). The Behaviors Care Area Assessment (CAA), dated 10/01/12, documented that R15 took [MEDICATION(S)] (antidepressant) 40 milligram (mg) daily and [MEDICATION(S)] (antipsychotic) 0.5mg daily for MDD and R15 was being seen by Compass Behavioral Health Care. The [CONDITION(S)] Drug Use CAA, dated 10/01/12, documented that R15 had a potential for issues related to [CONDITION(S)] medications and that pharmacy reviews were to be completed quarterly and as needed. The 07/09/21 Quarterly MDS documented R15 received scheduled pain medication and PRN pain medication, as well as seven out of the seven-day observation period of antipsychotics and antidepressants. The 12/02/21 Care Plan documented staff was to monitor R15 for [CONDITION(S)] medication side effects as well as possible dose reduction of [CONDITION(S)] medication. The Medication Regimen Review (MRR) and Gradual Dose Reduction (GDR) regarding R15 documented the following: On the 08/2020 MRR and GDR, the consultant pharmacist recommended that a lipid panel (a test that measures the amount of certain fat molecules called lipids in the blood) be completed for [MEDICATION(S)] (medication to lower lipid [fat] level in the body). The facility faxed the recommendation to the provider, but the facility failed to follow up on this recommendation. On the 09/2020 MRR and GDR, the consultant pharmacist recommended that [MEDICATION(S)] (antidepressant) 40mg by mouth (PO) daily, be decreased to 20mg PO daily and that [MEDICATION(S)] (antipsychotic) 0.5mg PO every evening, be decreased to 0.25mg every evening. The facility faxed the recommendation to the provider, but the facility failed to follow up on this recommendation. On the 10/2020 MRR and GDR, the consultant pharmacist recommended that a lipid panel (a test that measures the amount of certain fat molecules called lipids in the blood) be completed for [MEDICATION(S)] (medication to lower lipid [fat] level in the body). The facility faxed the recommendation to the provider, but the facility failed to follow up on this recommendation. On the 11/2020 MRR and GDR, the consultant pharmacist recommended that [MEDICATION(S)] (antidepressant) 40mg by mouth (PO) daily, be decreased to 20mg PO daily and that [MEDICATION(S)] (antipsychotic) 0.5mg PO every evening, be decreased to 0.25mg every evening. The facility faxed the recommendation to the provider, but the facility failed to obtain a rationale for the physician's denial of the GDR. On the 01/2021 MRR and GDR, the consultant pharmacist recommended that [MEDICATION(S)] (antidepressant) 40mg by mouth (PO) daily, be decreased to 20mg PO daily and that [MEDICATION(S)] (antipsychotic) 0.5mg PO every evening, be decreased to 0.25mg every evening. The facility faxed the recommendation to the provider, but the facility failed to follow up on this recommendation. On the 10/2021 MRR and GDR, the consultant pharmacist recommended that [MEDICATION(S)] (antidepressant) 40mg by mouth (PO) daily, be decreased to 20mg PO daily and that [MEDICATION(S)] (antipsychotic) 0.5mg PO every evening, be decreased to 0.25mg every evening. The facility faxed the recommendation to the provider, but the facility failed to follow up on this recommendation. Interview with Administrative Nurse B on 12/15/21 at 11:48 AM revealed the MRR's and GDR's from the consultant pharmacist are sent to Administrative Nurse B each month. She would fax each recommendation to the appropriate physician and document in the resident's chart that the fax was sent. Administrative Nurse B stated that sometimes the physician would send back the signed recommendation to the facility and sometimes it would be sent to the pharmacist from the physician. She also stated that some months, the facility did not receive a response from the provider. Administrative Nurse B only sent the recommendation to the physician once a month and did not try contacting the physician about it after that time. Interview with Consultant Pharmacist C on 12/16/21 at 04:43 PM revealed he completed the MRR's and GDR's every month for every resident and sends them to the facility. For R15, the recommendation for the reduction of [MEDICATION(S)] and [MEDICATION(S)] was sent every other month to give the physician time to respond. Physicians must provide a rationale with all disagree responses and when a rationale is not completed, Consultant Pharmacist C will send the recommendation again. Sometimes the physician would send the signed recommendation to the pharmacy instead of the facility, and Consultant Pharmacist C had conversations with those physicians about sending the signed response to the facility instead. Consultant Pharmacist C expected the facility to fax the MRR and GDR to the physician and then call the physician a few times to try to get a response on the recommendation. Consultant Pharmacist C stated that sometimes the physicians refuse to sign, so he will continue to send the recommendation. The 06/10/19 Drug Regimen Review policy documented the facility would encourage the physician receiving the pharmacy recommendation(s) and the Director of Nursing to act upon the recommendations. The facility was to encourage the physician to either accept and act upon the recommendations contained within the pharmacy recommendation or to reject all or some of the recommendations with an explanation as to why it was rejected. The facility failed to ensure the physician responded to the multiple consultant pharmacist recommendations for R15.

The facility reported a census of 30 residents, with 12 sampled, including five for unnecessary medications. Based on interview and record review, the facility failed to ensure residents were free from unnecessary [CONDITION(S)] medications, when multiple pharmacist recommendations for a gradual dose reductions (GDR) recommendations were not addressed for Resident (R) 15. Findings included: - R15's Electronic Health Record dated 07/01/20 included a diagnosis of major depressive disorder (MDD, major mood disorder). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R15 received scheduled pain medication and pain medication as needed (PRN). R15 also received six out of the seven-day observation period of antipsychotics (class of medications used to treat [CONDITION(S)] and other mental and emotional conditions) and antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression). The Behaviors Care Area Assessment (CAA), dated 10/01/12, documented R15 received [MEDICATION(S)] (antidepressant) 40 milligram (mg) daily and [MEDICATION(S)] (antipsychotic) 0.5mg daily for MDD. R15 was being seen by behavioral health care. The [CONDITION(S)] Drug Use CAA, dated 10/01/12, documented R15 had a potential for issues related to [CONDITION(S)] medications and pharmacy reviews were to be completed quarterly and as needed. The 07/09/21 Quarterly MDS documented R15 received scheduled pain medication,PRN pain medication, and daily antipsychotic and antidepressant medications during the seven-day observation period. The 12/02/21 Care Plan documented staff were to monitor R15 for [CONDITION(S)] medication side effects as well as possible dose reduction of [CONDITION(S)] medication. The Electronic Health Records (EHR) Physician Orders documented an order for [MEDICATION(S)] (antidepressant medication) 40 milligram (mg) tablet, staff would give one tablet by mouth daily started on 02/06/21. R15 also had an order for [MEDICATION(S)] (an antipsychotic medication) 0.5 mg tablet staff would give one tablet by mouth every evening started on 02/06/21. The 10/2021 through 12/2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented appropriate documentation of administrations of medications and monitoring of behaviors. The Gradual Dose Reductions (GDRs) from 09/2020 through 01/2021 documented Consultant Pharmacist C completed a GDR request for [MEDICATION(S)] and [MEDICATION(S)] every two months with no reduction in dosage or explanation/rationale by the physician for continuing the dosage. From 07/2021 through 10/2021, Consultant Pharmacist C completed a GDR request for [MEDICATION(S)] and [MEDICATION(S)] twice more with no reduction in dosage or physician explanation/rationale for continuing the dosage. Interview with Administrative Nurse B on 12/15/21 at 11:48 AM revealed the MRR's and GDR's from the consultant pharmacist are sent to Administrative Nurse B each month. She would fax each recommendation to the appropriate physician and document in the resident's chart that the fax was sent. Administrative Nurse B stated that sometimes the physician would send back the signed recommendation to the facility and sometimes it would be sent to the pharmacist from the physician. She also stated that some months, the facility did not receive a response from the provider. Administrative Nurse B only sent the recommendation to the physician once a month and did not try contacting the physician about it after that time. Interview with Consultant Pharmacist C on 12/16/21 at 04:43PM revealed he completed a GDR every two months to allow the provider to respond. He expected the provider to see the GDR, either agree or disagree [with explanation], and then sign the form, before faxing back to the facility. Consultant Pharmacist C expected the facility to fax the MRR and GDR to the physician and then call the physician a few times to try to get a response on the recommendation. Consultant Pharmacist C stated that sometimes the physicians refuse to sign, so he will continue to send the recommendation. The 06/10/19 Drug Regimen Review policy documented the facility would encourage the physician receiving the pharmacy recommendation(s) and the Director of Nursing to act upon the recommendations. The facility was to encourage the physician to either accept and act upon the recommendations contained within the pharmacy recommendation or to reject all or some of the recommendations with an explanation as to why it was rejected. The facility failed to ensure R15 did not receive unnecessary [CONDITION(S)] medications when multiple pharmacist GDR recommendations were not addressed for R15.

The facility reported a census of 46 residents. Three residents were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview and record review the facility failed to provide appropriate care and services to prevent the development of or promote healing of pressure ulcers for 2 of 3 sampled residents. The facility failed to ensure the staff implemented timely interventions in the prevention two pressure ulcers for resident #3; one unstageable 1 unstageable deep tissue injury (DTI- a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or sheer) and one which developed into a stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer) pressure ulcer which required wound care at a local wound clinic for the resident. The facility also failed to ensure staff repositioned resident #2 every hour while up in his/her chair as care planned and resident #2 developed a red area to his/her left buttock. Findings included: - Review of the signed physician orders dated 7/26/17 revealed resident #3's [DIAGNOSES REDACTED]. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance of 1 staff for bed mobility, transfers and dressing, toilet use and personal hygiene. The resident had impaired range of motion (ROM) to lower extremities on both sides and used a wheelchair for mobility. The resident had moderate pain frequently and received scheduled pain medications for 7 of 7 days of the observation period. The resident had a risk of pressure ulcers and no unhealed pressure ulcers. Review of the significant change MDS dated [DATE] revealed a BIMS score of 14, which indicated intact cognition. The resident continued to require extensive assistance of 1 staff for bed mobility, transfers, locomotion, and toilet use. The resident had impaired range of motion in both upper and lower extremities and used a wheelchair for mobility. The resident reported no pain. The resident had a risk of pressure ulcers and had 1 or more unhealed pressure ulcers, stage 1 or higher. The MDS revealed he/she had 1 unstageable (slough (dead tissue, usually cream or yellow in color) and/or eschar (dead tissue)), and 1 unstageable deep tissue injury-(DTI-a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or sheer) that measured 1 centimeter (cm) x 1 cm and had no [MEDICATION NAME] (new skin growing in a superficial wound), granulation (tissue formed during wound healing), slough (dead tissue, usually cream or yellow in color), or eschar (dead tissue). The treatments included pressure reducing device for chair, pressure ulcer care, and application of dressings to his/her feet. Review of the resident's care area assessments (CAAs) dated 8/11/17 revealed: Activities of daily living (ADL)/Functional Rehabilitation potential: Resident #3 had arthritis in both knees with pain, which weight bearing activity increased. The resident no longer walked and used a sit-to-stand mechanical lift (transferring device) only, for transfers. The resident required extensive assistance of 1 with ADLs. He/she called for assistance to the bathroom, on and off the toilet, transfers in/out of the bed or wheelchair, and to the recliner. The resident could reposition him/herself and had a positioning bar on his/her bed to help with independent bed mobility. The resident was alert and oriented, made his/her own decisions regarding his/her care and used a call light to summon help, as needed (PRN). The resident's arthritis hindered his/her ADL ability. Pressure Ulcer: The resident had unstageable wounds, 1 to the left heel and 1 to the left ankle. The resident explained that he/she tried blue foam boots during sleep and did not like them, so he/she did not wear them and he/she had a new pair of shoes. The resident received wound care per facility guidelines. Review of the Braden Skin Assessment (tool used to assess the skin for sensitivity, moisture, and other categories of the skin's health) Scores dated 10/3/16 revealed a score of 15 and on 7/28/17 a score of 17, both indicating low risk. Review of the resident's care plan reviewed on 8/14/17 revealed the following interventions: 7/13/17: staff were to monitor prominence to the resident's left inner foot and notify the charge nurse of redness or pain 7/26/17: suspected deep tissue injury to the left foot inner aspect- staff were to monitor daily, ensure the resident wore ankle boots when in bed or the recliner and apply slip on shoes only with Kerrafoam (absorbent dressing pad) dressing on the resident's left foot inner aspect and left heel. 7/31/17: physician ordered a multivitamin every day and [MEDICATION NAME] (a nutrition supplement to help support the nutritional needs of individuals with wounds) twice a day for wound healing. On 8/14/17 staff initiated a new problem and goal for wounds identified as unstageable in the resident's 8/11/17 care area assessment to his/her left foot and heel. Interventions dated 8/14/17 directed staff to: Assist to reposition every 2 hours in bed and 1 hour in chair and PRN Ensure the dietician completed an assessment every month and PRN Evaluate positioning to determine if the resident needed an assistive device Educate the resident on the importance of repositioning and any assistive devices used to assist with repositioning. The resident did not like the foam booties when tried and kicked them off. Prop the resident's feet on a pillow support as he/she allowed. Use slip-on shoes only. Place a dressing to the ankle and heel per wound treatment orders. Licensed wound care nurse (LWCN) to assess weekly and update interdisciplinary team (IDT), physician (MD) and implement new wound treatment orders PRN. 8/22/17: [MEDICATION NAME] (antibiotic medication) for 10 days, twice a day (BID) for left heel wound - discontinued (DCd) 8/29/17 8/23/17: Provide wound care via the outpatient clinic. 8/24/17: Alleviate all pressure from the left foot. Assist with pushing the resident in the wheelchair and do not let the resident use his/her legs to mobilize the wheelchair. 8/28/17: [MEDICATION NAME] and [MEDICATION NAME] (both antibiotic medications) intravenous (IV- external catheter used to allow a fluid to flow directly into a vein) started for left heel wound [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling). Review of the signed physician order summary dated 7/26/17 revealed no supplements or pressure ulcer care ordered. The summary included on 7/19/17 the resident's left inner bony area of the inner arch of the left foot was bothering him/her and upon inspection revealed a small red area which measured 0.4 cm by 0.5 cm. Review of the fax communication orders dated 7/28/17 (9 days after staff discovered a wound on the resident's inner left foot) revealed the resident had two dark red areas to his/her inner left foot and no open areas. The resident believed it was due to ill-fitting shoes. Staff noted suspected deep tissue injuries and requested to start multivitamin daily and [MEDICATION NAME] twice a day for wound healing which the physician approved on 7/31/17. Review of the wound notes revealed the following: 7/19/17: Left Inner Foot: 0.4 cm x 0.5 cm x 0 cm the resident stated the bony area at inner arch of left foot bothered him/her. Upon inspection noted small red area which measured 0.4 cm x 0. 5 cm. Preventative dressing applied. Kerrafoam put in place at the time as preventative. 7/21/17: Left Inner Foot: 0.4 cm x 0.5 cm x 0 cm 7/24/17: Left Inner Foot: 0.4 cm x 0.5 cm x 0 cm 7/26/17: Left Inner Foot: 1.0 cm x 1.0 cm x 0 cm. The resident stated his/her bony area at the inner arch of his/her left foot bothered him/her. Dark red, non-blanching area noted with persistent skin redness and surrounding skin red tender to touch. On 7/26/17 a suspected DTI (sDTI) was found on the resident's left inner heel that measured 3.0 cm x 2.0 cm x (blank). The wound had [MEDICATION NAME] tissue without drainage and had no interventions listed. 7/28/17: Left inner heel: staff documented measurements 0.0 cm x 0.0 cm x (blank) with blanchable redness noted. Red and tender to touch. Tissue type: necrotic/eschar. Treatment; daily monitoring. Covered with Kerrafoam dressing. (No interventions listed) On 7/28/17 staff initiated an intervention on the treatment administration record (TAR) for the resident to wear heel boots on both feet when he/she lay in his/her bed or recliner until his/her wound heeled however staff failed to document the resident wore his/her heel boots. On 7/31/17 the physician signed an order approving a multivitamin every day and [MEDICATION NAME] twice a day for wound healing. 8/2/17: Left Inner foot: 1 cm x 1 cm x 1 cm - circular maroon discoloration to bony prominence on left inner foot. Kerrafoam to prevent friction and shear was applied to the affected area. Suspected deep tissue injury (DTI-purple or maroon localized area of intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). Interventions included a turning repositioning program and protein supplement implemented 7/31/17. 8/2/17: Left inner heel: staff documented measurements 0 cm x 0 cm x 0 cm with persistent skin redness. Type Pressure ulcer - Suspected Deep Tissue Injury to left inner heel. Staff described wounds to the resident's left inner heel as 3 spots measuring 0.3 cm x 0.4 cm, 0.2 cm x 0.2 cm, and 0.4 cm x 0.4 cm. Daily monitoring of wound, and covered with Kerrafoam dressing to prevent friction and shear. Interventions included a turning and repositioning program, protein supplement, multi-vitamin, and ulcer care. 8/7/17: Left Inner Foot: 1 cm x 1 cm x 0 cm: circular maroon discoloration to bony prominence pressure ulcer with persistent skin redness. Kerrafoam to prevent friction and shear placed to the affected area. Interventions included: Pressure reducing chair, Turning repositioning program, multivitamin, protein supplement, and ulcer care. 8/9/17: Left Inner foot: 0.6 cm x 0.5 cm x 0 cm: No change from the prior note. 8/9/17: Left inner heel: 3 cm x 2 cm x (blank) :persistent redness, wound edge pink in color - tissue type [MEDICATION NAME]; description: DTI to left inner heel; staff described wounds as 3 maroon spots that became one big wound measuring 3 cm x 2 cm. Daily monitoring of wound, covered with Kerrafoam dressing to prevent friction and shear. Interventions included: turning and repositioning program, multivitamin, protein supplement, and ulcer care 8/12/17: Left inner heel 3 cm x 2 cm x (blank) - No change from the prior note. The wound notes lacked further documentation about the left inner foot wound and continued documentation about the left inner heel wound. 8/14/17: Left Inner foot 0.6 cm x 0.5 cm x 0 cm. No change from the prior note. 8/14/17: Left inner heel 3 cm x 2 cm x (blank) No change from the prior note. 8/16/17: Left inner heel 3 cm x 2 cm x (blank) persistent skin redness; tissue type [MEDICATION NAME]. Dead [MEDICATION NAME] tissue came off. 1.4 cm x 1 cm maroon area visible underneath. Daily monitoring of wound. Covered with Kerrafoam dressing to prevent friction and shear. DTI interventions included: turning and repositioning program, multivitamin, protein supplement, and ulcer care. The [MEDICATION NAME] was not administered BID as ordered on [DATE], 8/20/17. 8/21/17: Left inner heel 3 cm x 2 cm x (blank) No change from the prior note. 8/23/17: Left inner heel 3 cm x 2 cm x (blank) No change from the prior note. [MEDICATION NAME] not administered BID on 8/23/17. 8/26/17: Left inner heel 3 cm x 2 cm x (blank) No change from the prior note. [MEDICATION NAME] not administered BID on 8/26/17. 8/28/17: 3 cm x 2 cm x (blank): The resident received outpatient wound clinic treatment. Medi-honey (medical-grade honey product for the management of wounds) applied to wound bed, covered with gauze and secured by coban. Persistent skin redness - tissue type [MEDICATION NAME]. Interventions included: turning and repositioning program, multivitamin, protein supplement, and ulcer care. On 8/28/17 a PICC (peripherally inserted central catheter: a form of intravenous access that can be used for prolonged period of time) line was placed to administer [MEDICATION NAME] 1 gram IV daily and [MEDICATION NAME] 2 grams IV daily for 7 days for leg [MEDICAL CONDITION]. 8/30/17: left inner heel 3 cm x 2 cm x (blank). No change from the prior note. 9/4/17: left inner heel 3 cm x 2 cm x (blank). No change from the prior note. (no change in size from 8/9/17- 9/4/17) [MEDICATION NAME] not administered BID on 9/1/17 and 9/3/17. Review of the treatment administration record (TAR) dated 7/15/17- 8/14/17 revealed on 7/19/17 staff initiated checking the resident's left inner foot area daily and applied a preventative Kerafoam dressing and changing the dressing every 3-7 days. On 7/26/17 staff initiated checking the resident's left inner heel, applying kerrafoam dressing and changing the dressing every 3-7 days. Physician orders lacked staff notification of these wounds and/or staff request for orders for treatment interventions for the wounds between 7/19/17 and 7/28/17. Review of the nutrition assessment dated [DATE] revealed the dietician noted the resident received treatment to his/her left inner foot and received a multivitamin with minerals daily and [MEDICATION NAME] BID as recommended and ordered on [DATE]. Review of the Medication Administration Record [REDACTED]. Review of a physician order dated 8/28/17 revealed to place a PICC line for [MEDICATION NAME] 1 gram IV daily and [MEDICATION NAME] 2 grams IV daily for 7 days for leg [MEDICAL CONDITION]. Review of the nurse's notes revealed the following: 8/5/17: The resident complained of pain in his/her left foot. Staff applied a preventative dressing and administered 50 mg [MEDICATION NAME] (pain medication). 8/19/17: the resident complained of left heel pain. Staff found the wound moist with a necrotic area and foul odor noted and administered [MEDICATION NAME] ([MEDICATION NAME]) 50 mg for pain. 8/24/17: The resident went to wound clinic outpatient therapy for wound care. His/her wound measured 1.8 cm x 1.6 cm and had 90% necrosis (localized tissue death that occurred in a group of cells in response to disease or injury). 8/25/17: The resident returned from his/her appointment. He/she had significant necrosis and staff needed to alleviate pressure to his/her left heel at all times. 8/28/17: The resident returned from the wound clinic after he/she had necrosis debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). 8/28/17: Staff received a new order for [MEDICATION NAME] 1 gm IV daily and [MEDICATION NAME] (an antibiotic) 2 gm IV daily for 7 days. 8/30/17: A wound dressing appointment noted the resident's wound had eschar present and softening. 9/3/17: The resident complained of left heel pain. His/her wound had a necrotic middle noted with serous drainage and wore protective boots. Review of the Physician visits regarding the resident's wound revealed: 8/21/17: A necrotic area to the resident's left heel noted and the resident complained of pain to left foot at night; left heel ulcer, stage 2 8/24/17: Left heel stage 2 ulcer: evaluation performed size of wound 1.8 cm x 1.6 cm. 90% necrosis. Concern with surrounding area of heel very soft/tender. 8/25/17: Left heel pressure ulcer - re-evaluate. No significant change since yesterday. Necrosis still significant. 8/28/17: wound treatment progress notes: some mild debridement of necrosis. No changes in size. 8/30/17: no significant change to wound. Eschar still present but softening 9/1/17: removed dressing and noted minimal serous/bloody drainage with eschar very dry and unable to debride. Observation on 9/7/17 at 7:30 a.m. revealed direct care staff F entered the resident's room and assisted the resident to the side of the bed. The resident had on white socks and did not have on foot protectors. Observation on 9/7/17 at 2:20 PM revealed the resident wore fur-lined house slippers and sat in a wheelchair. Licensed nursing staff C removed the resident's dressing secured with self-adherent wrap off the resident's left foot which revealed a wound approximately 2 cm x 1.5 cm with circular eschar and reddish pink healing granulation tissue around it, and a small amount of dry brownish, yellow drainage. Staff C cleansed the area with normal saline. The resident's left inner foot had an approximate 1 cm circumference area, which looked like a blood blister over his/her bony prominence. Staff C put a small square of petroleum gauze over the wound then wrapped it in a gauze bandage, then an elastic bandage, per the wound clinic instructions prior to the resident leaving for his/her wound clinic appointment. During an interview on 9/7/17 at 7:30 AM resident #3 stated he/she did not know how or when he/she acquired a wound on his/her heel and did not know why he/she wore protective boots. The resident stated the staff just kept it wrapped up and he/she did not know why he/she did not wear protective boots last night. During an interview on 9/6/17 at 4:43 PM direct care staff E said the resident had a pressure ulcer on his/her left foot. Staff E stated when the resident sat in a recliner, staff kept the resident's legs elevated and his/her boots on to ensure the resident's heels were not pressing against anything. Staff E stated the resident wore both boots, but sometimes did not like the boots because the resident had problems with his/her knees. Staff E stated he/she had not seen the pressure ulcer because when he/she worked, it was covered. Staff E said staff kept 2 pillows under the resident's legs, a small pillow between his/her knees and then put the resident's boots on. Staff E stated the staff had to do everything for the resident. The resident used a sit-to-stand mechanical lift for all transfers and the staff assisted the resident in the bathroom. Interview with direct care staff F on 9/7/17 at 8:04 a.m. revealed the resident needed to wear heel boots when in bed and in his/her recliner and staff F did not know why the resident did not have them on the morning of 9/7/17. Staff F stated the resident may have refused to let staff put on heel boots that night. During an interview on 9/6/17 at 3:03 p.m. licensed nursing staff H reported the resident just finished an antibiotic for a left heel infection. Staff H reported staff put boots on the resident to relieve pressure. Staff H reported the resident had just finished antibiotics. The resident received dressing changes at the wound clinic. Staff put boots on the resident to relieve pressure and did not think he/she wore them all the time. The resident could not stand and wanted staff to propel him/her to keep pressure off the feet. Staff H thought licensed nursing staff B discovered the pressure ulcer, but did not know when. Staff H reported the resident received wound care at the local wound clinic 3 times a week. Staff did see the wound once and it was black and the physician decided the resident needed to go to the wound clinic. During an interview on 9/7/17 at 1:08 p.m. administrative nursing staff A reported the wounds were completely separate wounds. In early June the resident reported pain to his/her inner foot. Staff A completed wound care on July 5, 12, and 19, 2017 and then discontinued the dressing. On 7/26/17 licensed nursing staff B found a suspected DTI. Staff B stated the resident had 2 wounds then and thought his/her shoes might have caused them then changed his/her mind and thought he/she hit it. Staff A confirmed there was a gap between a 7/19/17 left inner heel red area observation and nutrition interventions added on 7/31/17. Staff A stated the nursing staff initiated protective heel boots as an intervention and needed to encourage the resident to wear his/her protective heel boots. Staff A confirmed staff failed to notify the physician until 7/28/17 after a second wound appeared on the resident's left inner heel on 7/26/17. At 5:28 PM staff A. reported he/she expected staff to offer and administer [MEDICATION NAME] as ordered for the resident and did not administer it twice daily as ordered. Attempts were made to contact the physician on 9/8/17 at 9:03 a.m., on 9/11/17 at 8:31 a.m., and again on 9/18/17 at 4:18 PM without success. Review of the facility policy Skin Integrity: Nursing intervention and wound treatment guidelines for health care center revised 8/10/16 revealed to initiate and implement wound treatment orders when pressure ulcer wounds were acquired. Review of the facility policy on Order Guidelines revised 01/2016, instructed the staff to sign off on the MAR indicated [REDACTED]. The facility failed to prevent resident #3 from developing two pressure ulcers while a resident in the facility; one unstageable DTI and one stage 2 pressure ulcer, and failed to implement timely and effective interventions to aid wound healing. - Review of resident #2's signed physician orders dated 8/14/17 revealed the resident's [DIAGNOSES REDACTED]. Review of the admission 5 day minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 14, which indicated intact cognition. The resident required extensive assistance from 2 staff for bed mobility and transfers and extensive assistance from 1 staff for locomotion on the unit and dressing. The resident had impaired range of motion on both sides of his/her lower extremities and used a wheelchair for mobility. The resident had moderate pain frequently, received scheduled pain medication and had a risk of developing pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The resident had 1 or more unhealed pressure ulcers: 1 stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer) pressure ulcer present on admission with a tissue type of slough (dead tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy). Skin and ulcer treatments included pressure reducing device for chair and bed, nutrition or hydration interventions, pressure ulcer care and application of ointments/medications other than to his/her feet. Review of the resident's care area assessment (CAA) dated 8/26/17 revealed: Activities of daily living (ADL)/Functional rehabilitation potential: The resident required extensive assistance with ADLs of 1 to 2 staff, used a sit-to-stand lift (assistive device used to transfer residents) for transfers, most often. The resident used a wheelchair only for mobility and the resident only slept in his/her recliner due to the need for comfort, related to a fracture in his/her pelvis and hip hardware in the resident's left hip. Pressure Ulcer: The resident had a stage 2 pressure ulcer to the left lateral (outside) heel, present on admission, and admitted with [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling) to upper left thigh. The resident received skilled nursing services to monitor improvement to infection [MEDICAL CONDITION] (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infections which cause inflammation throughout the entire body instead. Severe cases [MEDICAL CONDITION] can lead to the medical emergency, septic shock). The resident had a preventative dressing to the coccyx/left buttock and used a gel cushions to his/her wheelchair and recliner, and a low air loss mattress (LAL) mattress on his/her bed. Staff were to assist with turning and repositioning the resident as he/she allowed. The resident wore foam heel boots to the left foot, staff offloaded heels at all times and ensured the resident did not wear shoes. Review of the Braden Skin assessment from admitted d 8/13/17, revealed a score of 16 indicating low risk. Review of the resident's care plan dated 8/26/17 revealed the following: 8/16/17: Remind/Assist the resident to reposition every 2 hours while in bed and every 1 hour while in his/her chair and as needed (PRN). Review of the left heel wound charting revealed: 8/13/17: pressure ulcer stage 2 to the lateral aspect of the resident's left heel measured 1.6 centimeters (cm) x 1.2 cm x 0.3 cm, with a red and bloody wound bed. Interventions included: turning and repositioning program, pressure reducing chair, nutrition/hydration, multivitamin, zinc, ulcer care, dressing with or without topical medications, and protective skincare. Staff noted no other skin issues. 8/14/17: pressure ulcer stage 2 to the lateral aspect of the resident's left heel measured 1.6 cm x 1.3 cm x 0.2 cm, with a pink and moist wound bed and yellowish [MEDICATION NAME] (thin tissue forming the outer layer of a body's surface) tissue noted to the wound edges. Interventions included turning and repositioning program, pressure reducing chair, ulcer care, dressing with or without topical medications, and preventative protective skincare. Staff noted no other skin issues. 8/16/17: pressure ulcer stage 2 to the lateral aspect of the resident's left heel measured 1.6 centimeters (cm) x 1.2 cm x 0.2 cm, with a pink and moist wound bed, and thick macerated, yellowish [MEDICATION NAME] tissue noted to wound edges. The surrounding skin remained clean, dry, intact and pink in color. No change from the prior interventions. Staff noted no other skin issues. Review of the left buttock wound charting revealed the following: 8/24/17: The resident had a blanchable (to press on a person's skin to push blood away and wait for return to determine blood circulation) red spot to his/her left buttock which was not-painful and had no signs of swelling or heat. The area measured 2 cm x 2 cm. Interventions included a turning and repositioning program, pressure reducing chair, pressure reducing bed, nutrition hydration intervention, nutrition shakes, nutrition protein supplement, nutrition multi-vitamin, and zinc. 8/31/17: the resident had a blanchable red spot to his/her left buttock which was not painful and had no signs of swelling or heat, and measured 2 cm x 2 cm. Interventions included no change from the prior interventions. Observation on 9/7/17 at 7:05 a.m. revealed the resident sat in his/her overstuffed chair asleep with the footrest elevated. No change in the residents' position at 7:15 a.m., 7:30 a.m., 7:45 a.m. or at 8:00 a.m. At 8:16 a.m. observation revealed the resident sat in his/her overstuffed chair awake with staff in the room talking to the resident and family member entered the room, in the same position. At 8:20 a.m. the resident remained in the same position. At 8:32 a.m. licensed nursing staff C and the resident's family member were in the resident's room and the resident remained in the same position. At 9:00 a.m. the resident remained in the same position. No change in the resident's position at 9:15 a.m. At 9:26 a.m. (after the resident sat 2 hours and 21 minutes in the same position) therapy staff I transferred the resident from his/her wheelchair to a standing position in the bathroom. Licensed nursing staff J removed a large sacral occlusive dressing affixed over the resident's coccyx area to reveal a reddened area approximately 2 cm on his/her left buttock that had intact skin, no drainage, and the dressing did not cover it. Staff J reported he/she thought the bandage served to protect the resident's coccyx only and stated the red area on the resident's buttock had been discovered the day before. At 9:35 a.m. staff J changed the resident's dressing and applied wound gel to the wound on his/her left heel and covered with gauze and wrapped with soft gauze to secure. Licensed nursing staff J cleansed the resident's buttocks then sprayed zinc oxide protectant spray and affixed a new sacral occlusive dressing on the resident's coccyx. Staff J reported the staff applied ointment on the resident's coccyx and also to the left buttock wound also. During an interview on 9/6/17 at 5:02 p.m. resident #2 reported he/she had a sore on his/her heel when he/she lived in independent living which caused him/her to have an infection that put him/her in the hospital for a week and he/she sat in his/her chair most of the time because he/she could only take one or two steps. The resident stated he/she had a sore on his/her bottom on the left side which did not hurt and he/she did not remember the last time staff treated the wound but the nurse treated his/her foot one time daily and the time varied. The resident stated he/she sat in his/her chair during the day. During an interview on 9/7/17 at 6:10 p.m. administrative nursing staff A reported he/she expected staff to prompt the resident to reposition every hour when resident sat in his/her chair as care planned. Review of the facility policy on Skin Integrity: Nursing Intervention and Wound Treatment Guidelines for Health Care Center, revised 8/10/16, instructed staff to reposition a resident at least every hour when in a chair and directed staff to teach the resident to shift his or her weight every 15 minutes while in a chair if the resident was alert and capable. The facility failed to assist and remind resident #2 to reposition while he/she sat in his/her chair every hour as care planned and the resident developed a red area on his/her buttock.

The facility reported a census of 48 residents with three included in the sample. Based on observation, interview, and record review the facility failed to provide adequate supervision and appropriate adaptive equipment for one of three residents, who required assistance at meals and received a hot cup of coffee unsupervised. The resident spilled the coffee on him/herself where it remained for an hour and caused 2nd degree burns (partial thickness burn that affects the upper and lower layers of the skin) for resident #1. Findings included: - Review of the resident #1's signed physician orders dated 8/22/16 revealed the following Diagnoses: [REDACTED]. Review of the 7/14/16 quarterly MDS (minimum data set) revealed the resident had a BIMS (brief interview for mental status) score of 3, indicating severe cognitive impairment. The resident had an acute mental status change, had signs and symptoms of delirium which included fluctuating inattention and disorganized thinking, and hallucinations and delusions. The resident had functional limitation of range of motion to both sides of upper and lower extremities, required supervision of 1 staff with eating, and used a walker and a wheelchair for mobility. Review of the 8/28/16 significant change MDS revealed the resident had a BIMS score of 1, indicating severe cognitive impairment. The resident had fluctuating inattention, altered level of consciousness and had an acute onset of mental status change. The resident had hallucinations (perceptual experiences in the absence of real external sensory stimuli). The resident required extensive assistance of one staff with eating. The resident had functional impairment on both sides of upper and lower extremities and used a wheelchair for mobility. Review of the cognitive loss/dementia CAA (care area assessment) dated 8/31/16 revealed the resident had poor cognition and received medications for dementia. Review of the psychosocial well-being CAA dated 8/31/16 revealed the resident could not make daily decisions and relied on staff to help make decisions. The resident rarely conversed with other residents and his/her responses were mumbled. Review of the 8/31/16 Nutritional CAA revealed the resident needed assistance with food and fluid intake at meals and snacks. The resident's alertness fluctuated and at times could not eat and drink. Review of the 8/31/16 Hydration/Fluid maintenance CAA revealed the resident no longer ambulated and required a wheelchair for mobility. The resident received restorative nursing services for dining and eating. Review of the resident's care plan dated 8/15/16 revealed the resident had cognitive loss/dementia and included the following interventions: 8/31/16- the resident had severely impaired cognition and required assistance to attend meals and activities. 8/31/16- the resident required set up/supervision with eating at meals. 8/31/16- the resident liked coffee to drink. 8/31/16- staff were to assist with resident meal intake as needed if he/she was sleepy and not eating. 9/17/16- Burn occurrence- spilled hot coffee in his/her lap. Do not take hot beverages to table until staff is at the table to help. Make sure to use a lidded cup. 9/20/16- provide lidded cups with beverages. Review of the care conference summary dated 8/30/16 revealed the resident ate meals in the dining room and the facility discussed the resident's need for assistance with meal intake. The resident had hallucinations/delusions and when the resident had a bad day he/she did not eat. The resident did not have good posture in the wheelchair, and would start restorative therapy. The resident required complete assist with eating. Review of the 9/17/16 nurses note revealed direct care staff G reported to licensed nurse H at 12:30 p.m. that the resident had burns to his/her legs. An assessment by nursing staff H revealed the resident had redness and intact blisters to his/her inner thighs. Direct care staff G reported to nursing staff H the resident spilled hot coffee down the front of him/herself and did not have a lid on the cup as the care plan directed. Staff served the resident hot coffee in a regular coffee cup while staff brought other residents out to the meal. Direct care staff G took the resident to the bathroom and, soon after incident, and noticed the burns. The facility educated staff to provide the resident with no spill cups with lids, add ice cubes/water to coffee to cool it off, and not to serve beverages to the resident when staff were not present. Review of the 9/17/16 nurses note at 6:05 p.m. revealed the resident had some open blisters due to the difficulty of the area to keep the blister intact (the left top thigh from inner to outer area and the inner right thigh). The weekly wound care note dated 9/21/16 at 1:34 p.m. recorded by licensed nursing staff D revealed the resident had a partial thickness burn to the left thigh. The burned area measured 42 cm (centimeters) long X 7 cm wide. The resident had a second small area to the left thigh, measuring 3 cm X 3 cm and 90% of the epidermis (outer layer of skin) tissue to the affected area was missing. Staff D applied a new foam dressing and faxed the primary care physician for new orders because the current orders were standing orders. The same wound care note further revealed the resident was alert and oriented to name only. The resident needed 1 assist with ADLs (activities of daily living), sat at the assisted dining table and needed assist with feeding. The note included staff were to offer hot and cold beverages in cups with lids, at all times to prevent re-occurrence of the incident. Review of the nurses note dated 9/21/16 at 11:23 p.m. revealed the resident saw his/her primary care physician at 6:05 p.m. The physician signed new wound treatment orders for TAO (triple antibiotic ointment) and Kerralite cool (soothing, debriding and moisture-balancing dressing) dressings to left and right thigh daily and PRN (as needed). Review of the 9/20/16 facility investigation summary revealed the following: Reviewed camera footage for the dining room. Resident sitting at VIP (assisted) table facing North. At 11:27 a.m., direct care staff E served the resident a cup of coffee in a regular mug. At 11:28 a.m. the resident picked up the coffee mug and brought it close to his/her face, before spilling it on his/her lap. Staff in dining room were not looking in the resident ' s direction, and the spill went unnoticed. At 11:29 a.m. staff served the resident his/her meal. At 12:21 p.m., staff removed the resident from the table and assisted him/her to bathroom. The plan of correction: Care plan updated to include lids on cups. Follow-up required: Education provided to nurses and dietary staff in regards to providing hot drinks to VIP residents. Observation on 9/20/16 at 5:30 p.m. revealed staff propelled the resident in his/her wheelchair into the dining room. The resident sat at the table and had a lidded cup with a straw and reached for items at the table. Observation on 9/21/16 at 7:43 a.m. revealed the resident received the assistance of one staff to eat. The resident had a cup of juice in a lidded cup with a straw. Observation on 9/21/16 revealed a hot cup of coffee freshly poured from the dining coffee pot spigot and measured a temperature of 169 degrees Fahrenheit (F) as measured by dietary staff C at 10:58 a.m. Dietary Staff C stated he/she was looking into having the temperature lowered as they do not have a way to adjust it but they are contacting the manufacturer to find out how to lower the temperature. Staff C stated his/her dietary staff did not cool down coffee for any resident, unless the resident requested it to be cooled down. During an interview on 9/20/16 at 3:17 p.m. the resident said he/she hurt all over, especially in his/her legs and feet. During an interview with dietary staff C on 9/20/16 at 3:29PM, staff said the facility did not routinely take coffee temperatures, and did not take a temperature the day the resident got burned. Interview with dietary staff E on 9/20/16 at 4:45 p.m. revealed he/she served the resident's coffee the day he/she got burned. Dietary staff E stated the resident apparently used a lidded cup, but he/she did not know that. Staff E stated he/she had never seen a lid on the resident's coffee cup before that day. Staff E said he/she did not notice the resident spilled the coffee. Staff E said there was a dry erase board in the kitchen where special items/equipment for residents were listed and stated he/she did not remember the resident's name on the board. Observation of the dry erase board revealed the resident's name was written twice on the board, toward the bottom right in 1 inch letters and the opened dining room door covered part of it, and again in larger 4 inch letters that stated the residents name and lidded cup-- both lacked a date and the staff stated the large lettering was not there the day of the burn and that he/she did not see the small lettering in the bottom right corner of the board. Interview with direct care staff F on 9/20/16 at 5:54 p.m. revealed he/she stated the resident required help and encouragement to eat. Staff were always at the table to assist the residents. Staff F stated the resident had a lidded cup. Interview with direct care staff G on 9/21/16 at 11:50 a.m. revealed he/she pulled the resident away from the table after lunch on 9/17/16 and noticed the resident's pants and the bottom of his/her shirt were wet. Staff G stated he/she though it was tea spilled on the resident's shirt. Staff G said he/she took the resident to his/her room to change the resident's brief and upon taking off the resident's pants noticed the redness and blisters. Staff G stated he/she immediately got the nurse and then put cold wash rags on the areas. Staff G stated the spilled fluids on the resident's clothes were already cool when he/she noticed it and it was below the table level and not seen until he/she wheeled the resident away from the table. During an interview on 9/21/16 at 9:28 a.m., licensed nursing staff D said the resident received dining/eating training from restorative nursing. Staff D stated the resident required more assistance with eating and would try to feed him/herself. Staff D stated staff usually served drinks in mugs with lids for residents that spill. Staff D said staff observed the resident spill before and knew he/she needed more eating assistance and recommended to put the resident at the assisted eating table. Licensed nursing staff D did not see an area to add the lidded cup when he/she added the resident to the assisted dining table. Staff D reported the dietary staff were not to bring food or beverages to any resident at the assisted eating table until a direct care staff member was sitting there. During an interview on 9/21/16 at 9:55 a.m., licensed nursing staff H said direct care staff reported the resident's burn to him/her. Staff H said upon assessment it was a 2nd degree burn with blisters intact. Staff H said the direct care staff believed it to be tea and not coffee, so he/she was not sure how long the spilt coffee stayed on the resident. Staff H stated he/she received report that staff sat the coffee in front of the resident before the direct care staff had sat down at the table. Staff H stated he/she added the lidded cup, to the care plan, on the day of the spill. During an interview on 9/20/16 at 2:23 p.m., administrative nursing staff B revealed resident #1 experienced a burn over the weekend. Interview with the primary care physician on 9/21/16 at 1:28 p.m. revealed the elderly resident's faculties had worsened and the facility could expect more dwindling mishaps. Review of the facility policy on Precautions for Handling Hot Beverages, last revised 2011, revealed staff shall monitor, serve and hold hot beverages in a safe manner to prevent potential burns. The policy revealed the temperature of any hot beverage would be monitored regularly. The policy listed a time and degree chart that displayed the time to receive a second degree burn was <1 second and 1 second to receive a third degree burn if the water temperature was 150 degrees F. The policy listed additional precautions that may be implemented based on the needs and make-up of the resident served and included to assess and identify those individuals served who were at high risk for burning themselves with hot beverages; ensuring staff monitors the identified high risk resident during meal times and/or when staff served hot beverages; utilizing specialized spill proof lids and cups for those individuals identified as high risk for spillage and potential for burning; and assessing those individuals who requested beverages served hotter than 130 degrees F for the ability to consume hot beverages independently and safely. A suggested monitoring procedure in the policy included initial temperature taken when staff placed the beverage in the carafe. If the temperature was above 140 degrees F, staff allowed the beverage to cool to the serving temperature of 130 degrees F. The facility failed to provide adequate supervision and adaptive equipment as planned to prevent a hot coffee spill which resulted in a 2nd degree burn for cognitively impaired resident #1.

The facility census totaled 40 residents with 15 included in the sample. Based on observation, interview, and record review, the facility failed to assess the effectiveness of treatment, implement interventions to promote healing, and to notify the physician for further treatment orders for 1 of 2 residents reviewed for pressure ulcers, who developed a preventable stage III pressure ulcer (#18). The facility also failed to implement interventions to prevent the development of pressure ulcers for 1 of 2 residents (#30). Findings included: - Review of resident #18's signed physician orders dated [DATE] revealed the following Diagnoses: [REDACTED]. usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction extending into the tissue beneath the skin, forming a small crater). Review of the quarterly MDS (minimum data set) dated [DATE] revealed a BIMS (brief interview for mental status) score of 12 indicating moderate cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. The resident had frequent urinary incontinence and had no skin breakdown. Review of the significant change in status MDS dated [DATE] revealed a BIMS score of 12 indicating moderate impairment with cognition. The resident required extensive assistance with bed mobility, transfers, toileting and was non-ambulatory depending on staff to propel a wheelchair. The resident was frequently incontinent and had a stage 3 pressure wound on the coccyx measuring 3.5 cm (centimeters) x 4.0 cm with a depth of 0.9 cm. He/she received wound care with non-surgical bandages and pressure relieving devices to the bed and chair. Review of the ADL (activities of daily living) CAA (care area assessment) dated [DATE] revealed the resident admitted to the facility following [MEDICAL CONDITION](sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) with left sided [MEDICAL CONDITION] and dysphagia. The resident admitted to hospice on [DATE]. The resident had a stage 3 pressure ulcer beginning [DATE], had a urinary catheter in place for wound healing and to aid in resident comfort. The resident had a wound vac (treatment for [REDACTED]. The resident received a multivitamin and Arginade (high protein drink for wound healing) powder packet. The resident had frequent pain with dressing changes and transfers. The resident had an air mattress on the bed and a gel cushion to chair. Review of the Braden assessment from [DATE] prior to the skin breakdown to the coccyx revealed a score of 13 indicating moderate risk for breakdown. Review of the Braden assessment dated [DATE] revealed a score of 11 indicating the resident was high risk for skin breakdown. Review of the care plan with a date of [DATE] revealed the resident was at risk for pressure ulcers and other skin impairments such as skin tears. The resident had impairment in ADLs due to left sided weakness from a stroke increased his/her risk for skin breakdown. Approaches included; - Gel cushion for the wheelchair - Keep the resident's skin moisturized with [MEDICATION NAME] skin conditioner after bathing and PRN (as needed). - Reposition him/her every 2 hours and PRN. Review of the care plan with a date of [DATE] revealed the resident had actual impaired skin integrity, including a stage 3 pressure ulcer on his/her coccyx. Approaches included; - Use a low air loss mattress and cushion to his/her chair to reduce pressure. - Please assist the resident with position changes every 2 hours and PRN. - Provide nutritional supplements per facility wound and treatment guidelines. - Have the dietician complete an assessment monthly and PRN. - Please administer pain medication prior to dressing changes as the process was painful for the resident. - Allow the resident to use a foley catheter due to wound and incontinence. - Hospice to provide services. Review of the [DATE] to [DATE] TAR (treatment administration record) revealed the following treatments: [DATE] - [MEDICATION NAME] foam to coccyx change every ,[DATE] days and as needed until healed. [DATE] - The resident received the same treatment and continued the treatment on [DATE], [DATE] and [DATE] . The treatment changed on [DATE] to [MEDICATION NAME] silver foam to coccyx, change every 3 to 7 days and as needed until healed. This treatment was done on ,[DATE], ,[DATE], ,[DATE]. ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]. ,[DATE], ,[DATE], and [DATE] (staff initialed on each of the days). Review of the [DATE] to [DATE] MAR (medication administration record) revealed: Multivitamin with minerals daily, Arginade twice a day and vitamin C drink with meals started on [DATE]. Review of the lab results dated [DATE] revealed an [MEDICATION NAME] level of 2.8 g/dL (grams per deciliter) Low (3.5 - 5.0 g/dL) which could indicate the body is not properly or able to digest and absorb protein which is necessary for wound healing. Review of the physician telephone orders revealed: [DATE] - Continue the wet/moist dressings daily until seen by physician on [DATE]. [DATE] - Admit the resident to hospice care and discontinue the wound vac. [DATE] - Apply moist to wet dressing to wound every 3 days and as needed. [DATE] - Apply [MEDICATION NAME] (4% topical solution), 1 spray to the wound bed on coccyx with every dressing change. [DATE] - Apply sensicare (moisture barrier) to coccyx area every shift. Change dressing to coccyx twice daily and as needed (cleanse with SAF-Clens (a skin wound cleanser), lightly pack with 2 X 2 (two inch gauze pad) moistened with normal saline and cover with ABD (wound dressing). Do not use tape to secure dressing and continue [MEDICATION NAME] spray. Review of a fax to the physician dated [DATE] revealed the resident's bottom was swollen and red with a moderate amount of yellow drainage noted with a strong odor and with slough and black speckles showing. Wound started as a skin tear and became a stage 3 pressure ulcer. Current wound care not effective and want to change to [MEDICATION NAME] silver alginate sacral foam applied to wound bed. The physician replied to start dressings and send resident to the wound care clinic in a neighboring town. Review of notes from a physician visit on [DATE] revealed a large ulcer over sacrum measured 1 x 1 and ,[DATE] deep (2.5 cm x 2.5 cm x 1.3 cm) noted as a decubitus ulcer. Orders revealed resident was to have an appointment for the wound clinic. On [DATE], the wound care physician changed the treatment to SAF-gel, wet to moist dressing daily and as needed until wound vac arrived. Do not pack wound, just cover. On [DATE] orders received from the wound care physician for wound vac dressing to coccyx, change 3 times weekly on Monday, Wednesday and Friday for stage 3 pressure ulcer. Review of the [DATE] to [DATE] revealed the nurse changed the wound vac on Friday the 9th but did not get changed on Monday the 12th or Wednesday the 14th. The TAR lacked any documentation as to why the wound vac dressing was not changed on those days. During the time the wound vac dressing was not changed, the wound worsened from 2.5 cm x 2.5 cm on [DATE] to 3 cm x 3 cm x 0.8 cm depth on [DATE]. Review of the wound reports revealed the following measurements: - [DATE]- skin tear to the coccyx measuring 1.4 cm x 0.5 cm. - [DATE]- skin tear with measurements of 1.3 cm x 0.5 cm and no depth. - [DATE]- skin tear measuring 1.3 cm x 1 cm no depth or drainage. - [DATE]- coccyx skin tear measuring 1.5 cm x 1 cm with no depth or drainage - [DATE]- coccyx skin tear measuring 2 cm x 1.5 cm with no depth with slough noted in the wound. Primary care physician notified and dressing changed to every 3rd day and PRN. - [DATE]- skin tear to coccyx changed to a stage 3 pressure ulcer measuring 2.5 cm x 2.5 cm with slough and eschar (dark colored hard dead tissue) present in the wound. Low amount of drainage was in the wound. The physician referred the resident to a wound care center in a neighboring town and did not change the dressing even though the wound continued to worsen. - [DATE]- stage 3 pressure ulcer 3 cm x 2.3 cm x 0.8 cm deep low drainage, slough and eschar all present in the wound. The wound had tunneling though no measurements were written on the report and staff continued with the same dressing. - [DATE]- coccyx wound measured 3 cm x 3 cm x 0.8 cm depth with low drainage, slough and eschar. - [DATE]- coccyx wound 2.2 cm x 2 cm - [DATE]- stage 3 pressure ulcer measuring 2.5 cm x 2.8 cm x 0.9 cm deep. No tunneling observed with granulation tissue (new skin growth) in the wound and no slough or eschar. The nurse changed the wound vac dressing. - [DATE]- coccyx wound measured 3 cm x 3 cm x 0.8 cm with tunneling low drainage. - [DATE]- wound measured 3.5 cm x 3.5 cm x 0.9 cm. - [DATE]- stage 3 pressure ulcer measuring 3.3 cm x 2.8 cm x 0.9 cm with low drainage and granulation tissue. - [DATE]- healing stage 3 pressure ulcer measuring 2.5 cm x 2 cm x 1 cm deep. - [DATE]- healing stage 3 pressure ulcer on coccyx measuring 3 cm x 2 cm x 0.7 cm. Observation at [DATE] at 8:00 a.m. the resident lay in bed on his/her right side, the resident had just finished breakfast and was in bed awake. Observation on [DATE] at 11:40 a.m. revealed the resident sat at the dining table and ate from a plate of sweet and sour chicken, fried rice and scalloped potatoes. Further observation revealed the resident ate all the sweet and sour chicken, rice, and approximately ,[DATE] of the potatoes. Dietary staff served the resident a piece of Jell-O cake and the resident ate all the cake. The resident drank all his/her water. Observation on [DATE] at 10:19 a.m. revealed licensed nurse H and direct care staff I in the resident's room to change the dressing on the coccyx. After donning gloves, staff positioned the resident, and took his/her incontinent brief off. Nurse H removed the dressing on the coccyx and sprayed the wound with [MEDICATION NAME] spray. The nurse then removed his/her gloves, cleaned his/her hands with alcohol gel and replaced the gloves. Using wound cleaner and gauze pads, he/she cleaned wound after the [MEDICATION NAME] had been in the wound for approximately 4 minutes. The nurse again removed gloves, cleaned hands and donned clean gloves. He/she then placed SAF-gel into the wound followed by [MEDICATION NAME] silver wetted by normal saline solution placed into the wound. The nurse covered the wound with petroleum gauze. The nurse removed gloves, cleaned hands then covered the wound with an ABD (thick wound dressing) pad and secured with med pore tape. The wound looked clean with little drainage. The wound was located to the top and side of the coccyx. During an interview on [DATE] at 10:45 a.m., the resident reported he/she had gotten bumped one day going to the bathroom and the sore just would not heal. During an interview on [DATE] at 11:00 a.m., direct care staff D reported he/she thought the resident had gotten a skin tear by sliding down in his/her wheelchair while in the hallway. The resident had a lot of [MEDICAL CONDITION] and his/her skin was fragile. Staff turn him/her position at least every 2 hours and never to her back. The resident can only be up a short time to meals so he/she was the last one up and the first one laid down for a nap. During an interview on [DATE] at 3:30 p.m., direct care staff J reported he/she did not know how the resident got the wound. The direct care staff thought it might be getting better now that he/she was not incontinent due to a catheter. The resident sat on the toilet for bowel movements but for only short times then wanted to go back to bed. It was too uncomfortable for him/her to sit on the toilet. During an interview on [DATE] at 3:30 p.m. licensed nurse D reported the wound started as a skin tear when transferring the resident with the use of a sit-to-stand lift and he/she hit the handle of the toilet riser with his/her coccyx. The physician reclassified the wound to a pressure ulcer when it began to open up and nurse reported to the physician approximately 1 month after the skin tear occurred. Staff turned the resident at least every 2 hours and placed an air mattress on his/her bed and a gel cushion in the wheelchair. The nurse reported hoping the physician would start an antibiotic but he/she did not so after another week when the drainage had a strong foul odor and the wound had grown in size and depth the nurse requested a wound culture. The physician did not order the culture but agreed to see the resident. Because of the size, drainage, and depth of the wound the physician classified it as a stage 3 pressure ulcer. The physician [MEDICATION NAME](antibiotic) and a referral to the wound care center in a neighboring town. The wound clinic ordered a wound vac but that did not help and the wound got bigger. The family then decided they wanted to put the resident on Hospice services. Hospice discontinued the wound vac and a new treatment started. During an interview on [DATE] at 10:00 a.m. licensed nurse H reported he/she thought the resident had a skin tear on his/her coccyx from transferring the resident with a lift. The wound did not heal and the wound nurse measured it weekly. The physician from the wound clinic tried a wound vac but he/she thought that made the wound worse and it got bigger. The resident was on hospice and the wound vac was discontinued. The resident had dressing changes twice a day and the wound progressed towards healing. During an interview on [DATE] at 9:30 a.m. administrative nurse A reported he/she was sure there were no wound vac dressing change missed because the 2 days there was no documentation she still had wound measurements and descriptions of the wound. Nurse A believed the nurse forgot to initial for the treatments with student nurses shadowing the nurse. Nurse A reported he/she would expect the wound nurse to notify the physician if after 14 days there was no improvement to the wound or anytime if slough was present. On [DATE] at 11:05 a.m., an attempt to reach the residents primary care physician regarding the pressure ulcer failed due to the physician out of town for the next 2 weeks. During an interview on [DATE] at 4:39 PM, physician BB stated it was important to change wound dressings as ordered and if it was not done it could have worsened the wound. Review of the policy for Skin Integrity dated [DATE] revealed: · Nursing staff would assess skin integrity, implement preventative measures as indicated and treat skin breakdown. The primary care physician admission orders [REDACTED]. · Depending on resident's clinical situation and overall health status, most pressure ulcers would show signs of healing by the presence of granulation tissue and deceased size and exudate amount within ,[DATE] weeks. If the wound did not show evidence of healing, consideration should be given to changing the treatment plan. The facility failed to promote healing and assess the effectiveness of wound treatments and failed to notify the physician for further treatment orders for one resident who developed a preventable stage III pressure ulcer. - Review of the signed [DATE] physician orders revealed resident #30 had the following Diagnoses: [REDACTED]. Review of resident #30's admission MDS (minimum data set), dated [DATE], revealed a BIMS (brief interview for mental status) of 13, which indicated intact cognition. The resident required extensive assistance of one staff for most ADLs (activities of daily living), had impairment of one lower extremity, and used a walker and wheelchair for mobility. The resident had two stage 2 (partial thickness skin loss into but no deeper than the dermis) pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) present upon admission and a surgical wound. The MDS revealed staff were to provide a pressure reducing devices for his/her chair, implement a turn and position program, provide pressure ulcer care, and surgical wound care. Review of the 60 day assessment MDS, dated [DATE], revealed he/she had a BIMS of 15, which indicted intact cognition. The resident required setup or one staff assistance for most ADLs, had impairment of one lower extremity, and used a walker and wheelchair for mobility. The MDS further revealed he/she had 2 stage 2 pressure ulcers that were not present upon admission; the oldest stage 2 was dated [DATE]. Staff were to provide a pressure reducing device for his/her chair and bed, nutrition or hydration interventions to manage skin problems, and ulcer care with the application of ointments/medications. Review of the [DATE] pressure ulcer CAA (care area assessment), dated [DATE], revealed resident #30 admitted on [DATE] following surgical repair of his/her right hip. The CAA further revealed the resident admitted with two stage 2 pressure sores to his/her left buttocks and developed an intact clear fluid filled blister on his/her left heel on [DATE]. The CAA further revealed staff were to provide supplemental drink mix, vitamin C drink and tablet, and a multivitamin with iron. Staff instructed the resident to wear foam boots to his/her heel and reminded the resident to shift his/her weight every 2 hours. Staff provided extensive assistance of 1 staff with ADLs (activities of daily living). Review of the Braden skin scale assessment dated [DATE] revealed a score of 7, which indicated he/she had a high risk for the development of pressure ulcers. Review of the admission care plan dated [DATE] revealed the resident had impaired skin and surgical wounds to his/her right hip. The care plan directed staff to provide supplements and diet per physician ' s orders, assist to reposition, provide wound treatment and assessment per facility protocol and to monitor for pain. Further review of the care plan revealed a handwritten update, dated [DATE], that revealed an intact blister to left heel and staff provided a foam boot for the resident to wear. Review of the [DATE] pressure ulcer care plan revealed staff had identified multiple stage 2 pressure ulcers; 2 on the residents left buttocks and 1 on his/her left heel with the following interventions: *please prompt/cue and assist the resident to reposition every 2 hours and as needed (PRN). *apply foam boot to his/her left heel at all times when he/she lay in bed. * Put thigh high compression stockings on both legs in the morning and take off at bedtime. *Complete a dietician assessment PRN. *Use positioning devices, 2 positioning rails to bed for aid in bed mobility/repositioning. *Educate the resident on the importance of repositioning and how to use assistive devices. *Use the facility wound and treatment guidelines PRN for dressing and wound management. *Use a gel cushion in the resident's chair. The care plan also included handwritten updates/revisions that included: · [DATE]- the resident had an intact dried blister that was loose around edges with intact skin underneath. · [DATE]- the resident's left heel had a dried blood blister coming off with cleansing with a beefy red appearance. Staff applied Aqua-cel silver (type of wound dressing) to both open areas and covered with Aqua-cel foam. · [DATE]- he/she had a dried blister except for a small area came off with a pink wound bed that blanched (turned white, then turned pink again when the skin was pressed). Review of the facility admission resident-data collection form dated [DATE] revealed staff did not identify any skin issues on either heel for resident #30. Review of the [DATE] wound treatment orders revealed staff had identified a blister on resident #30's left heel that measured 5 cm (centimeters) x 5 cm and had categorized the blister as a stage 2 pressure ulcer. The orders further revealed staff were to change the wound dressing every ,[DATE] days, used Saf-Gel (dermal wound dressing used on chronic and acute wounds) and Aqua-cel (primary wound dressing that kept the wound moist to promote healing) foam to the heel and use protection of the heel with foam cushion. Review of the wound report for the left heel pressure ulcer revealed the following: [DATE]: 3.6 cm x 4.2 cm [DATE]: 3.6 cm x 4.2 cm, intact blister. [DATE]: 3.0 cm x 3.5 cm [DATE]: 3.0 cm x 3.5 cm [DATE]: 1.3 cm x 1.5 cm, dried intact blister [DATE]: 3.5 cm x 3.8 cm [DATE]: 2.0 cm x 0.8 cm low drainage [DATE]: 1.5 cm x 1 cm [DATE]: healed pressure ulcer, Aqua-cel continued as a preventative. Review of the TAR (treatment administration record) from [DATE] to [DATE] revealed staff did not change the left heel Aqua-cel foam dressing (ordered to be changed every ,[DATE] days and PRN until healed) from [DATE] to [DATE] (21 days). During an interview on [DATE] at 10:51 AM, direct care staff B revealed staff had placed the foam boot on, and used pillows to float his/her heels of resident #30 regularly. Staff B further stated resident #30 had consistent healing of his/her left heel ulcers. During an interview on [DATE] at 12:50 PM, licensed nursing staff D revealed he/she assessed weekly and as needed for skin issues. Staff D further stated the resident had limited mobility and staff encouraged him/her to transfer out of bed. Staff D further stated resident #30 dug his/her left foot into the mattress while watching television and staff would remind him/her not to push his/her left foot into the bed. At 2:32 PM Staff D further stated the resident had high risk for skin breakdown due to the surgical incision and not his/her heels, as resident #30 could independently move his/her lower legs. Staff D stated resident #30 gained mobility quickly and staff did not anticipate pressure to the heels would be a problem. During an interview on [DATE] at 3:19 PM, administrative nurse A revealed when a resident came to the facility with a surgical wound to the hip he/she expected staff to prompt or turn and reposition the resident every 2 hours, or use the wedge pillow or hip precautions. Staff A stated he/she sent weekly messages to staff identifying residents at risk for developing pressure ulcers. Staff A stated upon admission staff should assess for skin and implement preventative measures and update the care plan weekly. Staff A further stated staff had prompted #30 to reposition and installed bed positioning bars to aid him/her with independent bed positioning. Review of the facility policy titled Skin Integrity: Nursing Intervention and Wound Treatment Guidelines for Health Care Centers dated ,[DATE] revealed the following: *pressure ulcer dressing are routinely changed every ,[DATE] days. If the dressing is no longer intact, PRN dressing change will occur. *Assessment begins at the time of admission/re-admission using the Braden Scale. Pressure ulcers often develop within the first four weeks after admission, especially following a recent hospitalization . As a result, it may be beneficial to assess skin integrity more frequently during this time. *Under Pressure Ulcer Prevention: If a resident is assessed at risk, reposition at least every 2 hours or more frequently when in bed and at least every hour when in a chair; if capable, the resident should be taught to shift his/her weight every 15 minutes while in a chair. *Position to alleviate pressure over bony prominences and shearing forces over the heels. *Promote comfort, reduce friction/shearing and prevent bony prominences from rubbing together by using heel/elbow protectors and pillows/foam wedges. The facility failed to implement pressure ulcer preventative measures for one resident identified as being high risk, who then developed a pressure ulcer to the heel. Staff also failed to ensure resident #30 received dressing changes as ordered.