Every finding on record at McCoy Memorial Nursing Center

Based on observations, food code review, and interviews, the facility failed to ensure the kitchen was cleaned and equipment was maintained to ensure a cleanable surface for one of one kitchen. This failure had the potential to contribute to contamination and unclean food preparation practices for 113 of 115 census residents consuming food in the kitchen. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration, dated 01/18/23, revealed in Chapter 3-18 Food shall be protected from contamination that may result from a factor or source not specified. Chapter 4-5 revealed Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. Chapter 4-3 revealed Nonfood-contact surfaces of equipment that are exposed to splashes, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosive-resistant, non-absorbent, and smooth material. Chapter 4-16 revealed Equipment shall be maintained in a state of repair and condition that meets the requirement specified. During an observation on 07/29/26 at 2:48 PM alongside the Dietary Manager (DM), the DM stated the gas stove had been in the facility since the 1980's. The stove top revealed a thick black carbon build-up with a bubbled, disintegrated texture. The surface revealed a non-cleanable texture with uneven, flaky, bubbling carbonization throughout. One of the burners reflected a thick carbon build-up with food debris imbedded within and was non-functioning. The outside, and sides of the stove, oven, and fryer had a greasy buildup, and food spatter throughout. The DM stated they just wiped the stove top with a sanitizer rag to try and clean it. There was a five-well and a four-well steam table side by side. The wells had exposed heating elements, with the sides and bottom rusted and disintegrated throughout, with some insulation exposed. The bottom of the wells had loose disintegrated metal and rusted loose debris. This was a non-cleanable surface. The DM stated she thought a new steam table was ordered prior than two days ago. She stated she had asked for the water wells, instead of the electric wells. She stated the electric steam tables did not last long. She stated they were still using the steam tables, with pans, foil, etc. and were able to maintain temperature. At 3:04 PM, the DM stated there was no plan for the stove top or the four well steam table. During an interview on 07/30/26 at 7:10 AM, the Kitchen Supervisor (KS) stated they had a five well and a four well steam table for over two years. He stated they sand blasted the stove top years ago and it was clean at that time. At 7:17 AM, the DM stated she tried to chisel the carbonization build-up yesterday to see if she could get it off. The area remained with carbon build-up. She stated it did not take long for the carbon to accumulate. She confirmed the exposed insulation coming out of the insides of the two steam table wells. At 7:28 AM, there were vents in the ceiling with excess lint (one above the tray line area and one above the dish machine area). The ceiling above the steam table and food prep areas of the kitchen had food spatter and lint throughout. The walls behind the clean knife storage revealed food spatter. The DM stated maintenance had the ladder and she asked maintenance if they could paint the vents. She stated that they were last cleaned about six months ago. During an interview on 07/30/26 at 9:35 AM, the Administrator stated the new owners identified areas that need to be fixed. He stated the five well had been there since he started, about five years ago, and the four well table was purchased about three years ago. He confirmed that a new five well steam table was ordered two days ago. He stated there was no plan for the four well steam table at this time. He stated they tried to sand blast the stove once a year.

Based on job description review, interviews, and facility policy review, the facility failed to ensure a qualified Infection Preventionist (IP) was designated to oversee program implementation to prevent and control infections for 115 census residents. This failure had the potential to interfere with the skills and knowledge of the staff overseeing infections.Findings include: Review of the facility's policy titled, Infection Preventionist, implemented 05/24, revealed The facility will designate a qualified individual as Infection Preventionist (IP).The IP must have obtained specialized IPC [Infection Prevention and Control] training beyond initial professional training or education prior to assuming the role and must provide evidence of training through a certificate(s) of completion or equivalent documentation. Review of the job description titled, Infection Preventionist, signed by the IP on 04/20/26 and provided by the facility, revealed Required Qualifications.Must also meet state requirements for relevant licensures or certifications.Education, training, experience, or certification in infection control and prevention. Completed specialized training in infection prevention and control through accredited continuing education. During an interview on 07/29/26 at 2:05 PM, the IP stated she was in the IP course but had not completed it yet. She stated she was in Module 12. She stated the Director of Nursing (DON) assisted her, but she was not receiving assistance from anyone with an IP training certification. During an interview on 07/30/26 at 9:12 AM, the IP stated she had been in the position since April 2026. She stated she had been going through a notebook from the previous IP, had been using the DON as a resource, and there were two corporate staff resources available. During an interview on 07/30/26 at 9:15 AM, the DON stated they had two nurse consultants with IP certification. She stated she was aware of the IP training and education requirements. During an interview on 07/30/26 at 9:35 AM, the Administrator stated the IP was working on her certification and had additional resources.

Based on record review, staff interview, and facility policy review, the facility failed to ensure the resident or the resident's authorized representative received timely written notification of Medicare non-coverage through the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) or the Notice of Medicare Non-Coverage (NOMNC) for two residents (Resident (R) 2 and R48) of three residents reviewed for beneficiary notification, out of a total sample of 23 residents. This deficient practice had the potential to affect all residents receiving Medicare-covered services when the facility failed to obtain the resident's or authorized representative's signature acknowledging receipt of the SNFABN or NOMNC, failed to document telephone notification or notification attempts, failed to identify the individual contacted, and failed to document that written notices were mailed when telephone contact could not be verified. As a result, the facility could not demonstrate the residents or their authorized representatives received timely written notice of Medicare non-coverage or their appeal rights. Findings include: Review of the facility's policy titled, SNF Beneficiary Notices of Medicare Non-Coverage Determination, revised 04/2018, indicated: Residents or persons acting on their behalf are to be advised in writing at least two days before Medicare-covered services end. If the representative cannot be personally notified, the facility must: document the telephone contact, complete at least two documented telephone attempts if unable to reach the representative, mail the written notice and maintain documentation of these actions. The policy also requires the beneficiary or authorized representative to sign the SNFABN or NOMNC, or, if refusing to sign, the refusal must be documented and witnessed. 1. Review of R2's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), form provided by the Business Office Manager (BOM), revealed Beginning on 06/18/26 you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The care was identified as Skilled services covered by Medicare part A and the Reason Medicare May Not Pay: [R2] no longer requires Medicare skilled services. [R2] will convert to Medicaid on 06/18/26. The Signature of Patient or Authorized Representative signature line reflected Left voicemail w/RP (with Responsible Party), dated 06/11/26. The form did not contain the signature of the resident or authorized representative. There was no documentation identifying the individual who was notified, documenting telephone contact, documenting multiple contact attempts, or indicating the written notice had been mailed to the authorized representative. R2 remained at the facility. 2. The Business Office Manager (BOM) did not provide R48 or R48's authorized representative a SNFABN for Medicare Part A skilled services that were scheduled to end on 07/13/26. R48 discharged from the facility on 07/24/26. During an interview on 07/30/26 at 11:30 AM, the BOM stated residents or their representatives were notified when Medicare-covered skilled or therapy services were ending. The BOM stated a call was placed to R2's responsible party and left a message. The BOM said that she did not follow up with the responsible party and did not receive a call back if a decision was made about R2's care. The BOM said that R48's family said on admission that they did not want R48 to stay beyond 20 days and felt that it was a family-initiated discharge and did not require a SNFABN. The BON said that although R48 stayed past 20 days and received therapy services, the BOM still thought that it was a family-initiated discharge, and a form was not required.

Based on review of facility policy, record reviews, observations and interviews the facility failed to ensure medications were properly stored and safeguarded. Specifically, medications were observed on a bedside table in Resident (R)53's room. Review of the facility policy titled Medication Storage in the Healthcare Centers last revised 09/15/17 revealed, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel.During an observation on 07/22/25 at 11:40AM by two surveyors, a disposable cup containing seven loose pills were observed on the bedside table of R53. Review of R53's Electronic Medical Record (EMR) revealed R53 was admitted to the facility on [DATE] with diagnoses including but not limited to: symptomatic epilepsy and epileptic syndromes with simple partial seizures and unspecified dementia. R53's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 07/14/25, revealed a Brief Interview of Mental Status (BIMS) of 10 out of 15 indicating R53 was moderately cognitively impaired.During an interview on 07/22/25 at 11:57AM, Licensed Practical Nurse (LPN)1, stated she is assigned to R53 today and acknowledged her mistake and understood that medications should never be left at a resident's bedside without confirming they have been ingested. LPN1 went back to give medication to the resident, in the last 10 or 15 minutes. Then LPN1, stated, I'm going to be honest, this is my first time working with the resident, she put the cup to her mouth, and I thought she had taken her meds. I should have looked to make sure the resident had taken her meds; this is all on me. There is no time that meds should be left at resident's bedside side without seeing resident take medication.During an interview on 07/24/25 at 12:30 PM, the Director of Nursing (DON), outlined her expectations for nurses regarding medication administration. Nurses are expected to administer residents' medication and observe them taking it. If a resident refuses to take the medication, nurses are to collect and discard the medication and then notify the physician.

Based on interviews, record review, and review of facility policy the facility failed to protect Resident (R)3) from accident hazards in the resident's environment specifically, Certified Nursing Assistant (CNA)1 failed to engage the wheel locks on a shower chair, causing R3 to sustain a fall with major injuries. Findings Include: Review of a facility policy titled, Fall Prevention Program last revised 09/01/23, states, Each resident . will receive care and services in accordance with their individualized level of risk to minimalize the likelihood of falls. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's, dementia, and osteoarthritis. Review of R3's Annual Minimum Data Set (MDS) with an Assessment Reference Date of 05/22/24, revealed R3 had a Brief Interview of Mental Status (BIMS) score of 09 out of 15, indicating R3 was moderately, cognitively impaired. Review of R3's Nursing Progress Note dated 06/04/24 at 1:30 PM, revealed At 1220PM, CNA notified nurse that resident was being assisted with showering and resident fell from the shower chair. Nurse observed resident sitting on her buttocks with the shower chair behind her and the chair leaning forward onto the resident's back. The resident's left arm was wrapped on the arm of the chair in attempt to brace herself. The resident's right leg was extended in front of her and the left leg was bent at the knee. Resident was guarding her knee and complained of pain and states she was unable to extend her leg. Review of a Hospital Report from the local hospital dated 06/05/24, stated, Xray Tibia-Fibula: Comminuted fractures are seen of the proximal tibia fibula, the tibial fracture is severely comminuted. The fibular head fracture is relatively subtle. During an interview on 07/05/24 at 1:27 PM, CNA1 stated she was assisting R3 with her shower when she leaned over to dry her legs off and the shower chair slipped from up under her. CNA1 then stated that the shower chairs do have locks on the wheels, but R3's locks were not locked that day. CNA1 further stated that shower chairs are normally to be locked while using them. CNA1 repeated this statement twice confirming she did not lock the wheels on the shower chair. During an interview with R3 on 07/05/24 at 2:56 PM, R3 stated she was wet, and the chair was wet, and she fell . She said, I was drying off if I remember right. Then my legs went flying in different directions and I hurt my leg. Now, she cannot stand. During an interview on 07/05/24 at 2:55 PM, the Director of Nursing (DON) stated that staff should lock shower chairs or any chair with wheels while performing ADL care. The DON further stated that that particular shower chair would move anyways even if locked so they had it replaced after R3's fall.

Based on the review of the facility policy, record review, and interviews, the facility failed to refer Resident (R)8, with a new diagnosis of schizoaffective disorder/Bipolar type was screened for specialized services in a timely manner for 1 of 1 resident reviewed for new diagnosis of a mental illness. Findings include: Review of the facility's policy title Resident Assessment- Coordination with PASSAR Program with an implementation date of 10/30/23, states: This facility coordinates assessments with the preadmission screening and resident (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. Section 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level 2 resident review. Examples include: A: A resident who exhibits behavioral, psychiatric, or mood-related symptoms suggesting the presence of a mental disorder (Where dementia is not the primary diagnosis.) Review of R8's Admission Record located in the Electronic Medical Record (EMR), revealed R8 was admitted to the facility on [DATE] with diagnoses including but not limited to: bipolar disorder, cognitive communication deficit, dementia, and encephalopathy. On 01/28/23, a new diagnosis of schizoaffective disorder/bipolar type was added to the resident's diagnosis list. Review of R8's EMR did not reveal any documentation of a PASARR Level II. During an interview on 03/21/24 at 11:23 AM, the Registered Nurse/Minimal Data Set Coordinator (RNMDS) stated that she is still learning the process related to PASSARs and has recently went through the training. The RNMDS confirmed there was no referral for a Level 2 PASSAR done for R8. The RNMDS stated that there is typically a form that is to be filled out, which she stated she didn't know how and has not been doing that. The RNMDS concluded she normally reaches out to her point of contact, which is another RN at CLTC (Community of Long Term Care), to confirm if her completion of PASSARs are done correctly. During an interview on 03/21/24 approximately at 12:25 PM, the Facility's Physician (FP) states that he is familiar with the resident and her diagnoses which were obtained from family interviews and her health chart. The FP further states that given R8's mental illness, and progressed paranoia, visual hallucinations, and metabolic concerns/symptoms since admission, he concluded the new diagnosis of schizoaffective disorder. The FP stated the resident has had a history of PTSD related to being sexually abused in her younger years and states that he rarely changes what psych has already put in place for the resident, still trying to adjust medications for the resident to be stable and are always having to increase her medication dosages up most of the time. During a phone interview on 03/21/24 at 2:10 PM, the RN from Community of Long Term Care (RNCLTC) stated, If a resident acquired a new diagnosis of mental health illness while residing in the facility, with progressed behaviors, the facility would have to send over the referral/form to DMH (Department of Mental Health) to determine if it's suitable for the resident to reside in the facility or be transferred to a specialized environment. DMH is supposed to follow up on the referral in a timely manner.

Based on interview, record review and review of facility policy and procedure, the facility failed to ensure 100% (one hundred percent) vaccination of all staff including those who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Specifically, the facility failed to ensure a process for tracking and securely documenting the Covid-19 vaccination status of contracted staff. Facility census 108. Findings include: Review of facility policy titled Employee Covid-19 Vaccinations revised date 03/22 revealed .2. Employees who provide any care, treatment, or other services for the facility and/or its residents regardless of clinical responsibility or resident contact are required to be fully vaccinated (CMS (Centers for Medicare and Medicaid Services) term) or up to date (CDC (Centers for Disease Control and Prevention) term) against Covid-19. These include the following: a. Facility employees b. Licensed practitioners c. Students, trainees, and volunteers; and d. Individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement .4. The facility will ensure that all staff (except for staff who have pending requests for, or who have been granted exemptions to the vaccination requirements, or staff for whom Covid-19 vaccination must be temporarily delayed, as per CDC recommendations, due to clinical precautions and considerations) have received, at a minimum, a single-dose Covid-19 vaccine, or the first dose of the primary vaccination series for a multi-dose Covid-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents. 5. The facility will ensure that all staff (except for staff who have been granted exemptions to the vaccination requirements, or those staff for whom Covid-19 must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) are fully vaccinated (CMS term) or up to date (CDC term) for Covid-19 . Review of facility vaccination log identified one hundred and fifteen (115) employees of the facility and eighteen (18) contracted staff members for a total of one hundred and thirty-three (133) vaccination status for the facility. Further review identified two (2) staff granted exemptions (one for medical and one for religious), one (1) temporary delay/new hire exemption, and one (1) not vaccinated without exemption/delay. Review of facility contracts on 04/01/22 at 3:45 PM identified twelve (12) additional contracted services used by the facility to provide services to the residents. Review of facility Medical Vendors List dated 04/02/22 at 7:45 AM provided by the Assistant Director of Nursing (ADON) identified one hundred and twenty-two (122) additional employees that could potentially enter the facility and provide care, treatment, or other services to the residents. During an interview on 04/01/22 at 12:27 PM with the Assistant Director of Nursing (ADON)/ Infection Control Preventionist (IP) stated, I keep track of vaccination statuses for our staff, housekeeping, and therapy. We are trying to get every ones info (information) who is contracted. I have some info for hospice, nurse consultants, and RD (registered dietician) but it is not in a spreadsheet format. Pharmacy provides the vaccines for the facility and we set up a covid vaccine clinic every month when the pharmacist is here. I do not have information for the other contracted staff used by the facility .

Based on observation, interview, and record review, the facility failed to completely assess Resident (R)29 for choices of self administration of medications, 1 of 1 reviewed for self-administration of medications. Findings include: Review of facility policy titled, Self Administration Policy last revised 11/28/16, revealed Each resident who desires to self-administer medication may be permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. Self-administration should be written in the care plan once safety has been established. An observation and interview with R29 on 3/29/22 at 9:12 AM revealed R29 with medications in a cup. R29 was able to explain their [MEDICATION(S)] pill and what it is used for, and further stated that they do not like to take all of the medications at one time and that a few of the nurses often leave their medications in a cup for them to take later. R29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of R29's Quarterly Minimum Data Set (MDS) dated [DATE] with an Assessment Reference Date (ARD) of 2/1/22 revealed R29 has a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which reveals they are cognitively intact. Record review on 3/30/22 at 11:30 AM of R29's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 300 MG 2. [MEDICATION(S)] 5 MG 3. Stool Softener 100 MG Record review on 3/31/22 at 1:00 PM of R29's Self- Administration of Medication - Data Collection Tool revealed R29's assessment to self-administer only included Magic Mouthwash and did not document approval to self-administer any other medications. An interview on 4/1/22 at 2:17 PM with Registered Nurse (RN)1 revealed that residents that would like to self-administer medications should have an assessment completed for all of the medications they would be taking alone.

Based on record review, interview, and review of facility policy, the facility failed to update Resident (R)29's medical record to reflect their code status. Findings include: Review of facility policy titled: Coordination of Hospice Services last revised 11/27/17, revealed The facility will maintain communication with Hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities. R29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on 3/30/22 at 11:03 AM of R29's electronic medical record revealed their code status as Full Code as a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on 3/30/22 at 11:05 AM of R29's paper (physical) medical record revealed an Advanced Directive Acknowledgment of Receipt for R29 with Do Not Resuscitate (DNR) and two physician signatures dated 10/11/21. An interview on 4/01/22 at 1:56 PM with Licensed Practical Nurse (LPN)4 revealed that R29's code status is DNR and that staff are trained to review the paper medical record on the unit to ensure resident's code status. An interview on 4/01/22 at 2:17 PM with Registered Nurse (RN)1 revealed the paper medical record DNR order in R29's chart was written by the Hospice Physician and it should have been updated in the electronic medical record. She confirmed the electronic medical record and the physical medical record did not match for code status.

Based on record reviews, interviews, and review of the the facility policy titled, Body Audit Policy, and Pressure Ulcer Surveillance, the facility failed to ensure complete and accurate records related to body audits, assessments, measurements and documentation of a pressure ulcer that was described as large and necrotic for Resident (R)1 for 1 of 5 residents reviewed with pressure ulcers. The facility's failure constituted harm, past non-compliance. Findings include: The facility admitted R1 on 7/12/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record on 10/12/21 at approximately 12:00 Noon, revealed a Comprehensive Plan of Care which included, a stage 1 pressure ulcer to the left hip that resolved on 7/22/21 and a stage 2 decubitus to the sacrum that resolved on 7/22/21. On 7/29/21, the area to the right hip was documented as resolved. Further review on 10/12/21 at approximately 1:00 PM of the medical record for R1 revealed a nurse's note dated 9/1/21 at 11:30 that states, R1 was found slow to respond, with a temperature of 101.1. Tylenol was given for the elevated temperature and the temperature came down to 100.6. Responsible party concerned that the resident is not speaking, is slow to respond and has a noted large area to his/her coccyx. Additional review of the facility investigation dated 9/1/21 at 7:15 PM of a form titled, Investigation of Unknown Origin, described the area as large, necrotic with black eschar to the sacrum. No documentation could be found in the medical record of Resident #1 to ensure the large area had been assessed, measured nor documented. During an interview on 10/12/21 at approximately 1:30 PM with the Director of Nursing, (DON) confirmed that body audits were not completed as they should be, and Resident #1 developed a large necrotic pressure ulcer that was not treated. There had not been a body audit completed for Resident #1 since 8/19/21. Review on 10/12/21 at approximately 4:00 PM of the facility policy titled, Body Audit Policy, states, Resident's skin will be assessed on admission x 3 days, readmission on a weekly basis or more frequently as indicated for the presence of skin breakdown. If any skin issues are observed the policy states to Notify the physician and the Responsible party and document interventions as indicated. Review on 10/12/21 at approximately 4:20 PM of the facility policy titled, Pressure Ulcer Surveillance, states, A system of surveillance is utilized for preventing, identifying, reporting and investigating any new or worsened pressure injuries in the facility. Further review revealed the facility identified the issue and implemented the following: On 9/1/21 at approximately 7:30 PM, Resident #1 was slow to respond and had a temperature of 101.1 F. Upon preparing the paperwork to send Resident #1 to the emergency room for evaluation, a facility required procedure to complete a body audit was completed and Resident #1 was found to have a large, necrotic pressure ulcer on the coccyx that the facility was not aware of. Therefore, the attending physician was not aware of the pressure and an order had not been obtained for a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/1/21 at approximately 7:30 PM, the nurse caring for the resident notified the physician and the Director of Nursing. The DON came into the facility on [DATE], at that time, and completed a body audit on every resident residing in the facility, identifying there were missing weekly body audits for some residents. A weekly audit was started to ensure all the body audits were completed timely on every resident. In services were conducted with Nurses to ensure they were to complete the weekly body audits. Audits were and are being done to ensure the weekly body audits are being completed timely. In services were conducted with the Certified Nursing Assistants (CNA)s to ensure CNAs are to check resident's skin during incontinent care and during the residents baths and showers. The CNAs were instructed to inform the nurse caring for the resident would assess for the findings and notify the physician to obtain orders to address the skin issues. The DON and the Nurse Consultant to monitor by randomly checking a predetermined number of residents for body audits. Residents will be discussed in the morning meetings with nurses, supervisors, and the DON. The body audits and the findings will be addressed in the monthly QAA meetings, a QAPI was put into place to make sure the process is working and does not happen again to any resident. A process of surveillance was formulated and put into place. Policies were updated and procedures were developed to improve the process to detect skin breakdown early and to ensure treatments are started promptly. Verification of implementation was completed during the survey on 10/12/21. All in-services, audits and surveillance forms reviewed for completion.

Based on record reviews, interviews and review of the facility policy titled, Body Audit Policy, and Pressure Injury Prevention Guidelines, and Pressure Ulcer Surveillance, the facility failed to ensure body audits were completed, and a large necrotic pressure ulcer was prevented and treated prior to requiring hospitalization for elevated temperature and slow responsiveness for Resident (R)1 for 1 of 5 residents reviewed with pressure ulcers. The facility's failure constituted harm, past-noncompliance. Cross Refer: F580, F600, F842 Findings include: The facility admitted R1 on 7/12/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record on 10/12/21 at approximately 12:00 PM, revealed a Comprehensive Plan of Care which included, a stage 1 pressure ulcer to the left hip that resolved on 7/22/21 and a stage 2 decubitus to the sacrum that resolved on 7/22/21. On 7/29/21, the area to the right hip was documented as resolved. Further review on 10/12/21 at approximately 1:00 PM, revealed R1's nurse's note dated 9/1/21 at 11:30 that states, R1 was found slow to respond, with a temperature of 101.1. Tylenol was given for the elevated temperature and the temperature came down to 100.6. Responsible party concerned that the resident is not speaking, is slow to respond and has a noted large area to his/her coccyx. During an interview on 10/12/21 at approximately 1:30 PM with the Director of Nursing (DON), she confirmed that body audits were not completed as they should be, and R1 developed a large necrotic pressure ulcer that was not treated. There had not been a body audit completed for R1 since 8/19/21. Review on 10/12/21 at approximately 4:00 PM of the facility policy titled, Body Audit Policy, states, Resident's skin will be assessed on admission x 3 days, readmission on a weekly basis or more frequently as indicated for the presence of skin breakdown. If any skin issues are observed the policy states to Notify the physician and the Responsible party and document interventions as indicated. Review on 10/12/21 at approximately 4:10 PM of the facility policy titled, Pressure Injury Prevention Guidelines, and states, To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure ulcers, it is the policy of this facility to implement evidence-based interventions for all resident who are assessed at risk for, and/or has a pressure ulcer present. Review on 10/12/21 at approximately 4:20 PM of the facility policy titled, Pressure Ulcer Surveillance, states, A system of surveillance is utilized for preventing, identifying, reporting and investigating any new or worsened pressure injuries in the facility. Further review revealed the facility identified the issue and implemented the following: On 9/1/21 at approximately 7:30 PM, Resident #1 was slow to respond and had a temperature of 101.1 F. Upon preparing the paperwork to send Resident #1 to the emergency room for evaluation, a facility required procedure to complete a body audit was completed and Resident #1 was found to have a large, necrotic pressure ulcer on the coccyx that the facility was not aware of. Therefore, the attending physician was not aware of the pressure and an order had not been obtained for a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/1/21 at approximately 7:30 PM, the nurse caring for the resident notified the physician and the Director of Nursing. The DON came into the facility on [DATE], at that time, and completed a body audit on every resident residing in the facility, identifying there were missing weekly body audits for some residents. A weekly audit was started to ensure all the body audits were completed timely on every resident. In services were conducted with Nurses to ensure they were to complete the weekly body audits. Audits were and are being done to ensure the weekly body audits are being completed timely. In services were conducted with the Certified Nursing Assistants (CNA)s to ensure CNAs are to check resident's skin during incontinent care and during the residents baths and showers. The CNAs were instructed to inform the nurse caring for the resident would assess for the findings and notify the physician to obtain orders to address the skin issues. The DON and the Nurse Consultant to monitor by randomly checking a predetermined number of residents for body audits. Residents will be discussed in the morning meetings with nurses, supervisors, and the DON. The body audits and the findings will be addressed in the monthly QAA meetings, a QAPI was put into place to make sure the process is working and does not happen again to any resident. A process of surveillance was formulated and put into place. Policies were updated and procedures were developed to improve the process to detect skin breakdown early and to ensure treatments are started promptly. Verification of implementation was completed during the survey on 10/12/21. All in-services, audits and surveillance forms reviewed for completion.

Based on record reviews, interviews and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure Resident (R)1 received care and services needed to prevent the development of a large necrotic pressure ulcer requiring a hospital stay for 1 of 5 residents reviewed for facility acquired pressure ulcers. The facility's failure constituted harm at past non-compliance. Cross Refer: F580, F686, F842 Findings include: The facility admitted R1 on 7/12/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's medical record revealed he weighed 115 pounds (lbs) and was 72 inches tall on admission. Further review of medical record revealed R1 weighed 120 lbs at the time of discharge. Review on 1/19/22 at 8:30 AM of the Minimum Data Set (MDS) Assessment, dated 7/14/21 revealed under C0500: a Brief Interview of Mental Status (BIMS) score of 99, which indicated R1 was rarely understood. He was coded as having long and short term memory deficits. C1000 Cognitive skills for daily decision making was scored (2) as being moderately impaired-decisions poor, cues and supervision required. Section D for Mood was coded (0) or left blank. Section E-0100Z for Behaviors, [CONDITION(S)] was checked - and no other behaviors either checked or left blank. Section G - He is totally dependent for bed mobility, 2 person to physically assist with transfers. Locomotion on and off the unit 1 per to physically assist. Totally dependent with dressing, eating, toilet use, personal hygiene, and bathing. Range of motion impairment on both sides. Section GG - Functional abilities and goals. Prior to admission he was total care at home and family was unable to care for him at home. Section H - Bowel and Bladder are coded with a 3 indicating always incontinent of bowel and bladder. Pressure Ulcer coded to right hip a stage 3. Pressure ulcer to sacral region coded as a stage 2, and a pressure ulcer to the left hip stage 1. He or she received physical therapy upon admission. Review on 1/19/22 at 9:45 AM of the meal intake percentages revealed: No documentation of meal intake from 7/12/21 (admission) until 7/19/21. On 7/19/21 he consumed 100% of breakfast, lunch and dinner. No documentation of meal intake on 7/20/21 through 7/23/21. On 7/24/21 and 7/25/21 he consumed 100 % of lunch, but there was no documentation for breakfast or dinner. No documentation of meal intake on 7/26/21. On 7/27/21 he consumed 100% of breakfast, lunch and dinner. On 7/28/21 he consumed 100% of breakfast, but there was no documentation for lunch and dinner. On 7/29/21 he consumed 100% of breakfast, 75% of lunch, but there was no documentation for dinner. On 7/30/21 he consumed 100% of breakfast, lunch and dinner. No documentation of meal intake on 7/31/21 and 8/1/21. On 8/2/21 he consumed 100% of breakfast, lunch and dinner. On 8/3/21 he consumed 50% of breakfast, lunch and 100% of dinner. On 8/4/21 he consumed 25 % breakfast, 100% lunch, but there was no documentation of dinner. On 8/5/21 he consumed at 50% of breakfast, 75% of lunch, but there was no documentation for dinner. On 8/6/21 he consumed 100% of lunch, but there was no documentation for breakfast and dinner. On 8/7/21 he consumed 75% of breakfast, but there was no documentation for lunch and dinner. No documentation of meal intake on 8/8/21. On 8/9/21 he consumed 100% of breakfast, lunch and dinner. On 8/10/21 he consumed 100% dinner, but there was no documentation for breakfast and lunch. On 8/11/21 he consumed 75% of breakfast and 100% of lunch and dinner. On 8/12/21 he consumed 100% of breakfast, lunch and dinner. No documentation of meal intake on 8/13/21. On 8/14/21, he consumed 100% of breakfast and lunch, but there was no documentation of dinner. No documentation of meal intake on 8/15/21. On 8/16/21 he consumed 100% of breakfast and lunch, but there was no documentation of dinner. On 8/17/21 he consumed 100% breakfast, but there was no documentation of lunch or dinner. On 8/18/21 he consumed 100% of breakfast, but there was no documentation of lunch or dinner. On 8/19/21 he consumed 100% dinner, but there was no documentation of breakfast or lunch. On 8/20/21 he consumed 100% dinner, but there was no documentation of breakfast or lunch. On 8/21/21 he consumed 100% of breakfast, lunch and dinner. No documentation of meal intake on 8/22/21, 8/23/21, 8/24/21. On 8/25/21, 8/26/21, and 8/27/21 he consumed 100% of dinner, but there was no documentation of breakfast and lunch. No documentation of meal intake for 8/28/21. On 8/29/21 he consumed 50% of breakfast, lunch and dinner. On 8/30/21 he consumed 75% of breakfast, 100% lunch, but there was no documentation for dinner. On 8/31/21 he consumed 75% of breakfast and lunch, and 100% of dinner. On 9/1/21, he consumed 50% of breakfast, 75% of lunch, and 100% of dinner. Review on 1/19/22 at 10:00 AM of the physician's orders revealed R1 was taking the following medications as of 7/12/21: [MEDICATION(S)] for pain, Vitamin D 3, Pro stat AWC daily for wound healing, [MEDICATION(S)] 2 times daily for wound healing, Vitamin C for wound healing, [MEDICATION(S)] Sulfate for [CONDITION(S)], [MEDICATION(S)] for [CONDITION(S)] prevention and [MEDICATION(S)] for [CONDITION(S)]. Wound care for July: Apply barrier cream to buttock for breakdown prevention every shift. Cleanse stage 2 to sacrum with saline and apply collagen sheet and cover with allevyn dressing daily. Cleanse stage 1 to left hip with saline and cover with allevyn dressing 3 times daily. Cleanse state 3 to right hip with saline and apply collagen sheet and cover with a dry dressing daily. Air mattress to bed on alternating setting and check for function every shift. Side rails ½ x2 to aid in mobility and positioning. Heel protectors to bilateral feet as tolerated while in bed. Review on 1/19/22 at 10:05 AM of the physician's orders for August 2021 are as follows: Apply barrier cream to buttocks and sacrum for breakdown prevention every shift. Air mattress to bed in alternating setting and check function q shift. Side rails ½ x 2 to aid in mobility and positioning. Heel protectors to bilateral feet as tolerated while in bed. Review on 1/19/22 at 10:10 AM of the treatment sheet dated 8/1/21 through 8/31/21 was signed off by the nurses that the barrier cream was applied to his or her buttocks and sacrum every shift. The multiple pressure ulcers that he or she was admitted with had healed by 7/29/21. Review on 1/19/22 at 10:40 AM of the care plan for R1 related to wound care and potential for skin breakdown is as follows: Potential for further skin breakdown related to decreased mobility related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was admitted with a stage 3 to his or her right hip, a stage 1 to his left hip and a stage 2 to his sacrum. The stage 1 to his or her left hip resolved on 7/22/21. The stage 2 on his or her sacrum resolved on 7/22/21. On 7/29/21 the area to this right hip resolved. R1 has no skin breakdown at the present but still has the potential for skin breakdown related to decreased mobility and incontinent episodes. On 9/1/21 R1 present with a fever, slow to respond and an area to his or her coccyx. The goal is that the area to his or her coccyx will decrease in size within the next 90 days, and R1 will not develop any further skin breakdown. The interventions include: Pro Stat AWC as ordered for extra protein. Vitamin C as ordered. Incontinent care as needed per staff. Weekly body audits - staff to notify the physician of significant changes in R1's skin. Assistance per staff in turning and repositioning. Pressure relieving cushion to Geri chair when resident is out of bed. Air mattress to bed and on alternating setting, check function each shift. Heal protectors to bilateral feet as tolerated while in bed. Barrier cream as ordered. Side rails ½ x2 to aid in turning and positioning. Provide wedge to aid in positioning. Diet as ordered. Tylenol as ordered for pain and or temperature. Review on 1/19/22 at 10:45 AM of the progress notes: Physician's progress noted dated 7/12/21 (admission). Patient is a [AGE] year old with late effects of a stroke. According to his family over the past year he has had significant decline and was previously using a walker. R1 has had multiple falls and is now bedbound. He developed multiple ulcers. He became weaker and was eventually admitted to the hospital. No debridement was needed. He is unable to give any history due to his frail advanced debility. Family does state that his intake of meals is great at home as long as he is fed. Review of the Nurse's Notes dated 7/12/21 through 9/1/21 revealed R1 is incontinent of bowel and bladder, R1 is fed by staff, and wound care continues. Review on 1/19/22 at 12:15 PM of the Braden Scale dated 7/12/21 (admission) and 8/2/21 states: Sensory perception - No impairment. Moisture - Occasionally moist. Activity - Chair fast. Mobility - Completely Immobile. Nutrition - Excellent Total Score 16. As high risk for skin breakdown. Review on 1/19/22 at 2:20 PM of the Hospital Records after sent out to the hospital on 9/1/21 due to fever, slow to respond and a large necrotic pressure ulcer to R1's coccyx. admitted to the hospital on 9/1/21 and discharged to Hospice House on 9/9/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital Course: R1 a [AGE] year old with a bedridden state was admitted with [CONDITION(S)] and a large decubitus wound that is not healing. R1 did not improve with any kind of antibiotics or wound care. Review of a Urine Analysis dated 9/2/21 revealed a urinary tract infection. Review on 1/19/22 at 2:30 PM of the facility policy titled, Abuse, Neglect, and Exploitation, revealed under Policy, It is the policy of this facility to provide protection for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. During an interview on 10/12/22 with the Responsible Party (RP) of R1, she was very upset, yelling that the facility had let her family member rot. The RP stated that do not tell that to the facility staff. During an interview on 1/19/22 at 9:53 AM with the Director of Nursing (DON) confirmed that the pressure ulcer for R1 was not cared for properly. She stated it was a system failure. She stated that the facility has done everything possible to fix the issue and stated they have most likely over corrected it. The DON does all of the body audits herself to make sure they are being done as should be, as to catch any changes in resident's skin. Then she will meet with the wound care nurse to notify the physician of the findings. During an interview on 1/19/22 at 10:10 AM with the Wound Care Nurse she stated, all the wounds that R1 had upon admission are healed. She stated body audits are done on admission and then for 3 days after admission and then weekly. Then every nurse caring for the residents get 3 body audits a day. Not one nurse are responsible for the body audits all the time. The week of 8/26/2021 when the body audit for R1 was due, I was working the med cart because the scheduled nurse broke her elbow. I was in a hurry that day and did not get to the body audit or his whole body assessment. Other nurses did not see it either, so when I did not do the body audit I assumed everything was ok. But then the area was found by the night nurse when R1 was going out to the emergency room . The Certified Nursing Assistants (CNAs) will apply the barrier cream each shift. None of the CNAs reported any skin issues to me for R1. The Wound Care Nurse revealed a CNA stated she reported it to me, but did not have no recollection of anyone reporting any skin issues regarding R1. Interview on 1/19/22 at 10:22 AM with LPN #1 revealed, she took care of R1 from the time he was admitted to the facility until R1 was sent out to the hospital. LPN #1 stated she would do body audits on Thursdays, and when she assessed him, the bottom was only red. The CNAs never told me he had anything different from the redness and she never saw anything but redness. LPN #1 stated she can't remember what the date was on the last Thursday she assessed R1's skin, but she never saw a dressing on his bottom. LPN #1 stated the last body audit she conducted was on 8/19/21 because she was out sick on 8/26/21. LPN #1 stated she was unsure who would have done the body audit on that day. Interview on 1/19/22 at 10:30 AM with LPN #2 revealed, On 8/19/21, a CNA came to her and reported that R1 had a wound. LPN #2 stated she thought the CNA was reporting something that had already been looked at the previous weekend. LPN #2 stated she told the CNA the treatment nurse knew about it and staff were putting barrier cream on it. LPN #2 revealed she reported the wound to the treatment nurse, who was standing at the desk and stated that she would tell the wound doctor, and then she walked down the hall toward R1's room. LPN #2 stated she did not get up and go look at the wound herself. On the weekend dated August 14-15, CNA #1 came to me and stated that R1 had a reddened area to his left side and a bandage to his right hip. The bandage was dated 7/28/21. She stated this was reported to the treatment nurse who removed the bandage. The skin underneath was intact, no redness. The treatment nurse said that she would write the order for barrier cream. She denies looking at his sacrum at this time. Interview on 1/19/22 at 10:32 AM with CNA #1 revealed she usually take care of R1 and he normally has a heart shaped pink dressing on his bottom. During the week of 8/23/21 his dressing was off and she saw the red area on his bottom at the top of his butt. CNA #1 states that she went and told RN#2 that the dressing was off of the dark area on R1's bottom. CNA #1 stated that she noted the dark area the day he went out of the facility and also stated that she could not remember if the dressing had been put back on the resident. During an interview on 1/19/22 at 10:36 AM with LPN #3, Unit Manager, stated she does not do body audits unless she is on the medication carts or filling in for someone that is out. LPN #3 stated, she did look at R1's skin when he went out to the hospital and the area was not very big. LPN #3 stated that the attending physician does not look at the wounds, he just goes by what the nurses tell him. LPN #3 stated she called and spoke with the responsible party when R1 was going out to the hospital and R1's responsible party asked what was his diagnosis. LPN #3 stated she told her that I could not give R1's diagnosis. The RP was not really upset, and was not yelling or raising her voice. LPN #3 stated she told the RP she did not know if the hospital were going to admit R1 or send him back to the facility. LPN #3 stated that R1's RP revealed he had multiple wounds from home and RP stated that she could not take care of her father at home. The RP would visit almost daily and be in the room when the CNAs would change the briefs and was always checking his skin. LPN #3 stated she would make sure R1 would get out of bed and would put pillows between his legs. The RP would tell us how she wanted staff to care for R1 and we would do everything she wanted us to. The RP was always involved in R1's care. He ate great, his meal intake was monitored. R1 was being seen by the wound MD when they healed, he did not go back to the wound doctor. LPN #3 stated she did not know R1 had a wound until he was sent out to the hospital. LPN #3 futher stated before R1's bottom was only red and staff were putting the barrier cream on his bottom. LPN #3 stated she thought the CNAs were really good at doing their job. During an interview on 1/19/22 at 11:15 AM with CNA #2 stated she took care of R1 a few days before he went out to the hospital. She did not see a black area, but did notice R1 had a dressing previously because she could see the outline of the tape. CNA #2 stated she thought that since there had been a bandage on R1, the nurses were aware and would apply another one. CNA #2 stated she works with a different group every day and she was unsure if someone else reported R1's wound or not. CNA #2 further stated if she sees a resident has an open wound, she would report it to the nurses immediately. During an interview on 1/19/22 at 11:45 AM with CNA #3 revealed she was familiar with R1, but does not care for him daily. When she took care of R1 there was always a flower shaped pressure relieving dressing on his bottom. CNA #3 stated she did not report it because there was always a dressing on it and thought the nurses already knew about it.CNA #3 revealed she never saw a black area on R1's bottom because it was always covered. CNA #3 further stated if she sees an opened area and is unsure if the nurse knows about it then, she reports it immediately. During an interview on 1/19/22 at 11:55 AM with CNA #4 revealed she was familiar with R1 and stated she remembers taking care of him. CNA #4 stated that each time she takes care of R1 he always had a dressing on his sacrum. CNA #4 stated she never saw the wound without a dressing however, she would apply barrier cream to R1's sacrum daily and if there was a new wound she would report it to the nurse right away. Further review revealed the facility identified the issue and implemented the following: On 9/1/21 at approximately 7:30 PM, Resident #1 was slow to respond and had a temperature of 101.1 F. Upon preparing the paperwork to send Resident #1 to the emergency room for evaluation, a facility required procedure to complete a body audit was completed and Resident #1 was found to have a large, necrotic pressure ulcer on the coccyx that the facility was not aware of. Therefore, the attending physician was not aware of the pressure and an order had not been obtained for a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/1/21 at approximately 7:30 PM, the nurse caring for the resident notified the physician and the Director of Nursing. The DON came into the facility on [DATE], at that time, and completed a body audit on every resident residing in the facility, identifying there were missing weekly body audits for some residents. A weekly audit was started to ensure all the body audits were completed timely on every resident. In services were conducted with Nurses to ensure they were to complete the weekly body audits. Audits were and are being done to ensure the weekly body audits are being completed timely. In services were conducted with the Certified Nursing Assistants (CNA)s to ensure CNAs are to check resident's skin during incontinent care and during the residents baths and showers. The CNAs were instructed to inform the nurse caring for the resident would assess for the findings and notify the physician to obtain orders to address the skin issues. The DON and the Nurse Consultant to monitor by randomly checking a predetermined number of residents for body audits. Residents will be discussed in the morning meetings with nurses, supervisors, and the DON. The body audits and the findings will be addressed in the monthly QAA meetings, a QAPI was put into place to make sure the process is working and does not happen again to any resident. A process of surveillance was formulated and put into place. Policies were updated and procedures were developed to improve the process to detect skin breakdown early and to ensure treatments are started promptly. Verification of implementation was completed during the survey on 10/12/21. All in-services, audits and surveillance forms reviewed for completion.

Based on record reviews, interviews, and review of the facility policy titled, MD Notification, the facility failed to notify the attending physician of a necrotic decubitus pressure ulcer, acquired in the facility, to ensure orders for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure constituted harm, past non-compliance. Cross Refer: F600, F686, F842 Findings include: The facility admitted R1 on 7/12/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record on 10/12/21 at approximately 12:00 Noon, revealed a Comprehensive Plan of Care which included, a stage 1 pressure ulcer to the left hip that resolved on 7/22/21 and a stage 2 decubitus to the sacrum that resolved on 7/22/21. On 7/29/21, the area to the right hip was documented as resolved. Further review on 10/12/21 at approximately 1:00 PM of the medical record for R1 revealed a nurse's note dated 9/1/21 at 11:30 that states, R1 was found slow to respond, with a temperature of 101.1. Tylenol was given for the elevated temperature and the temperature came down to 100.6. Responsible party concerned that the resident is not speaking, is slow to respond and has a noted large area to his/her coccyx. Additional review of the facility investigation dated 9/1/21 at 7:15 PM of a form titled, Investigation of Unknown Origin, described the area as large, necrotic with black eschar to the sacrum. The large area had not been assessed, measured or documented. No documentation could be found in the medical record to ensure the physician had been notified. During an interview on 10/12/21 at approximately 1:30 PM with the Director of Nursing (DON), she confirmed that the physician was notified on 9/1/21 when the nurse sending the resident out to the emergency room for evaluation completed a body audit. There had not been a body audit completed for R1 since 8/19/21. Review on 10/12/21 at approximately 2:00 PM of the facility policy titled, MD Notification, states, It is the goal of this facility to provide quality care to its residents through proper and timely addressing of changes of residents' condition and status. Procedure: The physician will be notified in the following situations: The development of any new pressure injuries or wounds. Further review revealed the facility identified the issue and implemented the following: On 9/1/21 at approximately 7:30 PM R1 was slow to respond and had a temperature of 101.1 F. Upon preparing the paperwork to send Resident #1 to the emergency room for evaluation, a facility required procedure to complete a body audit was completed and R1 was found to have a large, necrotic pressure ulcer on the coccyx that the facility was not aware of. Therefore, the attending physician was not aware of the pressure ulcer and an order had not been obtained for a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/1/21 at approximately 7:30 PM, the nurse caring for the resident notified the physician and the Director of Nursing. The DON came into the facility on [DATE], at that time, and completed a body audit on every resident residing in the facility, identifying there were missing weekly body audits for some residents. A weekly audit was started to ensure all the body audits were completed timely on every resident. In services were conducted with Nurses to ensure they were to complete the weekly body audits. Audits were and are being done to ensure the weekly body audits are being completed timely. In services were conducted with the Certified Nursing Assistants (CNA)s to ensure CNAs are to check resident ' s skin during incontinent care and during the residents baths and showers. The CNAs were instructed to inform the nurse caring for the resident would assess for the findings and notify the physician to obtain orders to address the skin issues. The DON and the Nurse Consultant to monitor by randomly checking a predetermined number of residents for body audits. Residents will be discussed in the morning meetings with nurses, supervisors, and the DON. The body audits and the findings will be addressed in the monthly QAA meetings a QAPI was put into place to make sure the process is working and does not happen again to any resident. A process of surveillance was formulated and put into place. Policies were updated and procedures were developed to improve the process to detect skin breakdown early and to ensure treatments are started promptly. Verification of implementation was completed during the survey on 10/12/21.

Based on record views, interviews and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility neglected to ensure Resident #1 received the treatment, care and services to promote healing, and prevent infection of a a large, necrotic pressure area to the coccyx/sacral area of 1 of 3 residents reviewed for pressure ulcers. The facility's failure constituted harm, past non-compliance. The findings included: The facility admitted Resident #1 on 7/12/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record on 10/12/2021 at approximately 12:00 Noon, revealed a Comprehensive Plan of Care which included, a stage 1 pressure ulcer to the left hip that resolved on 7/22/2021. A stage 2 decubitus to the sacrum that resolved on 7/22/2021. On 7/29/2021 the area to the right hip was documented as resolved. Further review on 10/12/2021 at approximately 1:00 PM of the medical record for Resident #1 revealed a nurse's note dated 9/1/2021 at 11:30 states, Resident #1 was found slow to respond, with a temperature of 101.1. Tylenol was given for the elevated temperature and the temperature came down to 100.6. Responsible party concerned that the resident is not speaking, is slow to respond and has a noted large area to his/her coccyx. Additional review of the facility investigation dated 9/1/2021 at 7:15 PM of a form titled, Investigation of Unknown Origin, described the area as large, necrotic with black eschar to the sacrum. The large area had not been assessed, measured or documented. No documentation could be found in the medical record to ensure Resident #1 had received treatment, care and services to promote healing and to prevent infection of a pressure area for Resident #1. During an interview on 10/12/2021 at approximately 1:30 PM with the Director of Nursing, (DON) confirmed that a body audit had not been completed for Resident #1 since 8/18/2021 and no treatment had been initiated to care for the decubitus until 9/1/2021 when the nurse sending the resident out out to the emergency room for evaluation completed a body audit. Review on 10/12/2021 at approximately 2:15 PM of the facility policy titled, Abuse, Neglect and Exploitation. states, It is the policy of this facility to provide protections for the health, welfare and right of each resident that prohibit and prevent abuse, neglect, and exploitation. The definition of Neglect, states it is the failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress, Further review revealed the facility identified the issue and implemented the following: On 9/1/2021 at approximately 7:30 PM, Resident #1 was slow to respond and had a temperature of 101.1 F. Upon preparing the paperwork to send Resident #1 to the emergency room for evaluation, a facility required procedure to complete a body audit was completed and Resident #1 was found to have a large, necrotic pressure ulcer on the coccyx that the facility was not aware of. Therefore, the attending physician was not aware of the pressure and an order had not been obtained for a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/1/2021 at approximately 7:30 PM, the nurse caring for the resident notified the physician and the Director of Nursing. The DON came into the facility on [DATE], at that time, and completed a body audit on every resident residing in the facility, identifying there were missing weekly body audits for some residents. A weekly audit was started to ensure all the body audits were completed timely on every resident. In services were conducted with Nurses to ensure they were to complete the weekly body audits. Audits were and are being done to ensure the weekly body audits are being completed timely. In services were conducted with the Certified Nursing Assistants (CNA)s to ensure CNAs are to check resident's skin during incontinent care and during the residents baths and showers. The CNAs were instructed to inform the nurse caring for the resident would assess for the findings and notify the physician to obtain orders to address the skin issues. The DON and the Nurse Consultant to monitor by randomly checking a predetermined number of residents for body audits. Residents will be discussed in the morning meetings with nurses, supervisors, and the DON. The body audits and the findings will be addressed in the monthly QAA meetings, a QAPI was put into place to make sure the process is working and does not happen again to any resident. A process of surveillance was formulated and put into place. Policies were updated and procedures were developed to improve the process to detect skin breakdown early and to ensure treatments are started promptly. Verification of implementation was completed during the survey on 10/12/2021. All in-services, audits and surveillance forms reviewed for completion.

Based on record reviews, interviews, and review of the the facility policy titled, Body Audit Policy, and Pressure Ulcer Surveillance , the facility failed to ensure complete and accurate records related to body audits, assessments, measurements and documentation of a pressure ulcer that was described as large and necrotic for Resident #1 for 1 of 3 residents reviewed with pressure ulcers. The facility's failure constituted harm, past non-compliance. The findings included: The facility admitted Resident #1 on 7/12/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record on 10/12/2021 at approximately 12:00 Noon, revealed a Comprehensive Plan of Care which included, a stage 1 pressure ulcer to the left hip that resolved on 7/22/2021. A stage 2 decubitus to the sacrum that resolved on 7/22/2021. On 7/29/2021 the area to the right hip was documented as resolved. Further review on 10/12/2021 at approximately 1:00 PM of the medical record for Resident #1 revealed a nurse's note dated 9/1/2021 at 11:30 states, Resident #1 was found slow to respond, with a temperature of 101.1. Tylenol was given for the elevated temperature and the temperature came down to 100.6. Responsible party concerned that the resident is not speaking, is slow to respond and has a noted large area to his/her coccyx. Additional review of the facility investigation dated 9/1/2021 at 7:15 PM of a form titled, Investigation of Unknown Origin, described the area as large, necrotic with black eschar to the sacrum. No documentation could be found in the medical record of Resident #1 to ensure the large area had been assessed, measured nor documented. During an interview on 10/12/2021 at approximately 1:30 PM with the Director of Nursing, (DON) confirmed that body audits were not completed as they should be, and Resident #1 developed a large necrotic pressure ulcer that was not treated. There had not been a body audit completed for Resident #1 since 8/19/2021. Review on 10/12/2021 at approximately 4:00 PM of the facility policy titled, Body Audit Policy, states, Resident's skin will be assessed on admission x 3 days, readmission on a weekly basis or more frequently as indicated for the presence of skin breakdown. If any skin issues are observed the policy states to Notify the physician and the Responsible party and document interventions as indicated. Review on 10/12/2021 at approximately 4:20 PM of the facility policy titled, Pressure Ulcer Surveillance, states, A system of surveillance is utilized for preventing, identifying, reporting and investigating any new or worsened pressure injuries in the facility. Further review revealed the facility identified the issue and implemented the following: On 9/1/2021 at approximately 7:30 PM, Resident #1 was slow to respond and had a temperature of 101.1 F. Upon preparing the paperwork to send Resident #1 to the emergency room for evaluation, a facility required procedure to complete a body audit was completed and Resident #1 was found to have a large, necrotic pressure ulcer on the coccyx that the facility was not aware of. Therefore, the attending physician was not aware of the pressure and an order had not been obtained for a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/1/2021 at approximately 7:30 PM, the nurse caring for the resident notified the physician and the Director of Nursing. The DON came into the facility on [DATE], at that time, and completed a body audit on every resident residing in the facility, identifying there were missing weekly body audits for some residents. A weekly audit was started to ensure all the body audits were completed timely on every resident. In services were conducted with Nurses to ensure they were to complete the weekly body audits. Audits were and are being done to ensure the weekly body audits are being completed timely. In services were conducted with the Certified Nursing Assistants (CNA)s to ensure CNAs are to check resident's skin during incontinent care and during the residents baths and showers. The CNAs were instructed to inform the nurse caring for the resident would assess for the findings and notify the physician to obtain orders to address the skin issues. The DON and the Nurse Consultant to monitor by randomly checking a predetermined number of residents for body audits. Residents will be discussed in the morning meetings with nurses, supervisors, and the DON. The body audits and the findings will be addressed in the monthly QAA meetings, a QAPI was put into place to make sure the process is working and does not happen again to any resident. A process of surveillance was formulated and put into place. Policies were updated and procedures were developed to improve the process to detect skin breakdown early and to ensure treatments are started promptly. Verification of implementation was completed during the survey on 10/12/2021. All in-services, audits and surveillance forms reviewed for completion.

Based on record reviews, interviews and review of the facility policy titled, Body Audit Policy, and Pressure Injury Prevention Guidelines, and Pressure Ulcer Surveillance, the facility failed to ensure body audits were completed, and a large necrotic pressure ulcer was prevented and treated prior to requiring hospitalization for elevated temperature and slow responsiveness for Resident #1 for 1 of 3 residents reviewed with pressure ulcers. The facility's failure constituted harm, past-noncompliance. The findings included: The facility admitted Resident #1 on 7/12/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record on 10/12/2021 at approximately 12:00 Noon, revealed a Comprehensive Plan of Care which included, a stage 1 pressure ulcer to the left hip that resolved on 7/22/2021. A stage 2 decubitus to the sacrum that resolved on 7/22/2021. On 7/29/2021 the area to the right hip was documented as resolved. Further review on 10/12/2021 at approximately 1:00 PM of the medical record for Resident #1 revealed a nurse's note dated 9/1/2021 at 11:30 states, Resident #1 was found slow to respond, with a temperature of 101.1. Tylenol was given for the elevated temperature and the temperature came down to 100.6. Responsible party concerned that the resident is not speaking, is slow to respond and has a noted large area to his/her coccyx. Additional review of the facility investigation dated 9/1/2021 at 7:15 PM of a form titled, Investigation of Unknown Origin, described the area as large, necrotic with black eschar to the sacrum. The large area had not been assessed, measured nor documented. During an interview on 10/12/2021 at approximately 1:30 PM with the Director of Nursing, (DON) confirmed that body audits were not completed as they should be, and Resident #1 developed a large necrotic pressure ulcer that was not treated. There had not been a body audit completed for Resident #1 since 8/19/2021. Review on 10/12/2021 at approximately 4:00 PM of the facility policy titled, Body Audit Policy, states, Resident's skin will be assessed on admission x 3 days, readmission on a weekly basis or more frequently as indicated for the presence of skin breakdown. If any skin issues are observed the policy states to Notify the physician and the Responsible party and document interventions as indicated. Review on 10/12/2021 at approximately 4:10 PM of the facility policy titled, Pressure Injury Prevention Guidelines, and states, To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure ulcers, it is the policy of this facility to implement evidence-based interventions for all resident who are assessed at risk for, and/or has a pressure ulcer present. Review on 10/12/2021 at approximately 4:20 PM of the facility policy titled, Pressure Ulcer Surveillance, states, A system of surveillance is utilized for preventing, identifying, reporting and investigating any new or worsened pressure injuries in the facility. Further review revealed the facility identified the issue and implemented the following: On 9/1/2021 at approximately 7:30 PM, Resident #1 was slow to respond and had a temperature of 101.1 F. Upon preparing the paperwork to send Resident #1 to the emergency room for evaluation, a facility required procedure to complete a body audit was completed and Resident #1 was found to have a large, necrotic pressure ulcer on the coccyx that the facility was not aware of. Therefore, the attending physician was not aware of the pressure and an order had not been obtained for a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/1/2021 at approximately 7:30 PM, the nurse caring for the resident notified the physician and the Director of Nursing. The DON came into the facility on [DATE], at that time, and completed a body audit on every resident residing in the facility, identifying there were missing weekly body audits for some residents. A weekly audit was started to ensure all the body audits were completed timely on every resident. In services were conducted with Nurses to ensure they were to complete the weekly body audits. Audits were and are being done to ensure the weekly body audits are being completed timely. In services were conducted with the Certified Nursing Assistants (CNA)s to ensure CNAs are to check resident's skin during incontinent care and during the residents baths and showers. The CNAs were instructed to inform the nurse caring for the resident would assess for the findings and notify the physician to obtain orders to address the skin issues. The DON and the Nurse Consultant to monitor by randomly checking a predetermined number of residents for body audits. Residents will be discussed in the morning meetings with nurses, supervisors, and the DON. The body audits and the findings will be addressed in the monthly QAA meetings, a QAPI was put into place to make sure the process is working and does not happen again to any resident. A process of surveillance was formulated and put into place. Policies were updated and procedures were developed to improve the process to detect skin breakdown early and to ensure treatments are started promptly. Verification of implementation was completed during the survey on 10/12/2021. All in-services, audits and surveillance forms reviewed for completion.

Based on record reviews, interviews, and review of the facility policy titled, MD Notification, the facility failed to notify the attending physician of a necrotic decubitus, acquired in the facility, to ensure orders for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure constituted harm, past non-compliance. The findings included: The facility admitted Resident #1 on 7/12/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record on 10/12/2021 at approximately 12:00 Noon, revealed a Comprehensive Plan of Care which included, a stage 1 pressure ulcer to the left hip that resolved on 7/22/2021 and a stage 2 decubitus to the sacrum that resolved on 7/22/2021. On 7/29/2021, the area to the right hip was documented as resolved. Further review on 10/12/2021 at approximately 1:00 PM of the medical record for Resident #1 revealed a nurse's note dated 9/1/2021 at 11:30 that states, Resident #1 was found slow to respond, with a temperature of 101.1. Tylenol was given for the elevated temperature and the temperature came down to 100.6. Responsible party concerned that the resident is not speaking, is slow to respond and has a noted large area to his/her coccyx. Additional review of the facility investigation dated 9/1/2021 at 7:15 PM of a form titled, Investigation of Unknown Origin, described the area as large, necrotic with black eschar to the sacrum. The large area had not been assessed, measured or documented. No documentation could be found in the medical record to ensure the physician had been notified. During an interview on 10/12/2021 at approximately 1:30 PM with the Director of Nursing (DON), s/he confirmed that the physician was notified on 9/1/2021 when the nurse sending the resident out to the emergency room for evaluation completed a body audit. There had not been a body audit completed for Resident #1 since 8/19/2021. Review on 10/12/2021 at approximately 2:00 PM of the facility policy titled, MD Notification, states, It is the goal of this facility to provide quality care to its residents through proper and timely addressing of changes of residents' condition and status. Procedure: The physician will be notified in the following situations: The development of any new pressure injuries or wounds. Further review revealed the facility identified the issue and implemented the following: On 9/1/2021 at approximately 7:30 PM Resident #1 was slow to respond and had a temperature of 101.1 F. Upon preparing the paperwork to send Resident #1 to the emergency room for evaluation, a facility required procedure to complete a body audit was completed and Resident #1 was found to have a large, necrotic pressure ulcer on the coccyx that the facility was not aware of. Therefore, the attending physician was not aware of the pressure and an order had not been obtained for a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/1/2021 at approximately 7:30 PM, the nurse caring for the resident notified the physician and the Director of Nursing. The DON came into the facility on [DATE], at that time, and completed a body audit on every resident residing in the facility, identifying there were missing weekly body audits for some residents. A weekly audit was started to ensure all the body audits were completed timely on every resident. In services were conducted with Nurses to ensure they were to complete the weekly body audits. Audits were and are being done to ensure the weekly body audits are being completed timely. In services were conducted with the Certified Nursing Assistants (CNA)s to ensure CNAs are to check resident ' s skin during incontinent care and during the residents baths and showers. The CNAs were instructed to inform the nurse caring for the resident would assess for the findings and notify the physician to obtain orders to address the skin issues. The DON and the Nurse Consultant to monitor by randomly checking a predetermined number of residents for body audits. Residents will be discussed in the morning meetings with nurses, supervisors, and the DON. The body audits and the findings will be addressed in the monthly QAA meetings a QAPI was put into place to make sure the process is working and does not happen again to any resident. A process of surveillance was formulated and put into place. Policies were updated and procedures were developed to improve the process to detect skin breakdown early and to ensure treatments are started promptly. Verification of implementation was completed during the survey on 10/12/2021.

Based on record review and interviews, the facility failed to ensure that a resident's clinical record was accurately documented related to their advance directive status for 1 of 20 sampled records reviewed. Resident #37 medical record was documented as being a Do Not Resuscitate (DNR) due to a red page in front of chart indicating (DNR) with no other DNR information in chart. The June, July and August 2020 cumulative orders signed by the physician indicated the resident was a full code. The findings included: The facility admitted Resident #37 on 9/15/16 and readmitted the resident on 6/15/20 with [DIAGNOSES REDACTED]. A review of the paper medical record on 8/19/20 at approximately 10 AM revealed an 8.5 by 11 red tab that indicated in large print DNR (Do Not Resuscitate) in front of the record. There was no other information in the medical record to indicate the resident or his/her responsible party requested DNR as the advance directive of choice. Further record review revealed typed monthly cumulative orders for June, July and August 2020 which were signed by a physician that indicated the resident was a full code. An interview on 8/19/20 at approximately 10:04 AM with Licensed Practical Nurse (LPN) #1, who looked in the medical record revealed he/she could not find a signed documentation of the advance directive for DNR. LPN #1 stated he/she would notify medical records to locate the documentation for the advance directive. An interview on 8/19/20 at approximately 10:56 AM with LPN #1 revealed staff was still looking for the advance directive information signed by the resident and his/her responsible party. An interview on 8/19/20 at approximately 12:25 PM with the Social Services Directive revealed the facility had to contact the doctor's office to obtain a copy of the DNR signed by the resident and his/her responsible party. The documentation was faxed to the facility on [DATE]. A review of the DNR documentation revealed the resident's Advance Directive Acknowledgement was signed on 6/24/20 and the South Carolina Emergency Medical Services form was signed by the resident and his/her responsible party on 6/24/20. An interview with the facility Administrator on 8/20/20 at approximately 11:25 AM revealed he/she was aware that the monthly cumulative orders signed by the physician indicated the resident was a full code and that the resident should have been documented as DNR. -

Based on record review and interview the facility failed to provide services that met professional standards. Resident #133, 1 of 3 residents reviewed for accuracy of medication administration, had a medication discontinued but it continued to be signed off as given by three different nurses for 9 days after it was discontinued. The findings included: Resident #133 was admitted with [DIAGNOSES REDACTED]. Record review of the October physician's orders [REDACTED]. Further review of the Physician's Telephone Orders revealed an order on 9/25/17 that stated, D/C (discontinue) [MEDICATION NAME]). Record review of the Consultant Pharmacist Drug Regimen Review on 10/10/17 at 12:45pm revealed an entry on 10/4/17 that stated, [MEDICATION NAME] d/cd (discontinue). Further review of the 9/25/17 physician progress notes [REDACTED]. Review of the Care Plan contained a hand written entry that stated, D/cd (Discontinue) 9/25/17). Record review of the October 2017 MAR indicated [REDACTED]. During an interview on 10/10/17 at 2:45pm, LPN #1 verified the [MEDICATION NAME] was discontinued on 9/25/17 but was on the current MAR. At 2:58pm, LPN #1 stated s/he spoke with the pharmacy, and the medication has not been sent since it was discontinued. S/he stated it was initialed as administered but the resident did not receive the medication because the medication was not sent by the pharmacy. During an interview on 10/10/17, at 4:27pm, the Director of Nursing verified that three different nurses documented the medication as given, and s/he will provide education and counsel the nurses. S/he provided documentation from the pharmacy that the medication had not been sent for the nurses to administer.

Based on observations during both initial tour and meal preparation/service, and interviews, the facility failed to store and serve food under sanitary conditions in one of one main kitchen. Food was improperly stored in the walk-in freezer and cold food was served at greater than 41 degrees Fahrenheit (F), placing all residents fed from the main kitchen at risk. The findings included: During the initial tour with the Certified Dietary Manager (CDM) on 10/3/16 at 10:28 AM, two opened, unlabeled, undated bags of food items were noted in the walk-in freezer. The CDM verified that one bag of french fries and one bag of hashbrowns were opened, unlabelled and undated. S/he removed them from the freezer. During the review of food temperatures prior to the lunch meal service on 10/5/16 at 12:02 PM, the temperature of the potato salad when tested was 41 degrees F. Review of the extended menu revealed that not all pureed diet items had been prepared, although the tray line and dietary aides were ready for meal service. The potato salad was placed in the walk-in refrigerator at 12:12 pm, while pureed diet items were being prepared. At 12:33 PM, when all of the pureed diet items had been prepared and were ready to be served, the potato salad was removed from walk-in refrigerator and returned to the service line. Recheck of the potato salad temperature at 12:34 PM revealed a temperature of 50 degrees F. At 12:40 PM, the dietary aide and CDM placed the bowls with individual servings of potato salad in an ice bath. Between 12:42 PM and 12:44 PM, a total of four meal trays were prepared and placed on the delivery cart without potato salad. At 12:44 PM, when the 5th meal tray was prepared, the dietary aide placed the potato salad on the tray without checking the temperature. At 12:45 PM, the surveyor requested that the temperature of the potato salad be checked before service. The dietary aide calibrated the thermometer and confirmed the temperature of 43-44 degrees F. The dietary aide then continued serving the potato salad with temperature of 43-44 degrees F. When the CDM was made aware of the potato salad temperature, s/he responded, It's coming down. S/he did not stop the tray line. On 12/5/16 at 12:48 PM, the surveyor alerted the CDM that the tray line had to be stopped because the potato salad could not be served. The CDM announced to the kitchen staff that the potato salad would not be served, and that mashed potatoes would be served as a substitute.