Every finding on record at Mcnaughten Pointe Nursing and Rehab

Based on medical record reviews, observation, and staff interview, the facility failed to ensure residents' medications were not prepared and removed from the original packaging prior to time of medication administration. This affected eight (Residents #3, #4, #5, #6, #7, #8, #9, and #11) of the eight residents reviewed for medication administration. The facility census was 122. Findings include:Observation completed on 06/23/26 from 3:51 A.M. through 4:11 A.M. of five medication carts revealed medication for eight residents (#3, #4, #5, #6, #7, #8, #9, and #11) residing on the East unit had been pulled from their original package provided by the pharmacy and placed in a medication cups for administration at a later time. An interview on 06/23/26 at 3:58 A.M. with Licensed Practical Nurse (LPN) #202 confirmed medication for eight residents (#3, #4, #5, #6, #7, #8, #9, and #11) had been pre pulled from their original package and placed in medication cups to be administered at 5:00 A.M. The actual medication administration time was at 6:00 A.M. for most of the residents, but they could be given up to an hour before or an hour after the scheduled time. LPN #202 also claimed that all medications were to remain in the pharmacy provided package until time of administration and not to be removed prior. Review of the medical records for Residents #3, #4, #5, #6, #7, #8, #9, and #11 revealed all residents have medication scheduled to be administered at Rise or 6:00 A.M. Review of the facility's medication administration times revealed when a medication was scheduled to be administered at Rise that means the medication was scheduled between 5:00 A.M. and 10:00 A.M. Request of a Medication Administration or Medication Error policy and procedure revealed the facility did not have either. This deficiency represents non-compliance investigated under Complaint Number 3032122.

Based on record review and interview, the facility failed to ensure the practitioner was timely notified of ongoing symptoms of nausea and holding of tube feeding administration for Resident #118. This affected one (Resident #118) of three residents reviewed for tube feeding management. The facility census was 116.Findings include:Review of the closed medical record for Resident #118 revealed an admission date of 10/08/25 with diagnoses including chronic respiratory failure, dependence on respirator status, dependence on renal dialysis, osteomyelitis of vertebra, sacral, and sacrococcygeal region, dysphagia oropharyngeal phase, and gastrostomy status. Resident #118 discharged from the facility on 10/24/25.Review of Resident #118's physician orders for October 2025 revealed an order dated 10/09/25 for Novasource Renal (an enteral nutrition formula) at 40 ml per hour (ml/hr) over 22 hours via g-tube (gastrostomy tube) and 10 ml/hr water flush over 22 hours; may be held every Monday, Wednesday, and Friday for dialysis treatment; check gastrostomy tube placement each shift. There were no orders for the tube feeding to be held for nausea or emesis.Review of Resident #118's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and received enteral nutrition and hydration via feeding tube and did not eat by mouth.Review of Resident #118's Medication Administration Record (MAR) for October 2025 revealed the tube feedings and water flushes were administered as ordered and gastrostomy tube placement checked each shift.Review of a progress note dated 10/15/25 at 8:07 A.M. revealed Resident #118 requested to turn off the tube feeding at 5:55 A.M. and it remained off until the time of this note (8:07 A.M.) due to nausea. It was passed on to the next shift to monitor the resident, and the responsible party was notified. There was no documentation that the physician or nurse practitioner (NP) were notified.Review of a progress note dated 10/15/25 at 10:38 A.M. revealed Resident #118 had continued complaints of nausea. There was no documentation that the physician or NP were notified.Review of a progress note dated 10/15/25 at 3:48 P.M. revealed Resident #118 continued to request the tube feeding be turned off at times, the NP was notified and to continue to monitor the resident.Review of a progress note dated 10/15/25 at 4:13 P.M. revealed Resident #118 refused for the tube feeding to be turned on after several attempts. Nurse Practitioner (NP) #248 was notified and the family.An interview on 05/21/26 at 9:25 A.M. with the Director of Nursing (DON) revealed the physician or NP should have been notified if a tube feeding was held for more than two hours. The DON verified there was no evidence the NP or physician was notified of the nausea and tube feeding being held until the progress note entry on 10/15/25 at 3:48 P.M. indicating the NP was notified. This deficiency represents non-compliance investigated under Complaint Number 3016838.

Based on observation, interview, and review of the facility policy, the facility failed to ensure proper incontinence care was completed for Resident #40. This affected one of four residents reviewed for incontinence care (Resident #15, #25, #20 #10). The census was 118.Findings include:Review of Resident #40's medical record revealed an admission date of 09/20/24. Diagnoses include hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, memory deficit following other nontraumatic intracranial hemorrhage, chronic obstructive pulmonary disease, peripheral vascular disease, neuromuscular dysfunction of bladder, chronic diastolic (congestive) heart failure, generalized muscle weakness, unqualified visual loss right eye and normal vision to left eye.Review of Resident #40's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09. Review of Resident #40's functional abilities revealed Resident #40 was dependent on staff for toilet hygiene and impairment to one side of his upper extremities. Review of Resident #40's bladder and bowel revealed Resident #40 is always incontinent of bladder and bowel.Observation on 04/16/26 at 8:45 A.M. with Certified Nursing Assistant (CNA) #200 performing incontinence care for Resident #40 revealed CNA #200 did not perform hand hygiene in between glove changes during incontinence care instead verbalizing they were performing hand hygiene without physically performing physical hand hygiene task. CNA #200 used a towel that was halfway placed in the plastic bag on the bed to dry Resident #200's buttock after completing incontinence care as there was not another clean towel to complete the incontinence care. Interview with CNA #200 on 04/16/26 at 9:12 A.M. confirmed she did not perform hand hygiene and did not have enough linen to complete the incontinence care using clean linen for all task. Review of the facility's policy titled. Hand Hygiene dated 11/28/17 confirmed staff will perform hand hygiene when indicated, using proper technique.Review of the facility's policy titled. Skin: Incontinence Care Protocol dated 09/2017 confirms perform proper hand hygiene and wear gloves when providing incontinence care.This deficiency represents non-compliance investigated under Complaint 2967065.

Based on interview, record review, and facility policy, the facility failed to ensure physician-ordered wound care treatments were accurately followed. This affected one (Resident #28) out of four residents reviewed for pressure injuries. The facility census was 112. Findings include: Review of Resident # 28's medical record revealed that he was admitted on [DATE] with diagnoses that included cervical 5 to cervical 7 incomplete quadriplegia, chronic pain syndrome, congestive heart failure, dysphagia, contracture of right hand, contracture of left hand, depressive disorder and insomnia. Review of Resident # 28's care plan dated 06/30/21, revealed a focus for alteration in skin integrity as evidenced by pressure ulcer present at the right buttocks with staff intervention to provide treatment(s) per physician order(s). Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status of 15, indicating intact cognition. Resident #28 was non ambulatory and dependent on staff for activities of daily living. Review of Resident #28's current physicians' orders dated 08/20/25, revealed an order for Santyl 250 units per gram (u/G) Ointment with instructions to apply to the right buttocks one time a day three times a week on Monday, Wednesday and Friday for wound care and to apply topically to right buttocks every twenty-four hours as needed. A second order for the right buttocks, dated 07/23/25, revealed an order to cleanse with normal saline, pat dry, apply triad paste and Abdominal gauze pad (ABD) every shift and every twenty-four hours as needed for soilage/dislodgement. Review of Encore Wound Care weekly wound sheet for the right buttocks dated 07/23/25, revealed a physicians' order was received for right buttocks to cleanse with normal saline, pat dry, apply triad paste and ABD pad every shift and as needed. The previous wound sheet for the right buttock dated 07/16/25, revealed a physicians' order to cleanse with normal saline, pat dry, apply Santyl, apply RTD (highly absorbent antimicrobial foam dressing with Methylene Blue, Gentian [NAME] and Silver Sodium Zirconium Phosphate) dressing and cover with silicone super absorbent dressing every day- shift for wound care and as needed for soilage/dislodgement. Review of Resident # 28's Treatment Administration Records (TAR) dated July 2025, August 2025 and September 2025, revealed nurses signatures for administration of the treatment to the right buttocks for the Santyl order was documented as completed on the following days: 07/25/25, 07/28/25, 07/30/25, 08/01/25, 08/04/25, 08/06/25, 08/08/25, 08/11/25, 08/13/25, 08/15/25, 08/18/25, 08/20/25, 08/22/25, 08/25/25,08/27/25, 08/29/25, 09/01/25, 09/03/25, 09/05/25 and 09/08/25. Interview on 09/10/25 at 9:50 A.M. with Manager of Clinical Services (MCS) #300 confirmed Resident #28 had two different wound treatment orders at the same time, for the right buttocks and the treatment order for Santyl should have been discontinued in July 2025 (when the Triad order was received). Interview on 09/10/25 at 1:25 P.M. with the Director of Nursing (DON) revealed that the current treatment order for Resident # 28's right buttocks was to cleanse with normal saline, pat dry, apply triad paste and cover with ABD pad every shift and every twenty-four hours as needed for soilage/dislodgement. The DON stated that the facility had not received any Santyl for Resident #28 for administration since July 2025. The order for Santyl was discontinued at time of discovery on 09/10/25. Interview on 09/11/25 at 1:36 P.M. with Licensed Practical Nurse (LPN) #139 confirmed she completed Resident # 28's right buttocks treatment on 08/18/25 as ordered to apply Santyl to the right buttocks one time a day on her shift. She stated that she checked the physicians' orders and treatment order in Point Click Care (PCC) prior to completing the treatment. LPN #139 also revealed that she found Santyl for Resident #28 in the wound treatment cart. Review of the Skin Assessment Policy dated 12/02/15, revealed residents with pressure injuries shall receive necessary treatment and services to promote healing, prevent infection and prevent new injuries from developing consistent with professional standards of practice, and licensed nurses collaborate with other members of the healthcare team to ensure necessary treatment and services are provided related to data collected for completion of skin assessments and documented per facility policy.

Based on observation, record review, staff interview, and review of facility policy, the facility failed to complete a thorough investigation and root cause analysis regarding falls for Resident #59 and failed to ensure adequate supervision, a thorough investigation and root cause analysis were completed for Resident #92 who fell while on an unknown (to facility staff) leave of absence by himself. This affected two residents (#59 and #92) out of three residents reviewed for accidents. The facility census was 112.Findings include: 1. Review of the medical record revealed Resident #59 was admitted on [DATE] and re-entered on 03/18/25 with diagnoses including right heart failure, obstructive sleep apnea, dysphagia, gastrostomy status, personal history of sudden cardiac arrest, anemia, Down syndrome, restlessness and agitation, constipation, insomnia, hyperlipidemia, and gastro-esophageal reflux disease without esophagitis. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #59 was unable to complete the Brief Interview for Mental Status (BIMS) or mood interview, required extensive to total assistance for nearly all activities of daily living, and had experienced two or more falls since the prior assessment. Review of the care plan for revealed Resident #59 was considered a fall risk due to debilitation, weakness, medical conditions, incontinence, Down Syndrome, a history of falls, and poor safety awareness. The goal was to reduce the factors that increased the chance of falling. Interventions included keeping a chair alarm in place and checked each shift, encouraging and reminding the resident to ask for help, ensuring the call light was always within reach, and placing floor mats on both sides of the bed each shift. Staff were to keep frequently used items close by, install a left assist bar on the bed to support mobility, and provide a new wheelchair cushion for better positioning and comfort. The resident was to be supervised during times of restlessness, have a pressure-sensitive bed alarm checked each shift, and receive help from one or two staff members for all transfers. Additional measures included offering rest periods, helping the resident get up early if awake before the end of the night shift, and making therapy referrals as needed.Review of the medical record revealed that Resident #59 experienced multiple falls on 04/09/25, 04/11/25, 04/21/25, 05/24/25, 06/11/25, 06/21/25, and 06/23/25. Post-fall assessments revealed delayed or incomplete investigations. For the 05/24/25 fall, no post-fall investigation or root-cause analysis was documented beyond recording vital signs and completing a head-to-toe assessment. The 06/23/25 fall assessment noted the resident sitting on the floor and implemented only a new get-up list intervention without a root-cause analysis into the fall.Interview on 09/10/25 at 1:19 P.M. with the Director of Nursing confirmed that following the 05/24/25 fall, the only action taken was to move the resident closer to nurse traffic, and no additional investigation/analysis into the root cause of the falls were completed. 2. Review of the medical record revealed Resident #92 was admitted on [DATE], re-entered on 06/25/25, and discharged on 09/10/25 to a skilled facility. Diagnoses included cerebrovascular disease unspecified, other specified disorders of the brain with bilateral symmetrical gliosis, schizophrenia unspecified, and type two diabetes mellitus without complications. Resident #92 was his own responsible party. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition, a mood score of 10, no behaviors, independence with most transfers and ambulation, and shortness of breath with exertion. Review of the care plan for Resident #92 revealed that the resident was at risk for falls with the potential for injury related to incontinence and multiple medical conditions, including psychotropic medication use and bilateral cataracts. Interventions included encouraging the resident to ask for assistance, ensuring the call light was within reach, maintaining a clutter-free environment, monitoring side effects of psychotropic medications, and providing non-skid socks and proper footwear. Review of the progress notes for Resident #92 revealed the following: on 08/09/25 at 7:30 A.M., a nurse was informed by another staff member that the local emergency room (ER) had called to report that the resident was in the emergency room due to a fall on the street. The nurse went to the resident's room to check on him, and the roommate reported that the resident had put on his hat and told the roommate he was going to the store without notifying staff of his leave of absence. The Nurse Practitioner, Utilization Manager, Director of Nursing, and the resident's brother were notified of the incident. Later that day, at 11:49 A.M., the nurse received notifications from hospital that the resident was in the emergency room for evaluation following the fall on the sidewalk while on the leave of absence. Hospital staff reported the resident was alert and oriented to person, place, time, and situation and upon arrival he denied pain and exhibited no distress. The resident's physician and family were notified, with no concerns voiced. On 08/11/25 at 12:14 P.M., this writer spoke with Station 23 regarding the resident's encounter on 08/09/25. A medic on the run reported that a bystander found the resident face down on the sidewalk on Yorkland Road and called 911. Upon arrival, the resident was alert and oriented times three, able to answer questions appropriately, and stated that he had left the facility intending to go to the store when he lost his balance and fell forward on the sidewalk. Emergency medical staff documented that the resident reported he was headed to the store when he lost his balance and fell forward. The resident was transported to the emergency room for evaluation. A skin assessment was completed upon return, and an elopement assessment with wander guard placement followed. Further review of the medical record revealed there was no documented evidence that the facility conducted a root cause analysis or identified and implemented additional interventions to prevent future falls/accidents for Resident #92 following the 08/09/25 lack of supervision incident. Interview on 09/10/25 at 3:39 P.M. with the Regional Director of Nursing (RDON) revealed the immediate intervention was a hospital transfer. The RDON confirmed there was no specific root-cause analysis or ongoing interventions related to the fall. The care plan was updated only to include education for the resident to sign out prior to leaving the facility. No therapy referral or post-fall interdisciplinary team note was completed. Interview on 09/10/25 at 4:45 P.M. with Resident #92 revealed he tripped outside. He stated that when he returned to the facility, staff told him to sign out before leaving and not to do that. He was observed sitting in a chair wearing non-slip shoes. Review of the facility policy titled Fall Management, originally dated 10/17/16, focused on reducing fall risks through interdisciplinary assessment and care planning, with prompt attention for residents who fell. The process emphasized notifying the charge nurse, assessing injuries, and conducting an interdisciplinary evaluation of health conditions, environment, equipment, medications, staff, or resident practices to determine the root cause. Based on this, the team implemented interventions or training to prevent recurrence, updated the care plan, and communicated new fall reduction strategies accordingly.

Based on record review, staff interview, and facility policy, the facility failed to obtain cultures and sensitivities prior to administering antibiotics for multiple episodes of urinary tract infections (UTIs) for Resident #36. This affected one (Resident #36) of three residents reviewed for UTIs. The facility census was 112.Findings include:Review of the medical record for Resident #36 revealed an admission date of 08/27/19 with diagnoses that included morbid (severe) obesity due to excess calories, type two diabetes mellitus with diabetic neuropathy (unspecified), dysuria, and lower abdominal pain (unspecified).Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident required extensive assistance including wheelchair use, setup for eating and oral hygiene, total dependence for toileting, bathing, lower-extremity dressing, and putting on/off footwear; maximal assistance for upper-extremity dressing and bed mobility; moderate assistance for personal hygiene; and was dependent upon staff or not assessed for most transfers. The resident was always incontinent of urine and frequently incontinent of bowel and reported no UTI in the past 30 days.Review of physician orders for Resident #36 showed treatment for multiple UTIs (an infection in the urinary tract with signs and symptoms associated with pain, burning, and urgency among other symptoms), including Levaquin 750 milligrams (mg) orally once daily from 03/14/25 through 03/19/25, Nitrofurantoin 100 mg orally twice daily from 05/10/25 through 05/15/25, and Ciprofloxacin 250 mg orally twice daily from 08/12/25 through 08/16/25. Orders also included a one-time urine culture with reflex culture collected on 07/24/25 for dysuria and lower abdominal pain, Pyridium 100 mg orally from 07/25/25 through 07/27/25, and a follow-up urology appointment scheduled for 08/26/25.Review of the progress notes for Resident #36 revealed a health status note dated 03/13/25 at 8:07 P.M. that stated the resident's urinary analysis (UA) returned and the Certified Nurse Practitioner (CNP) ordered Levaquin 500 mg daily for five days. On 03/14/25 at 7:27 P.M., an infection note stated that the antibiotic (ATB), Levaquin oral tablet one time a day for UTI for five days, was initiated.Review of the UA for Resident #36 with a collection date of 03/13/25 and a reported date of 03/15/25 revealed several abnormalities suggestive of a possible UTI, including turbid clarity, positive leukocyte esterase, elevated white blood cells (>50/high power field), mildly elevated red blood cells (3-5/high power field), and the presence of few bacteria, alongside elevated squamous epithelial cells indicating potential contamination. Despite these findings, a reflex urine culture identified 10,000 to 50,000 colonies per milliliter (mL) of Gram-negative bacilli (three kinds), which the laboratory interpreted as suggestive of contamination rather than a true infection, with a note to contact microbiology for further workup if desired. However, no sensitivity testing was performed to identify a specific pathogen to guide antibiotic therapy.Review of the orders for Resident #36 revealed that on 07/24/25, a UA with reflex culture was ordered for dysuria and lower abdominal pain and was discontinued on 08/11/25. The resident was started on Pyridium (a urinary analgesic used to relieve pain, burning, urgency and other discomforts from urinary tract irritations) from 07/25/25 through 07/27/25.Review of the UA results dated 07/24/25 revealed the statement autocancel by system.Further review of the medical record revealed the 07/24/25 UA with reflex culture was not obtained and there was no further evidence that the resident did not have any signs or symptoms of a UTI after the completion of Pyridium (which decreases the signs and symptoms of a UTI).Review of the progress notes for Resident #36 revealed on 08/11/25 at 1:34 P.M., the resident requested to be taken to the hospital due to complaints of bladder incontinence. The CNP ordered that the resident be taken to the local hospital for examination. Upon return from the hospital, Resident #36 had an active UTI and was ordered Ciprofloxacin 250 mg orally twice daily from 08/12/25 through 08/16/25.Interview on 09/08/25 at 10:56 A.M. with Resident #36 revealed that the resident stated they had been experiencing a UTI for some time, starting in June 2025, and had been treated with multiple antibiotics. The resident stated that the facility would run a urinary analysis (UA) but expressed uncertainty as to why the UTI would not resolve.Interview on 09/09/25 at 4:12 P.M. with the Director of Nursing (DON) confirmed that for the March 2025 episode, no culture and sensitivity was completed, and the laboratory noted three or more isolates present, indicating possible contamination with no follow-up. Regarding the July 2025 episode, the UA order placed on 07/25/25 had an end date of 08/11/25; the DON stated the nurse practitioner may have intended to wait until 08/11/25 to complete the UA. The DON confirmed the resident had been started on Pyridium for bladder pain, which may have masked UTI symptoms, and the DON was unsure why follow-up testing was not completed.Interview on 09/10/25 at 10:22 A.M. with the Director of Nursing (DON) revealed that the laboratory reported autocancelled UAs either due to inability to obtain a specimen or cancellation by the laboratory, though the laboratory could not specify the reason. Regarding the July 2025 UTI, the DON stated that the nurse practitioner cancelled the UA because the resident had no symptoms after two days of Pyridium (started on 07/25/25 through 07/27/25); however, the UA order's cancel date was 08/11/25. The DON again confirmed that Pyridium could mask UTI signs and symptoms, and when the resident went to the hospital, a UTI was confirmed, and antibiotics were prescribed upon return.Interview on 09/11/25 at 11:27 A.M. with Manager of Clinical Services #300 revealed that all antibiotics administered were broad-spectrum, and no culture or sensitivity testing was obtained for any of the broad-spectrum antibiotic courses.Review of the facility policy titled Antibiotic Stewardship Program, dated 11/28/17 with a revision date of April 2025, revealed that McGeer criteria shall be used to define infections, but providers may consider Loeb minimum criteria when determining whether to treat an infection with antibiotics. Reassessment of empiric antibiotics is conducted for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports, and/or changes in the clinical status of the resident. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized. Additionally, antibiotic orders obtained upon admission or readmission to the facility shall be reviewed for appropriateness, as well as those obtained from consulting, specialty, or emergency providers.

Based on interview, record review, and review of the American Nurse's Association standards of professional nursing practice, the facility failed to ensure specified parameters were obtained and recorded during medication administration. This affected one resident (#121) of four residents reviewed for medication administration. The facility census was 117.Findings include: Review of the closed medical record for Resident #121 revealed an admission date of 04/22/25 and discharge date of 05/15/25. Diagnoses included but were not limited to Tracheostomy, chronic respiratory status, dependence on ventilator, dysphagia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, gastrostomy, epilepsy, pleural effusions, vascular dementia, Down Syndrome, end stage renal disease, dependence on renal dialysis, and depression.Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not able to be completed because Resident #121 did not respond or verbally communicate. Staff reported the resident had both short-term and long-term memory problems. Resident #121 received antidepressant and anticonvulsant medications with indications documented. Resident #121 received oxygen therapy, suctioning, tracheostomy care, invasive mechanical ventilation, dialysis, and had IV access.Review of Resident #121's physician's orders revealed an order dated 05/01/25 for Midodrine (a medication used to raise blood pressure) 5 milligrams (mg), give one tablet via the percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the stomach to allow for enteral feedings and medication administration) three times daily for hypotension. Additional instructions included to hold the medication for a systolic blood pressure of greater than 120 millimeters of mercury (mmHg).Review of Resident #121's Medication Administration Record (MAR) for May 2025 revealed multiple doses of Midodrine were administered with no blood pressure readings documented at the corresponding times in the vital signs tab or in the nursing progress notes to indicate the blood pressure readings were within permitted range at the time of administration.Interview on 07/23 25 at 2:25 P.M. with Registered Nurse (RN) #548 revealed all vital signs tied to medication administration are obtained by the nurse at the time of medication administration. Routine vital signs are obtained by the Certified Nursing Assistants (CNA). The CNAs give the nurses the vital signs, and they are documented by the nurse. Vital signs are documented under the vital signs tab or in the progress notes.Interview on 07/23/25 at 2:32 P.M. with RN #503 revealed routine vital signs are completed by the CNAs. Vital signs that need checked to see if it is safe to give medication are done when the medication is due. All vital signs are documented in the vital signs tab by the nurses.Interview on 07/24/25 at 7:45 A.M. with CNA #462 revealed CNAs obtain the residents' vital signs and give them to the nurses to chart.Interview on 07/24/25 at 7:55 A.M. with RN #415 revealed routine vital signs are completed by the CNAs. Vital signs that need checked to see if it is safe to give medication are done when the medication is due. RN #415 reported all vital signs are documented in the vital sign tab by the nurses.Interview on 07/24/25 at 10:53 A.M. with the Director of Nursing (DON) revealed the expectation is the nurses sees that vital signs are obtained prior to medication administration with parameters, and then the nurse documents the vital signs either in a progress note or on the vital signs tab within the electronic medical record. The DON stated the nurses are taught that the expectation is to document the vital signs if the medication needs to be held. When the nurses are administering medications and they decide to withhold a medication, they select a corresponding chart code to indicate why the medication was held. The DON reported there is no trigger to document if the vital sign is within parameters. A policy for medication administration was requested on 07/23/25 and 07/24/25 and was not received during the survey.Review of the American Nurses Association standards of Professional Nursing Practice revealed all professional nurses should maintain accurate and timely documentation of patient care, including assessments, interventions, and outcomes.

Based on record review, review of resident council minutes, review of audio/video footage, observation and interview the facility failed to ensure a resident was afforded privacy and dignity during care. This affected one resident (#46) of four residents reviewed for dignity. The facility census was 126. Findings include: Review of Resident #46's medical record revealed an admitted [DATE] with diagnoses including acute and chronic respiratory failure, dependence on a ventilator, dysphagia following cerebral infarction, and hemiplegia and hemiparesis following cerebral infarction unspecified side. Review of Resident #46's admission Minimum Data Set assessment dated [DATE] revealed the resident was rarely or never understood and was dependent on staff for all activities of daily living. Review of audio/video footage taken from Resident #46's room via an audio/video monitoring camera that was placed in the resident's room with the video time stamp dated 03/17/25 at 2:36 P.M. revealed the resident to be lying in her bed and receiving care from two unidentified Certified Nursing Assistants (CNAs). Resident #46 was naked and exposed in front of a window with the window blind open at the time. On 04/07/25 at 1:07 P.M. interview with Resident Representative #100 revealed concern with the resident not being provided privacy during care including not closing the window blind. Resident Representative #100 stated there were children that lived next door and she was afraid they could see into the resident's room through the open blind while she received care. On 04/07/25 at 1:15 P.M. observation of the resident's room and window revealed the resident was lying in bed and the blind was open. The resident's room was on the ground floor and passersby could see into the resident's room if the blind was not closed. In an interview on 04/07/25 at 3:23 P.M. the Director of Nursing reviewed the video and confirmed Resident #46 was unclothed and exposed in front of a window with the window blind open at the time. The DON was unable to identify the two CNAs caring for the resident. Review of Resident Council minutes dated 03/10/25 revealed a request was voiced during the meeting that the CNAs be reminded to knock on doors before entering resident rooms to respect resident privacy. This deficiency represents non-compliance investigated under Complaint Number OH00163801.

Based on interview, review of audio/video footage and review of Centers for Disease Control Guidelines for Enhanced Barrier Precautions, the facility failed to ensure infection control procedures were implemented to prevent the spread of infection. This affected one Resident (Resident #46) of four residents reviewed for infection control. The facility census was 126. Findings include: Review of Resident #46's medical record revealed an admitted [DATE] with diagnoses including acute and chronic respiratory failure, dependence on a ventilator, dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction unspecified side. Review of Resident #46's admission minimum data set (MDS) dated [DATE] revealed the resident to be rarely or never understood and to be dependent on staff for all activities of daily living. Further review of the MDS revealed Resident #46 had an enteral feeding tube and a tracheostomy. Review of audio/video footage taken from Resident #46's room via an audio/video monitoring camera that was placed in the resident's room with the video time stamp dated 03/18/25 at 11:51 A.M. revealed Resident #46 was receiving care from an unidentified Certified Nursing Assistants (CNA). The unidentified CNA was wearing gloves and a mask but was not wearing a gown. Resident #46 was on enhanced barrier precautions (EBP). The unidentified CNA proceeded to perform incontinence care on Resident #46 by cleansing her from back (rectum) to front (her urethra) potentially contaminating her urethra with fecal bacteria. The unidentified CNA then repositioned Resident #46 without removing his potentially soiled gloves and performing hand hygiene. In an interview on 04/07/25 at 3:23 P.M. the Director of Nursing (DON) viewed the video and confirmed the unidentified CNA was wearing gloves and a mask but was not wearing a gown. Resident #46 was on enhanced barrier precautions due to her feeding tube and tracheostomy. The unidentified CNA proceeded to perform incontinence care on Resident #46 by cleansing her from back to front potentially contaminating her urethra with fecal bacteria. The DON verified incontinence care should be from from front to back to prevent potential contamination from stool into the urinary tract. The unidentified CNA then repositioned Resident #46 without removing his potentially soiled gloves and performing hand hygiene. The DON stated they did not have an enhanced barrier precautions policy but followed the Center for Disease Control (CDC) guidelines. Review of the CDC's guidelines for Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated 06/21, revealed residents known to be colonized or infected with a multidrug-resistant organisms (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) should use EBP including a gown and gloves to interrupt the spread of novel or targeted MRDOs. Resident-to resident pathogen transmission in skilled nursing facilities occurs, in part, via healthcare personnel, who may transiently carry and spread MRDOs on their hands or clothing during resident care activities. Residents who have complex medical needs involving wounds and indwelling medical devices are at higher risk of both acquisition and colonization by MRDOs. Examples of indwelling medical devices include but are not limited to feeding tubes and tracheostomy/ventilator. This deficiency represents non-compliance investigated under Complaint Number OH00163801.

Based on medical record review and staff interview, the facility failed to offer/complete therapy orders as expected. This affected one (Resident #64) of three resident medical records reviewed. The census was 125. Findings Include: Resident #64 was admitted to the facility on [DATE]. Her diagnoses were end stage renal disease, dependence on renal dialysis, type II diabetes, hypertensive heart and chronic kidney disease, anemia, congestive heart failure, hyperlipidemia, mild cognitive impairment, insomnia, anxiety disorder, age related nuclear cataract, macular degeneration, and hyperkalemia. Review of her minimum data set (MDS) assessment, dated 08/13/24, revealed she had a mild cognitive impairment. Review of Resident #64 physician orders, dated 10/15/24, revealed she was ordered physical therapy three to five times per week, for 30 days. Review of Resident #64 physical therapy notes, dated 10/15/24 to 10/31/24, revealed her rolling week of therapy was from Tuesdays to Monday. During the first week of ordered physical therapy (10/15/24 to 10/21/24), she was offered therapy on Tuesday, 10/15/24, Friday, 10/18/24, and Monday 10/21/24 of the first week she was ordered physical therapy. She completed therapy on 10/15/24 and 10/21/24, but she did not complete it on 10/18/24; her documentation stated she was unavailable. On the second week of ordered physical therapy (10/22/24 to 10/30/24), she was offered therapy on Thursday, 10/24/24, Friday, 10/25/24, and Monday, 10/28/24. She completed therapy on 10/28/24, but she did not complete therapy on 10/24/24 (documented as being sick), and 10/25/24 (documented as being unavailable). There was no other documentation to support that she was offered therapy more than three times per week, and she was not offered therapy to make up for the days that she missed to meet the ordered three to five times per week. Interview with Therapy Director #501 on 10/31/24 at 12:45 P.M. confirmed Resident #64 was to have physical therapy three to five times per week. She also confirmed that if a resident misses a therapy session for any reason (being sick, physician/medical appointment, etc), they have enough openings in their schedule each week to offer more therapy opportunities to each of the residents on their case load. She confirmed there were only three attempts to perform physical therapy for Resident #64 and they should have offered it more time. She confirmed she does not know why it wasn't offered more. She also confirmed Resident #64 did not complete physical therapy at least three times per week. Interview with Director of Nursing (DON) on 10/31/24 at 3:30 P.M. confirmed Resident #64 attends dialysis three times weekly, which would affect the dates/times she would be able to perform physical therapy. This deficiency represents non compliance under Complaint Number OH00158713.

Based on medical record review, review of hospital records, review of a fall investigation, resident and staff interviews, and facility policy review, the facility failed to provide timely and effective pain management as well as adequately monitor resident pain. Actual harm occurred on 01/11/24 when Resident #65 fell , complained of pain to her right ankle, was not provided effective pain management, and was subsequently unable to get out of bed on 01/12/24 due to increased pain associated with the fall. The resident was transferred to the hospital on 01/12/24 at 6:52 P.M. (approximately 24 hours after the fall occurred) with complaints of right ankle pain. The resident required Oxycodone-Acetaminophen for pain. Upon assessment, the resident's ankle was resting in an extremely plantarflexed position (top of the foot pointed away from leg) with mild swelling and tenderness to palpation (indicates objective painful symptoms) about the medial and lateral ankle (the inside and outside portions of the ankle). The x-ray of the resident's right foot and ankle revealed a bimalleolar equivalent ankle fracture with medial malleoli avulsion fracture. This affected one (Residents #65) out of two residents reviewed for pain management. The facility census was 117. Findings include: Review of the medical record for Resident #65 revealed an initial admitted [DATE]. Medical diagnoses included unspecified sequelae of nontraumatic intra cerebral hemorrhage, secondary Parkinsonism, chronic kidney disease stage four, schizoaffective disorder bipolar type, major depressive disorder, anxiety disorder, and nondisplaced fracture of lateral malleolus of right fibula (added on 01/12/24). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/10/24, revealed Resident #65 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The assessment revealed Resident #65 required partial to moderate assistance with transfers and required variable assistance ranging from supervision or touch assistance to substantial or maximum assistance from staff to complete other activities of daily living (ADLs). The resident received scheduled pain medications and had not received any as needed pain medications. No pain had been reported. Review of a Fall Incident Report, dated 01/11/24 at 6:50 P.M., revealed Resident #65 was in the bathroom calling out for help. Licensed Practical Nurse (LPN) #210 entered the bathroom and noted Resident #65 standing with a walker. LPN #210 cleaned the resident and assisted with putting Resident #65's pants back on. Resident #65 continued standing with a walker. LPN #210 reached for the resident's wheelchair. Resident #65 attempted to sit in the wheelchair, lost her balance, and sat on the floor. Resident #65 twisted her right ankle. Resident #65 was transferred to the bed and assessed. Resident #65 complained of pain to her right ankle. Resident #65 stated, I twisted my ankle. LPN #210 checked Resident #65's range of motion (ROM) and Resident #65 complained of pain to her right ankle. Resident #65's vital signs were within normal limits. LPN #210 used a non-verbal pain scale to determine Resident #65's pain level and documented a pain level of three on the incident report. Resident #65 was alert and oriented to person, place, time, and situation. An injury to Resident #65's right inner ankle was noted. Certified Nurse Practitioner (CNP) #329 was notified. Resident #65's brother was contacted, and a message was left to return the phone call to the facility. There was no indication LPN #210 administered any medication or non-pharmacological interventions for Resident #65's reported pain at the time of the incident. Review of the Medication Administration Record (MAR), dated January 2024, revealed Resident #65 had an order for Tylenol Extra Strength 500 milligrams (mg) with instructions to give one tablet by mouth two times daily for pain. The order had a start date of 11/24/23. This medication was administered at bedtime on 01/11/24 for what staff documented was a pain level of zero (out of 10), upon rise on 01/12/24 with a pain level of three (out of 10), and at bedtime on 01/12/24 with a pain level of six (out of 10). Resident #65 had an additional order with a start date of 11/01/23 for Tylenol 325 mg with instructions to give two tablets by mouth every eight hours as needed for pain. This medication was not administered to Resident #65 on 01/11/24 or 01/12/24. Review of the progress notes for Resident #65 revealed on 01/11/24 at 7:47 P.M., LPN #210 noted Resident #65 was in the bathroom, attempting to transfer to the wheelchair, lost balance and sat on the floor, injuring her right ankle. On 01/12/24 at 6:05 P.M., LPN #202 noted Resident #65 was not able to get out of bed today (01/12/24) due to pain in her right ankle as a result of yesterday's (01/11/24) fall. An x-ray was completed and revealed an acute fracture of the distal fibula in the right ankle. Resident #65 was to be transferred to the hospital for further evaluation. Certified Nurse Practitioner (CNP) #329, the Unit Manager (UM), and Resident #65's family were notified. Review of the care plan for Resident #65, revised on 01/12/24, revealed Resident #65 was at risk for an alteration in comfort due to acute fracture of the distal fibula in the right ankle with cast in place. Interventions included administer medications as ordered, monitor for effectiveness of interventions, monitor for increased levels of pain and notify the physician, monitor for side effects of pain and anxiety medications, notify the physician for review of or change in pain medications if needed, complete pain assessment per facility policy, and offer non-pharmacological interventions. Review of the hospital records for Resident #65 revealed the resident arrived at the emergency roiagnom on [DATE] at 6:52 P.M. (approximately 24 hours after the fall occurred) with complaints of right ankle pain. X-rays and a computed tomography (CT) scan of the resident's head and cervical spine were completed. Resident #65 was administered Oxycodone-Acetaminophen for pain. Upon assessment, the resident's ankle was resting in an extremely plantarflexed position (top of the foot pointed away from leg). Mild ankle swelling was noted. There was tenderness to palpation (indicates objective painful symptoms) about the medial and lateral ankle (the inside and outside portions of the ankle). The x-ray of the resident's right foot and ankle revealed a bimalleolar equivalent ankle fracture with medial malleoli avulsion fracture. Post splint x-rays revealed persistent anterior subluxation (partial dislocation) of the talus (the large bone in the ankle that articulates with the tibia of the leg and the calcaneum and navicular bone of the foot). Resident #65 underwent a closed reduction to improve alignment of the tibiotalar joint and splinting in the emergency department. Resident #65 was discharged back to the facility from the hospital on 01/13/24 at 2:02 A.M. Review of the progress notes dated 01/13/24 at 2:40 A.M. revealed Resident #65 returned to the facility at approximately 2:10 A.M. on a stretcher with two Emergency Medical Services (EMS) staff. Resident #65 returned with a new order for Oxycodone-Acetaminophen (narcotic pain medication) 5-325 mg per tablet with instructions to administer one tablet by mouth every six hours if needed for severe pain for up to three days. On 01/14/24 at 5:00 A.M., Resident #65's right ankle had a dry and intact cast. Resident #65's right foot was warm, and color was within normal limits. Resident #65 was able to wiggle toes and denied pain at that time. Interview on 03/07/24 at 12:48 P.M. with LPN #213 (the floor nurse for Resident #65) revealed according to the facility's policy, at rise medications should be administered between 5:00 A.M. and 10:00 A.M. and bed time medications should be administered between 6:00 P.M. and 11:00 P.M. Resident #65 usually received her bed time medications closer to 6:00 P.M. Interview on 03/07/24 at 1:55 P.M. with Resident #65 revealed she was in her bathroom with one staff person (was not sure if it was an aide or a nurse). Resident #65 indicated she attempted to get in her wheelchair and fell . Resident #65 stated the staff member left her alone for a very short time while she went to get help. Resident #65 stated she reported pain in her right ankle and leg. Resident #65 stated she did not receive pain medication until she went to the hospital the next day. Resident #65 stated her right ankle hurt the whole time and it wasn't mild pain. Interview on 03/11/24 at 12:59 P.M. with LPN #202 revealed she was the day shift nurse for Resident #65 on 01/12/24. LPN #202 stated she was told in report that Resident #65 had a fall on 01/11/24 and Resident #65 had an order for an x-ray. LPN #202 stated she did assess Resident #65 and the resident complained of pain when she touched the right ankle. LPN #202 stated Resident #65 refused to give an exact number on the pain scale which was not abnormal for the resident. LPN #202 stated she would consider Resident #65's pain to have been moderate per her nursing judgement. LPN #202 stated she did administer Tylenol to Resident #65 but did not recall exactly when. LPN #202 revealed the resident did not want to get out of bed on 01/12/24 due to having pain in her right ankle. LPN #202 confirmed she had not administered any as needed pain medications to Resident #65. Interview on 03/11/24 at 5:21 P.M. with LPN #210 revealed she was the nurse on duty when Resident #65 had a fall in her bathroom. LPN #210 stated she was with Resident #65 when Resident #65 attempted to pivot from standing with a walker to sit in her wheelchair and lost her balance. Resident #65 twisted her right ankle and sat on the floor. Resident #65 immediately complained of pain to her right ankle. A State tested Nursing Assistant was called to assist and the resident was assisted off the floor and placed in her wheelchair and then transferred into bed. LPN #210 stated she completed a head-to-toe assessment on Resident #65 but was not able to complete a ROM exam on the resident's right ankle due to the resident's complaints of pain. LPN #210 denied asking the resident what her exact pain level was. LPN #210 stated she contacted CNP #329 who ordered an x-ray but did not order any additional pain medication. LPN #210 stated she administered scheduled Tylenol to Resident #65 with dinner between 5:00 P.M. and 6:00 P.M. (before the resident's fall occurred) but did not administer any additional pain medications after the fall. LPN #210 stated the x-ray had not been completed by the end of her shift. LPN #210 stated she left between 8:00 P.M. and 8:30 P.M. on 01/11/24. LPN #210 confirmed she had not assessed Resident #65 for effectiveness of the pain medication administered prior to the fall and had not administered any as needed pain medication to Resident #65 following the fall. Interview via telephone on 03/12/24 at 6:40 P.M. with LPN #230 revealed she was the night shift nurse for Resident #65 on 01/11/24 into the morning of 01/12/24. LPN #230 stated she was told in report Resident #65 had a fall during day shift on 01/11/24. LPN #230 stated she was not informed Resident #65 had any injuries or had complained of any pain following the fall. LPN #230 stated Resident #65 was alert with some confusion. LPN #230 stated the resident had a history of reporting inaccurate pain levels to the nursing staff and would often either refuse to answer or would give a random number on the pain scale. LPN #230 stated Resident #65 did complain of pain on 01/12/24 in the morning but stated she did not worry about the pain scale number provided by the resident because the Tylenol medication was scheduled and would be administered to Resident #65 regardless of the pain level being reported. LPN #230 stated she administered Tylenol to Resident #65 between 6:00 A.M. and 7:00 A.M. on 01/12/24. LPN #230 stated she had not assessed Resident #65's right ankle or leg during her shift because she was not aware of any injuries or concerns. LPN #230 confirmed she had not administered any as needed Tylenol to Resident #65 or reassessed the resident for effectiveness of the Tylenol that was administered in the early morning. Review of the facility policy titled Pain Assessment and Management, dated 03/31/16, revealed the alert and oriented resident may be asked to describe his/her pain status. Pertinent information may include a numeric rating scale of 0-10; with zero being no pain and ten being the most severe pain the resident can imagine. A verbal descriptor scale including mild, moderate, severe or very severe/horrible. The resident's expectation for pain relief; can he/she live with the pain at the current level, and if not, how much relief is needed to live comfortably. Non-pharmacological methods to reduce pain in a resident may be implemented. Pharmacological interventions should be provided according to physician orders. Evaluate the resident's response to interventions. Notify the physician as needed.

Based on medical record review, review of hospital records, staff and resident interview, review of facility policy, and review of the Centers for Disease Control and Prevention guidelines, the facility failed to appropriately obtain consent and timely administer a flu and pneumococcal immunizations. Actual harm occurred on 02/29/24, when Resident #104 was diagnosed with pneumonia and was hospitalized for ten days for treatment including intravenous antibiotic therapy. The resident's representative gave permission for the resident to receive the pneumococcal vaccination on 02/01/24 (admission); however, the facility failed to administer the vaccination to the resident. This affected two (Residents #89 and #104) of five residents reviewed for immunizations. The facility census was 117. Findings include: 1. Review of the medical record for Resident #104 revealed an original admitted [DATE]. Resident #104 was discharged to the hospital on 02/29/24 and readmitted back to the facility on [DATE]. Diagnoses included respiratory failure with hypoxia, hemiplegia and hemiparesis, dysphagia, dialysis dependence, diabetes, muscle weakness, chronic embolism, and tracheostomy. Review of Resident #104's Vaccine Consent, dated 02/01/24, revealed Resident #104's representative gave permission for the facility to administer the pneumococcal and flu immunization. Review of the Minimum Data Set (MDS) assessment, dated 02/08/24, revealed Resident #104 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 (out of 15). Review of Resident #104's physician orders from 02/01/24 to 02/29/24 revealed no evidence of the pneumococcal or flu immunization having been ordered or administered to Resident #104. Review of Resident #104's Medication Administration Record (MAR), dated February 2024, revealed no evidence of the flu or pneumococcal immunization having been ordered or administered. Review of Resident #104's immunization history record revealed no evidence the resident received a pneumonia or flu immunization between 02/01/24 and 02/29/24. Review of Resident #104's progress notes, dated 02/01/24 to 02/29/24, revealed no mention of the flu or pneumococcal immunization having been administered. Record review revealed the resident was transported to the hospital on 02/29/24. Review of a progress note dated 02/29/24 at 2:28 P.M. revealed Resident #104 had muscle weakness present. Further review of the progress notes revealed there was no mention of what change in condition led to Resident #104 being sent to the hospital on 02/29/24. Review of Resident #104's hospital paperwork, dated 02/29/24 to 03/10/24, revealed Resident #104 presented to the emergency department with tachyarrhythmia and a temperature of 102 degrees Fahrenheit. The resident was admitted to the hospital on 02/29/24 with an admitting diagnosis of pneumonia. Resident #104 was started on intravenous Vancomycin (antibiotic) 0.9% in sodium chloride 500 milligrams/100 milliliters piggyback three times weekly with dialysis and Zosyn 3.375 grams in sodium chloride every 12 hours. A chest Computed Tomography (CT) was done at the hospital on 02/29/24 which revealed Resident #104 had left lower lob infiltrate with small left pleural effusion which could represent lobar pneumonia. Review of Resident #104 progress note, dated 03/10/24, revealed the resident returned to the facility from the hospital after having been admitted with pneumonia. Interview on 03/12/24 at 11:45 A.M. with the Director of Nursing (DON) revealed Resident #104's daughter had signed the consents for the flu and pneumonia immunizations upon admission on 02/01/24. The DON revealed Resident #104 was alert and oriented and should have been offered the opportunity to sign the consents herself. The DON confirmed the flu and pneumonia vaccine was never ordered or administered to Resident #104 and confirmed she was diagnosed with pneumonia during her hospital stay on 02/29/24. Upon return from the hospital, the facility spoke with Resident #104 who stated she was agreeable to receive the pneumococcal immunization but declined to receive the flu immunization. Interview on 03/12/24 at 3:10 P.M. with Resident #104 revealed if she had been offered the choice of getting the pneumococcal vaccine upon admission on 02/01/24, she would have been agreeable. Resident #104 indicated she was still agreeable to receive the pneumococcal vaccine. Resident #104 revealed she had not previously received a pneumococcal immunization. Interview on 03/12/24 at 5:00 P.M. with the DON revealed the admitting nurse was responsible for obtaining proper consents for immunizations upon admission and if they do not obtain them, the Unit Manager should obtain consent and the resident should be administered the immunization. The DON confirmed Resident #104 was not provided with pneumococcal immunization and was hospitalized and treated for pneumonia. Review of the facility policy titled Immunization for Pneumococcal, Influenza and COVID-19, dated 07/03/23, revealed the facility would minimize the risk of acquiring, transmitting or experiencing complications from pneumonia and influenza by offering immunizations in accordance with national standards of practice. For pneumonia vaccines: each resident shall be evaluated upon admission and each resident shall be offered the pneumococcal vaccine unless medically contraindicated. The facility would provide education and offer vaccination based on CDC guidelines. For Influenza vaccines: shall be routinely offered from October through March unless medically contraindicated. Review of the Centers for Disease Control and Prevention guidelines titled, Pneumonia Vaccine Recommendations, dated 09/12/23, revealed pneumococcal vaccines were recommended for people who have long-term health conditions, like heart disease or respiratory disease. The CDC also provided information which stated for residents who had not received any pneumococcal vaccines or the vaccination history was unknown and were between the ages of 19 and 64, give one dose of PCV15 or PCV20. If PCV20 is used, their pneumococcal vaccinations are complete. If PCV15 is used, follow with one dose of PPSV23 to complete their pneumococcal vaccinations. The recommended interval between PCV15 and PPSV23 is at least one year. The CDC also provided information which stated for residents who had not received any pneumococcal vaccines or the vaccination history was unknown and were age 65 or older, give one dose of PCV15 or PCV201. If PCV20 is used, their pneumococcal vaccinations are complete. If PCV15 is used, follow with one dose of PPSV232 to complete their pneumococcal vaccinations. The recommended interval between PCV15 and PPSV23 is at least one year. The minimum interval is eight weeks and can be considered in adults with immunocompromising conditions, cochlear implants, or cerebrospinal fluid leaks. 2. Review of the medical record for Resident #89 revealed an admitted [DATE]. Diagnoses included quadriplegia, chronic respiratory failure, dependence on vent, spinal injury, tracheostomy, dysphagia, and muscle weakness. Review of Resident #89's Vaccine Consent, dated 09/15/23, revealed Resident #89's representative signed the consent for Resident #89 to receive the flu and pneumococcal immunization. Review of Resident #89's physician orders revealed an order, dated 09/20/23, for Resident #89 to receive the flu vaccine. Further review of Resident #89's physician orders revealed no evidence of a pneumococcal immunization having been ordered. Review of the MDS assessment, dated 09/22/23, revealed Resident #89 was cognitively impaired with a BIMS of 8 (out of 15). Review of Resident #89's progress notes from September 2023 through October 2023 revealed no evidence of the flu or pneumococcal immunization have been administered or withheld. Additionally, there was no evidence of Resident #89 having a fever around 09/20/23. Review of Resident #89's MAR from September 2023 through March 2024 revealed no evidence Resident #89 received a flu or pneumococcal immunization. Additionally, there was no evidence Resident #89 had a fever around 09/20/23. Interview on 03/12/24 at 11:45 A.M. with the DON revealed Resident #89's representative had signed the consents for Resident #89 to receive the flu and pneumococcal immunizations upon admission. The DON revealed she was waiting to provide Resident #89 the flu vaccine during the flu vaccine blitz on 09/20/23 and revealed it was not provided on 09/20/23 due to Resident #89 having a fever. The DON was unable to provide any information as to why the flu and pneumonia immunizations were not given including evidence of a fever. The DON was unable to explain why the pneumococcal immunization was not given. Review of the facility policy titled Immunization for Pneumococcal, Influenza and COVID-19, dated 07/03/23, revealed the facility would minimize the risk of acquiring, transmitting or experiencing complications from pneumonia and influenza by offering immunizations in accordance with national standards of practice. For pneumonia vaccines: each resident shall be evaluated upon admission and each resident shall be offered the pneumococcal vaccine unless medically contraindicated. The facility would provide education and offer vaccination based on CDC guidelines. For Influenza vaccines: shall be routinely offered from October through March unless medically contraindicated. Review of the Centers for Disease Control and Prevention guidelines titled, Pneumonia Vaccine Recommendations, dated 09/12/23, revealed pneumococcal vaccines were recommended for people who have long-term health conditions, like heart disease or respiratory disease. The CDC also provided information which stated for residents who had not received any pneumococcal vaccines or the vaccination history was unknown and were between the ages of 19 and 64, give one dose of PCV15 or PCV20. If PCV20 is used, their pneumococcal vaccinations are complete. If PCV15 is used, follow with one dose of PPSV23 to complete their pneumococcal vaccinations. The recommended interval between PCV15 and PPSV23 is at least one year. The CDC also provided information which stated for residents who had not received any pneumococcal vaccines or the vaccination history was unknown and were age 65 or older, give one dose of PCV15 or PCV201. If PCV20 is used, their pneumococcal vaccinations are complete. If PCV15 is used, follow with one dose of PPSV232 to complete their pneumococcal vaccinations. The recommended interval between PCV15 and PPSV23 is at least one year. The minimum interval is eight weeks and can be considered in adults with immunocompromising conditions, cochlear implants, or cerebrospinal fluid leaks.

Based on review of medication storage refrigerator daily temperature logs, observation, staff interview, and facility policy review, the facility failed to ensure medication storage refrigerators were maintained at an appropriate temperature and the temperature was routinely monitored. This affected one (South Unit) medication storage room out of three medication storage rooms in the facility and had the potential to affect all 25 residents (#1, #4, #5, #6, #8, #9, #11, #12, #13, #15, #19, #20, #38, #39, #56, #57, #59, #64, #78, #85, #87, #91, #92, #98, and #108) who received medications from the South Unit medication storage room. The census was 117. Findings include: Review of the South Unit medication storage refrigerator daily temperature log for January 2024 and February 2024 revealed four daily temperature entries for the entire month of January 2024 and no daily temperatures for the entire month of February 2024 Observation of the medication storage room located on the South Unit on 03/06/24 at 11:10 A.M. revealed the medication storage refrigerator daily temperature log dated March 2024 only had three daily temperatures recorded from 03/01/24 through 03/06/24. There were no other temperature logs in the medication storage room. The medication refrigerator temperature was observed to be 34 degrees Fahrenheit (F). Interview on 03/06/24 at 11:05 A.M. with Administrative Registered Nurse (ARN) #190 confirmed the temperature of the medication storage refrigerator on the South Unit was not consistently being recorded in January 2024, February 2024, and March 2024. ARN #190 stated the refrigerator temperatures should be checked daily and documented on the temperature logs. Interview on 03/06/24 at 11:15 A.M. with Administrative Licensed Practical Nurse (ALPN) #165 confirmed the daily medication refrigerator temperature logs for January 2024, February 2024, and March 2024 for the medication storage refrigerator located in the South Unit's medication storage room were incomplete and the temperature was not routinely being recorded. Review of the facility policy titled Medication Storage, dated 10/17/16, revealed medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F shall be kept in a secured refrigerator with a thermometer to allow routine temperature observations and monitoring.

Based on medical record review, resident interview, staff interview, and review of meal choice sheets, the facility failed to ensure residents were consistently offered meals according to their choices and preferences. This affected two (Residents #34 and #46) out of two residents reviewed for food choices and had the potential to affect all eight Residents (#33, #34, #46, #52, #89, #95, #97, #107) living on the North Hall who receive meals from the kitchen. The census was 117. Findings include: 1. Review of the medical record for Resident #34 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, vent dependence, diabetes, and dysphagia. Review of Resident #34's physician orders, dated 08/22/23, revealed an active order for a regular textured diet with low concentrated sweets and no added salt. Review of the Minimum Data Set (MDS) assessment, dated 02/08/24, revealed Resident #34 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and required set up assistance for eating. Review of the Plan of Care, dated 02/11/24, revealed Resident #34 had potential for alteration in nutrition and hydration with interventions to honor food preferences as able. Interview on 03/05/24 at 9:42 A.M. with Resident #34 revealed Resident #34 did not get options for food if he did not like what was being served. Resident #34 revealed he asked a staff member for alternatives and they didn't come back to give him the information on what alternatives were available. Interview on 03/06/24 at 12:35 P.M. with Resident #34 revealed staff do not go around the unit to get meal choices and he gets stuck with whatever the main special was. He revealed he has asked staff in the past to check on meal items and alternatives but they do not consistently honor alternatives/preferences and sometimes do not return to provide an update to him if his requested item was not available. 2. Review of the medical record for Resident #46 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, vent dependence, diabetes, pulmonary hypertension, and schizophrenia. Review of Resident #46's physician orders, dated 12/01/23, revealed an active order for a regular textured diet with low concentrated sweets and no added salt. Review of the MDS assessment, dated 02/08/24, revealed Resident #46 was cognitively intact with a BIMS score of 15 and required set up assistance for eating. Review of the Plan of Care, dated 02/12/24, revealed Resident #46 had a potential for alteration in nutrition and hydration with interventions to honor food preferences as able and obtain food preferences. Interview on 03/05/24 at 10:34 A.M. with Resident #46 revealed Resident #46 was concerned about getting choices for food and revealed she only gets offered the main dish. Interview on 03/06/24 at 12:30 P.M. with Kitchen Manager #151 revealed residents are asked about their food choices by the aides or activity staff (depending on the halls). He stated the North Hall had aides go room to room and take orders every few days and would discuss what was on the menu and offer an alternative from the everyday menu. Interview on 03/07/24 at 5:25 P.M. with State tested Nursing Aide (STNA) #309 revealed activity staff was responsible for asking residents about menu choices and alternative meals. Interview on 03/07/24 at 5:30 P.M. with Licensed Practical Nurse (LPN) #160 revealed activity staff was responsible for asking residents about menu choices and alternative meals. Interview on 03/07/24 at 5:36 P.M. with Activities Director #170 and Activity Staff #180 revealed the activity staff were responsible for all halls except the North Hall and the Rehab Hall. They revealed they read off the menu for the next few days and make note for each resident if they wanted something the alternative meal or something from the every day menu. They revealed the nurse aides were responsible for taking orders and reviewing the menu with the North and Rehab Halls as those residents were typically more medically complex. The Activity Director revealed they had discussed with the Administrator related to menu choices and were working on a plan for better consistency. The Activity Direcor was not familiar with the current status or what interventions were being put in place for the North Hall. They revealed staff fill out a menu change sheet and provide a few days worth to the kitchen at one time. Interviews on 03/11/24 from 8:45 A.M. to 8:52 A.M. with STNA #342 and STNA #313 revealed activity staff was responsible to ask residents about menu choices and alternative meals. Interview on 03/12/24 at 10:30 A.M. with the Administrator revealed the STNA's, kitchen staff and activity staff were responsible for obtaining menu choices from residents. He was unsure who specifically was responsible for the North Hall and revealed they were talking about updating the process, but had no additional information about what the actual the process was. Interview on 03/12/24 at 11:10 A.M. with Diet Technician #172 revealed obtaining menu choices was not a new process and the staff should know what their responsibilities were. Diet Technician #172 revealed the STNA's should be getting meal choices from the residents on the North Hall. Review of resident meal choices sheets dated 03/06/24, 03/10/24, and 03/11/24, revealed there were no entries for the North Hall residents including Residents #34 and #46. There were no additional meal choice forms for 03/06/24, 03/10/24, and 03/11/24 that were provided for review.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure residents were dressed in a dignified manner. This affected one (Resident #57) out of three residents reviewed for dignity. The census was 117. Findings include: Review of the medical record for Resident #57 revealed an admitted [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, diabetes, and muscle wasting and atrophy. Review of the Minimum Data Set assessment, dated 12/18/23, revealed Resident #57 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. Resident #57 required substantial/maximal assist with upper body dressing and was dependent for lower body dressing. Review of the plan of care, dated 12/21/23, revealed Resident #57 required assistance with activities of daily living (ADL) due to decreased self-performance with interventions to allow time for breaks, max assistance for upper body dressing and dependence on one to two staff for lower body dressing. Observation and interview on 03/04/24 at 11:45 A.M. revealed Resident #57 was wearing a medical gown. Resident #57 indicated staff had not got her up and dressed for the day. Observation and interview on 03/05/24 at 9:04 A.M. with Resident #57 revealed she was wearing a medical gown. Resident #57 revealed she would prefer to wear clothes and revealed sometimes staff forget about her and don't get her up and ready for the day since I stay in bed most of the day. She revealed she was not sure how much clothing she had available. Resident #57 gave the state surveyor permission to look in her clothing dresser and only socks and blankets were present in the clothing dresser. Resident #57 revealed she was typically left in a gown at all times. Observation on 03/05/24 at 1:00 P.M. revealed Resident #57 was wearing a medical gown. Observation on 03/06/24 at 10:55 A.M., 2:40 P.M. and 5:35 P.M. revealed Resident #57 was wearing a medical gown. Observation and interview on 03/07/24 at 8:28 A.M. with Resident #57 and State tested Nursing Aide (STNA) #287 revealed Resident #57 was wearing a medical gown. Resident #57 revealed she had been cleaned up already that morning. STNA #287 confirmed Resident #57 was typically in a medical gown and was wearing a medical gown at the time of interview. STNA #287 revealed Resident #57 had clothes that were likely in the laundry and the laundry gets delivered on Thursday's. STNA #287 revealed staff would put a gown on until her clothes returned from the laundry. STNA #287 also revealed the facility had extra clothing which was kept in the laundry room and was provided to the facility through donations. Resident #57 revealed she was agreeable to the facility providing donated clothing for her to wear.

Based on observations, resident interview and staff interviews, the facility failed to ensure a homelike environment was provided for two Residents (#8 and #9) of two reviewed for homelike environment. Facility census was 117. Findings include 1. Review of the medical record for Resident #8 revealed an admitted [DATE]. Diagnoses included quadriplegia c5-c7 incomplete, respiratory failure, dysphagia, and contracture of multiple unspecified sites. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15 and required substantial/maximum assistance dependence on staff for mobility and hygiene. Review of the plan of care dated 02/14/24 revealed resident had oral intake with help of tube feeds with interventions to provide tube feeding as ordered, dressing changes to the tube site and flushes as ordered. Observation and interview on 03/04/24 at 10:49 A.M. revealed resident had a metal cart with over 10 boxes piled on it and resident stated it was likely his tube feeding supplies. The boxes were stacked chest high against the wall across from resident bed. Resident #8 revealed the boxes had been there pretty much since admission. Interview on 03/04/24 at 4:50 P.M. with State tested Nursing Aide (STNA) #272 confirmed items in residents room included feeding tube supplies and wound dressing supplies she revealed she did not know why they were in resident's room and not in a facility storage area. She confirmed having boxes stacked of medical equipment in the residents room next to his bed is not a clean homelike environment. Interview on 03/04/24 at 5:20 P.M. with Licensed Practical Nurse (LPN) #165 revealed she was working on moving the boxes and placing them in a cabinet that had space in the resident's room. LPN #165 also confirmed having stacked boxes of medical supplies was not homelike. She revealed they were billed under resident's Medicare part B insurance and needed to keep them just for Resident #8. 2. Review of the medical record for Resident #9 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, diabetes, atrial fibrillation, contracture of the right and left hands and unspecified psychosis. Review of the MDS assessment dated [DATE] revealed Resident #9 was cognitively impaired with a BIMS of 8 out of 15 and was dependent on staff assistance for all mobility. Observation and interview on 03/04/24 at 5:12 P.M. revealed her bedside curtain by the window was dirty with over 20 spots or brown and red splattering from four feet high to the ground. Resident also confirmed the curtain looked dirty. Observation on 03/05/24 at 10:05 A.M., 2:40 P.M., and 4:55 P.M. revealed curtain remained soiled with several brown and red spots. Observation on 03/06/24 at 11:20 A.M., 12:50 P.M., and 3:10 P.M. revealed curtain remained soiled with several brown and red spots. Observation and interview on 03/07/24 at 8:50 A.M. with STNA #259 confirmed Resident #9's curtain had numerous stains on it and was dirty. She revealed it should be taken down and washed and replaced with a clean curtain. Facility reported they have no policy related to providing and ensuring a homelike environment.

Based on resident interview, staff interviews, and record review ,the facility failed to ensure care conferences were held with members of the interdisciplinary team including resident participation. This affected two Residents (#57 and #64) of three reviewed for care conferences. Facility census was 117. Findings include: 1. Review of the medical record for Resident #57 revealed an admitted [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, diabetes, and muscle wasting and atrophy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15 and required substantial/maximal assist and dependence on staff for activities of daily living. Review progress notes dated 01/09/23 revealed a care conference was held with son upon request as well as a meeting on 02/07/23. Progress note dated 06/30/23 revealed family was sent an invitation to schedule a care conference. Progress note dated 09/30/23 revealed family was sent an invitation to schedule a care conference. Progress note dated 12/29/23 revealed resident and family was sent an invitation to schedule a care conference. Interview on 03/05/24 at 9:04 A.M. with Resident #57 revealed she would like to attend care conferences but revealed she does not know where they were held and when they were. She also revealed she was unsure if she could attend due to not having any shoes to wear when she leaving her room. Resident revealed she was unaware of being invited to attend or getting information about a care conference meeting being offered. 2. Review of the medical record for Resident #64 revealed an admitted [DATE]. Diagnoses included dementia, malnutrition, dysphagia, atrial fibrillation, muscle weakness and insomnia. Review of the MDS assessment dated [DATE] revealed Resident #64 had significant cognitive impairment with a BIMS of 99 and required partial to moderate assistance with dressing, toileting, and personal hygiene. Review of care conference forms dated 01/13/23 and 02/07/23 revealed Social Services and a Unit Manager was present. Resident's family was marked as being in attendance one of the meetings. Review progress notes dated 01/13/23 revealed a care conference was held with grandson and a second meeting was held on 02/07/23. Progress note dated 06/30/23 revealed the family was sent an invitation to schedule a care conference. Progress note dated 09/30/23 revealed resident and family was sent an invitation to schedule a care conference. Progress note dated 12/29/23 revealed resident and family was sent an invitation to schedule a care conference. Facility provided documentation (last pages of care plan) where members of the interdisciplinary team signed off each quarter indicating the care plan had been updated. Interview on 03/05/24 at 5:05 P.M. with Social Services #319 revealed care conferences are offered and letters are sent out to families but revealed if family did not schedule or want to attend, no care conferences were held. She confirmed facility had no documentation for who attended care conferences and what was discussed as care conferences were not held for Residents #57 and #64 since first quarter of 2023. Interview on 03/06/24 at 5:00 P.M. with Social Services #319 revealed she was unaware all residents should have quarterly care conference discussions even if the resident and family do not attend. Interview on 03/11/23 at 5:00 P.M. with Social Services #319 provided documentation that the interdisciplinary team reviewed the care plan, but confirmed the interdisciplinary team did not have a discussion regarding residents overall care as part of the quarterly process. Social Services confirmed residents were sent a letter and they can reach out to staff if they want to attend. Revealed she was trained to provide a letter to prove they were offered a care conference instead of talking with the resident to encourage them to participate in a care conference discussion. Social Services also confirmed letters were mailed 6/30/23, 09/30/23, and 12/29/23 to residents and families. Social Services was unable to provide an explanation if these letters were invitations for the following quarter or the current quarter. If the invitations were sent for the current quarter social services was unable to provide reasoning as to why invitations 24 to 72 hour to get the letter and reach out to the facility to meet the timeframe and letters likely would not have reached residents home by mail prior to the end of the quarter. If the letter invitations were for the following quarter, facility was unable to provide any evidence of facility offering or inviting residents and family for Resident #57 and #64 to attend care conferences. Interview on 03/11/23 at 5:20 P.M. with Social Services #319 confirmed again the care plan was signed off by several members of the team but had no evidence a discussion was had on each individual residents and confirmed a discussion did not take place. Interview on 03/12/24 at 6:30 P.M. with Regional Nurse #326 confirmed the employees who signed off on the care plan sheets had updated their sections of the resident's care plan but had not had a meeting or discussion of the revisions that were made. Review of appendix PP revealed the interdisciplinary (IDT) care team would meets its responsibility in developing the care plan through a means determined by the facility. Examples provided included face to face meetings, teleconference and written communication. It also states that when an IDT members participates via written communication, the medical record must reflect involvement of resident, resident representative, and other members of the interdisciplinary team meeting. The Appendix PP also states facility staff have a responsibility to assist residents to engage in care planning process including encouraging participating for resident in care planning and attending care conferences. Facility must provide advanced notice of care planning conferences to enable resident participation. Facility did not have a policy related to care conferences and interdisciplinary discussions related to resident care.

Based on observations, resident and staff interviews and record review, facility failed to ensure a resident with hand contracture's was provided with nail trimming and care. This affected one Resident (#8) of one reviewed for nail care for dependent residents. Facility census was 117. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE]. Diagnoses included quadriplegia c5-c7 incomplete, respiratory failure, dysphagia, and contracture of multiple unspecified sites. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15 and required substantial/maximum assistance dependence on staff for mobility and hygiene. The MDS also revealed resident had an upper extremity impairment. Review of the plan of care dated 02/14/24 revealed resident required total assistance with activities of daily living (ADL) due to decreased self-performance with diagnoses of spinal cord injury, multiple contracture's, range of motion impaired to bilateral upper and lower extremities with interventions for bathing assistance of one to two staff and grooming assistance including nails, shaving and hair required maximum assistance. Review of shower sheets dated 02/07/24, 02/10/24, 02/14/24, 02/17/24, 02/21/24 and 02/28/24 revealed staff answered no to nails being trimmed and when asked on the form to provide reasoning, staff provided no documented response why nail care was not provided each of these dates. Review of shower sheets dated 02/24/24, 03/02/24, and 03/06/24 revealed the section regarding whether nail care was provided and the section for staff to explain why it was not provided was not completed. Observations and interviews on 03/04/24 at 10:51 A.M. with Resident #8 confirmed his hands were contracted with tips of his fingers having contact with his palms. Resident had several nails that were long (over 1/2 inch growth past the nail bed). Resident revealed he received showers and revealed staff had not trimmed his fingernails in several weeks. Observation on 03/06/24 at 12:30 P.M. revealed resident was observed to have long fingernails. Observation and interview on 03/07/24 at 8:33 A.M. with Resident #8 revealed he had long nails and was agreeable to have them cut. Resident revealed staff had not offered recently to trim his nails. Observation and interview on 03/07/24 at 8:50 A.M. with State tested Nursing Aide #259 confirmed Resident #8 had long nails and no protection from his nails and his palm skin. STNA spoke with resident who informed her he was agreeable to have his nails trimmed and STNA revealed she would return and trim resident's nails. Facility had no policy related to resident activity of daily living care for dependent residents.

Based on record review, review of skin grid assessments, review of the wound Certified Nurse Practitioner (CNP) notes, review of an After Visit Summary, staff interviews, and facility policy review, the facility failed to complete timely and accurate skin grid assessments, implement treatment changes timely, and follow up on the wound CNP recommendations timely for one resident (Resident #71). The facility also failed to follow up on discharge recommendations as indicated in the After Visit Summary following a hospitalization for one resident (Resident #71). This affected one resident (Resident #71) of one reviewed for non-pressure skin care. The facility census was 117. Findings include: Review of the medical record for Resident #71 revealed an initial admitted on 01/29/24 and a discharge date on 03/08/24. Medical diagnoses included chronic respiratory failure with hypoxia, asthma, dependence on respirator (ventilator) status, tracheostomy status, anoxic brain damage, and persistent vegetative state. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 was in a persistent vegetative state with no discernible consciousness. Resident #71 was totally dependent on one to two staff to complete all Activities of Daily Living (ADLs). Resident #71 required suctioning, tracheostomy care, invasive mechanical ventilator, intravenous medications, intravenous access, and oxygen. Resident #71 had an open lesion other than ulcers, rashes, cuts present at the time of the assessment as well as a surgical wound. Review of the significant change MDS 3.0 assessment date 02/05/24 revealed Resident #71 had an open lesion other than ulcers, rashes, cuts present at the time of the assessment. Review of Resident #71's census revealed the resident was in the hospital from 11/11/23 to 11/22/23 and 01/13/24 to 01/29/24. Review of the After Visit Summary (AVS) dated 01/29/24 revealed Resident #71 was hospitalized for sepsis and discharged back to the facility on intravenous (IV) antibiotics. Discharge nursing orders included to fax labs including complete blood count (CBC), sedimentation rate (SR), c-reactive protein (CRP), and creatinine to Infectious Disease physician every Monday and to call the Infectious Disease Physician on 02/12/24 with an update to determine stop date, peripherally inserted central catheter (PICC) line plans, oral antibiotics, and a follow up appointment. Wound care instructions for peg site skin breakdown and wound included: may change outer dressing daily as needed for soilage and reapply Triad to maintain dime thickness. Otherwise, change dressing every three days. Please use a plain foam dressing cut with a slit to accommodate the tubing. Remove previous dressing and cleanse wound with mild soap and water, rinse and pat dry. Careful attention to remove all previous cream. Apply triad cream at dime thickness and cover with gauze. Date and time dressing. This will promote autolytic debridement for healing. Review of Treatment Administration Record (TAR) dated January 2024 revealed Resident #71's wound treatment was implemented to start on 01/30/24. The treatment implemented from 01/30/24 to 02/04/24 was to clean with normal saline, pat dry, and apply calcium silver alginate to small open area and apply quarter size amount of triad paste to site and surrounding area and cover with abdominal (ABD) dressing. The treatment was to be completed every shift and as needed. The treatment order was created by Wound Licensed Practical Nurse (WLPN) #195. Review of the Skin Grid-Non-Pressure assessment dated [DATE] (three days after readmission) and completed by WLPN #195 revealed Resident #71 had a non-pressure area at the peg site (area where gastrostomy tube was placed in the abdomen). The area was an open lesion measuring 1.1 centimeters (cm) long by 2.4 cm wide by 0.2 cm deep with moderate serosanguineous drainage note. The area was unchanged. WLPN #195 noted the area was much improved since last visit with a shallow granular base and surrounding scar tissue. There was no indication of a skin assessment being completed upon admission on 01/29/24 by WLPN #195. There was no indication of a treatment order for the area in the skin assessment. Review of the Wound Certified Nurse Practitioner (WCNP) #330's note dated 02/01/24 revealed Resident #71 was seen for an open lesion at the resident's peg site. The area measured 1.1 cm long by 2.4 cm wide by 0.2 cm deep. The treatment included to apply triad and silver alginate for moisture control and antimicrobial benefits. WCNP #330 ordered to apply triad first, pack the wound with alginate every shift and as needed. There was no indication to use calcium alginate on the wound or to cover the wound with an ABD dressing. Review of the TAR dated February 2024 revealed the treatment for Resident #71's peg site wound implemented on 02/04/24 was to clean with normal saline, apply triad paste first then silver calcium alginate. Cover with split gauze and secure with tape every shift and as needed. This treatment remained in place until 03/05/24. The treatment was marked as administered every shift as ordered. The treatment was created by WLPN #195. Review of the progress notes for Resident #71 dated from 01/29/24 through 03/05/24 revealed there was no indication of any contact with the Infectious Disease physician on 02/12/24 as indicated in the discharge instructions. There was also no indication of labs being drawn or faxed to the Infectious Physician every Monday as ordered in the discharge instructions on 02/05/24, 02/12/24, 02/19/24, 02/26/24, or 03/04/24. Review of the Skin Grid Non-Pressure assessment dated [DATE] and completed by WLPN #195 revealed the peg site area measured 2.4 cm long by 2.6 cm wide by 0.2 cm deep. The area had moderate serosanguineous drainage. The area was improved with a shallow pink base that was hyper granular area. The area was cauterized. The assessment did not mention any concerns with the surrounding skin. Review of WCNP #330's note dated 02/15/24 revealed Resident #71's open lesion area at the peg site measured 2.4 cm long by 2.6 cm wide by 0.2 cm deep. There was surrounding excoriation to the skin around the site. The area was cauterized. No wound treatment changes were indicated. Review of the Skin Grid Non-pressure assessment dated [DATE] and completed by WLPN #195 revealed Resident #71's peg site open lesion measured 2.2 cm long by 2.8 cm wide by 0.2 cm deep with heavy serosanguineous drainage noted. The area was unchanged but noted a large amount of drainage of tube feeding and stomach contents. Granular tissue was still visible. There was no indication of WCNP #330's recommendation for a general surgery consult or changes to the peri wound. Review of WCNP #330's note dated 02/22/24 revealed Resident #71's peg site open lesion measured 2.2 cm long by 2.8 cm wide by 0.2 cm deep with a large amount of drainage of tube feeding and stomach contents. The surrounding skin had maceration and excoriation. WCNP #330 noted the area would continue to decline until further evaluation and recommended a general surgery consult for evaluation of peg tube placement. The periwound was noted to be excoriated and macerated. WCNP #330 changed the wound treatment to apply triad first, pack wound with alginate, and cover with an ABD pad every shift and as needed. This wound treatment was not implemented as recommended. Review of the Skin Grid Non-pressure assessment dated [DATE] and completed by WLPN #195 revealed Resident #71's peg site open lesion measured 8.9 cm long by 5.9 cm wide by 0.2 cm deep with heavy serosanguineous drainage noted. The area was declined and noted to be much larger with a large amount of drainage with tube feeding and stomach contents. Increased area maceration and excoriation was noted. The area was 30% granulation and 70% excoriation and maceration. There was no indication the area was cauterized, WCNP #330's recommendation for a general surgery consult, or that the area was noted to be unavoidable. Review of WCNP #330's note dated 02/29/24 revealed Resident #71's peg site open lesion measured 8.9 cm long by 5.9 cm wide by 0.2 cm deep with heavy serosanguineous drainage. The area was noted to be declined but unavoidable. WCNP #330 again recommended a general surgery consult. Silver nitrate was used to cauterize the excess granulation tissue. There were no wound treatment changes recommended. There was no evidence of any follow up related to WCNP #330's recommendations for a general surgery consult in Resident #71's medical record. Interview on 03/07/24 at 11:49 A.M. with WCNP #330 revealed she visited the facility one time a week to assess the facility's residents with wounds, including Resident #71. WCNP #330 reported Resident #71 had several wounds upon readmission from her most recent hospitalization on [DATE]. WCNP #330 stated the resident's peg site needed surgical intervention. Stated she did change the wound treatment today, 03/07/24, due to continued excoriation and maceration of the skin on the resident's abdomen. WCNP #330 confirmed the area declined on 02/29/24 but she did not make any new treatment recommendations until 03/07/24. WCNP #330 confirmed WLPN #195 should have completed an assessment of Resident #71's peg site prior to her visit on 02/01/24 (three days after readmission). WCNP #330 confirmed WLPN #195's skin grid assessments should be the same as her notes because they complete rounds together. WCNP #330 stated she was available for continued consultation as needed via telephone but had not received any communication from WLPN #195 other than during their weekly rounds. WCNP #330 confirmed the treatments provided to Resident #71 should match the treatment recommendations from her notes. Interview on 03/07/24 at 4:28 P.M. with WLPN #195 confirmed she was not a wound certified LPN. WLPN #195 confirmed a full skin grid assessment was not completed on Resident #71 until 02/01/24 (three days after readmission). WLPN #195 confirmed the wound treatment implemented on 01/30/24 did not match the discharge wound treatment recommendations on the After Visit Summary. WLPN #195 confirmed wound treatments for any newly identified areas or if WCNP #330 recommended a treatment change for an ongoing wound, the treatment should be implemented immediately. WLPN #195 confirmed any discharge instructions should be reviewed by herself and the unit managers when a resident was readmitted to the facility. WLPN #195 confirmed Resident #71's peg site wound was noted as declined but no treatment changes were ordered until 03/06/24 (six days later). WLPN #195 stated typically if a wound has declined, the treatment was changed. Interview via telephone on 03/11/24 at 3:15 P.M. with Infectious Disease Registered Nurse (IDRN) #332 confirmed there was not any evidence the facility had faxed any labs to the Infectious Disease Physician's office as ordered in the discharge instructions. IDRN #332 also confirmed there was not any evidence the facility had called the Infectious Disease office on 02/12/24 to determine plans for treatment of Resident #71 as ordered in the discharge instructions. Interview on 03/11/24 at 3:37 P.M. with the Director of Nursing (DON) revealed she did not provide any oversight or assistance with resident wounds. The DON stated WLPN #195 and WCNP #330 handled all the facility's wounds. The DON confirmed the treatment order implemented on 01/30/24 for Resident #71 did not match the treatment recommendations from the discharge instructions. The DON confirmed the wound treatment implemented on 02/04/24 through 03/05/24 did not match the treatment orders recommended by WCNP #330. The DON confirmed the weekly skin assessments should include a full description of the wound area, the treatment order, any changes from the previous week's assessment, and any recommendations made by WCNP #330. The DON confirmed there was no evidence WLPN #195 had consulted with WCNP #330 in the resident's record. Review of the facility policy, Nursing Assessments, dated 03/01/24, revealed the policy stated, Licensed nurses ensure assigned nursing assessments are completed timely by evaluating residents as scheduled and per the resident needs. Licensed nurses collaborate with other members of the healthcare team to ensure appropriate interventions related to data collected for completion of nursing assessments are in place and documented per facility policy. Review of the facility policy, Skin Assessment, dated 09/2107, revealed the policy stated, at the time of admission/re-admission, the resident is evaluated for special needs related to skin care. Residents receive a weekly skin integrity check performed by licensed personnel. Resident response to preventative efforts is monitored and evaluated. Approaches are revised as appropriate. Areas of alteration in skin that are present, or which develop subsequently to admission, are treated according to medical direction and are conscientiously followed. Review of the facility policy, Skin Evaluation, revised 03/01/24, revealed the policy stated, Licensed nurses may collect patient data that includes the LPN's observation, measurement, and comparative analysis of a wound to a staging chart, and document the observation, measurement and comparative analysis in accordance with recognized standards of practice.

Based on record reviews, interviews, observations, and facility policies, the facility failed to ensure accurate and timely wound assessments and care was provided for three residents (#51, #71, and #89) out of four residents reviewed for wounds. The facility census was 117. Findings include: 1. Review of the medical record for Resident #51, revealed an admitted [DATE]. Diagnoses included: moderate protein-calorie malnutrition, vascular dementia, unspecified severity, without behavioral disturbance, psychosis disturbance, mood disturbance and anxiety, and end stage renal disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of resident is rarely/never understood. The resident was assessed to be dependent with all bed mobility. Review of nursing admission skin assessment for Resident #51 dated 10/20/23 revealed three wounds. Wound #1 was sacrococcygeal moisture-associated skin damage (MASD), wound #2 was a left heel stage 1 (an observable, pressure- related alteration of intact skin whose indicators may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the injury may appear with persistent red, blue, or purple hues) pressure ulcer and wound #3 was a right heel stage 1 pressure ulcer. Review of treatment administration record (TAR), progress notes, and skilled nurse's notes, for Resident #51 revealed no documentation on wound treatments for all three wounds upon admission until 10/22/23 and resident was sent to out to the hospital on 10/23/23. Review of nursing readmission skin assessment for Resident #51 dated 11/07/23 revealed three wounds. Wound #1 a sacrum stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer, wound #2, a surgical site to the abdomen and wound #3, a right heel deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). Review of physician order for Resident #51 dated 11/08/23 revealed encourage/assist resident to turn and reposition as tolerated every shift. Review of nursing wound assessments for Resident #51 dated 11/09/23 revealed 6 wounds. Wound #3 was now a right shoulder unstageable (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound.) wound, wound #5 a left heel deep tissue injury, wound #6 left buttock unstageable pressure ulcer and wound #7 a right buttock stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) pressure ulcers were not documented on the readmission skin assessment dated [DATE] and all stated they were acquired on admission. Review of physician's order for Resident #51 start date 12/29/23 revealed clean patient sacrum with normal saline and pack with 3 sheets of calcium alginate, then pack with fluff gauze, cover 4 ABD's secure with tape and apply triad paste to surrounding areas. every shift for wound care Review of the TAR for January 2024 for Resident #51 revealed missing treatments for the sacrum wound for day shift on the following dates: 01/20/24, 01/21/24 and 01/22/24 and for night shift on the following dates: 01/01/24, 01/04/24, 01/05/24, 01/08/24, 01/13/24, 01/14/24, 01/18/24 and 01/19/24. Review of readmission skin assessment for Resident #51 dated 02/04/24 revealed three wounds. Wound #1 a coccyx stage 2 pressure ulcer, wound #2 a sacrum stage 4 pressure ulcer and wound #3 was a skin tear. Review of nursing wound assessment for Resident #51 dated 02/05/24 revealed four wounds. Wound #1 a sacrum stage 4 pressure ulcer, wound #4 a right heel unstageable pressure ulcer, wound #5 a left heel unstageable pressure and wound #6 a right buttock stage 3 (full-thickness tissue loss into subcutaneous tissue but does not go into the muscle or bone) pressure ulcer and were all acquired on admission. Observation of Resident #51 on 03/11/24 revealed at 8:56 AM, 10:58 AM, and 2:15 PM the resident was on her back in bed. Observation of Resident #51 on 03/11/24 revealed at 9:12 AM, 11:14 AM and 3:23 PM the resident was on her back in bed. Interview on 03/11/24 at 3:24 P.M. with State tested Nursing Aide (STNA) #313 revealed Resident #51 was on her back and had not been turned. STNA #313 was also unable to verbalize how often to turn and reposition residents. Review of the TAR for March 2024 revealed documentation of turning and repositioning resident on day shift for 03/07/24 and 03/11/24 during day shift hours. Interview on 03/12/24 at 10:49 A.M. with Licensed Practical Nurse (LPN) #195 verified Resident #51's readmissions to the facility did not contain all the residents' wounds as the facility required and verified missing treatments for the month of January with no explanation as to why they were missed. Reviewed the missing treatments for Resident #51 for admission on 10/20/23 and stated, That was a weekend, so the floor nurse should have called the physician for orders until Monday, and it looks like she didn't do that. 2. Review of the medical record for Resident #89, revealed an admitted [DATE]. Diagnoses included: quadriplegia, chronic respiratory failure, and latent syphilis. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 15 out of 15. The resident was assessed to be dependent with all care including toileting and rolling left and right in bed and was assessed to have one or more unhealed pressure ulcer: one stage 3 that was present upon admission. Review of admission skin assessment for Resident #89 dated 09/15/23 revealed six wounds. Wound #1 a right posterior calf stage 3 pressure ulcer, wound #2 a left heel unstageable pressure ulcer, wound #3 a posterior head stage 2 pressure ulcer, wound #4 a sacrum stage 1 pressure ulcer, wound #5 a left ear stage 2 pressure ulcer and wound #6 a right buttock non pressure blister. Review of readmission skin assessment for Resident #89 dated 10/09/23 revealed five wounds. Wound #1 a left heel unstageable pressure ulcer, wound #2 a right posterior upper calf stage 2 pressure ulcer, wound #3 a sacrum stage 1 pressure ulcer, wound #4 left (unidentified) stage 2 pressure ulcer and wound #5 a right buttock stage 1 pressure ulcer. Review of nursing wound assessment for Resident #89 dated 10/12/23 revealed five wounds but did not include wound #5 right buttock stage 1 pressure ulcer and included a wound #4 posterior head unstageable pressure ulcer documented as being acquired on admission. Review of nursing wound assessment for Resident #89 dated 10/19/23 revealed no documentation on the right buttock stage 1 pressure ulcer documented on readmission. Review of readmission skin assessment for Resident #89 dated 10/24/23 revealed three wounds. Wound #1 a left heel unstageable pressure ulcer, wound #2 a right posterior upper calf stage 1 pressure ulcer, and wound #3 a sacrum stage 2 pressure ulcer. Review of physician's order for Resident #89 dated 10/26/23 revealed encourage/assist to turn and reposition as tolerated every shift. Review of nursing wound assessments for Resident #89 dated 11/02/23 revealed three wounds but did not include wound #3 a sacrum stage 2 pressure wound and included a wound #6 left ear stage 3 pressure ulcer. Review of nursing wound assessments for Resident #89 dated 11/09/23 revealed two wounds. Wound # 6 the left ear stage 3 pressure ulcer was not documented on. Review of Resident #89's progress notes, skilled nursing notes and MAR and TAR for November and December 2023 revealed no documentation of refusal of care. Review of dietary note for Resident #89 dated 01/11/24 revealed current diet provides adequate kcal/protein to promote wound healing. Review of nursing wound assessment for Resident #89 dated 01/18/24 revealed right posterior calf 6.7 centimeters (cm) X 3.1 cm X .4 cm to be a stage 3 pressure ulcer. Review of nursing wound assessment for Resident #89 dated 01/25/24 revealed right posterior calf 15.2 cm X 6.8 cm X .5 cm to be a stage 4 pressure ulcer. Review of dietary note for Resident #89 dated 01/25/24 revealed current diet provides adequate kcal/protein to promote wound healing. Review of progress notes, skilled nurse's notes, MAR and TAR for Resident #89 revealed no documentation of injury and refusal of care occurring to the right posterior calf to worsen wound between the dates of 01/18/24 to 01/25/24. Observation of Resident #89 on 03/06/24 revealed the resident was on back in bed at 9:50 A.M., 11:52 A.M. and 2:15 P.M. Observation of Resident #89 on 03/07/24 revealed the resident on back in bed at 9:02 A.M., 10:31 A.M. and 2:14 P.M. Observation of Resident #89 on 03/11/24 revealed resident on back in bed at 9:34 A.M., 11:45 A.M. and 3:31 P.M. Interview on 03/11/24 at 9:09 A.M. with LPN #204 revealed unsure of how often residents should be turned and repositioned on the ventilator unit and was the nurse for part of the hall for the day. Interview on 03/11/24 at 3:32 P.M. with Resident #89 revealed she had not been turned on today and does not get turned on often by the staff. Denied refusing care for wound and turning and wanted to be turned on her side. Interview on 03/11/24 at 3:46 P.M. with LPN # 204 revealed Resident #89 wanted to be turned and verified she had not been today and stated, I will get an aide to do that. Interview/Observation on 03/11/24 at 4:12 P.M. with Resident #89 revealed the resident on her back and stated, I have not been turned yet. Interview on 03/11/24 at 4:13 P.M. with LPN #204 revealed Resident #89 had not been turned yet and stated, the aide is on break, we will get to it when we do, have a good day. Interview on 03/12/24 at 10:46 P.M. with LPN #195 verified for Resident #89 the discrepancies with documentation from the resident's readmission skin assessments to the weekly wound assessments. Also verified the residents wound worsened on the dates of 01/18/24 to 01/25/24 and denied the resident refuses care and stated sometimes, she wants us to come back at a different time, but she has never refused wound care for me. Verified the readmission assessments should match the weekly wound assessments and verified wounds are typically healed out so the facility can keep track but confirmed wound #5 right buttock stage 1 pressure ulcer and wound #3 a sacrum stage 2 pressure wound were healed out for the resident. 41266 3. Review of the medical record for Resident #71 revealed an initial admitted on 01/29/24 and a discharge date on 03/08/24. Medical diagnoses included chronic respiratory failure with hypoxia, asthma, dependence on respirator (ventilator) status, tracheostomy status, anoxic brain damage, and persistent vegetative state. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 was in a persistent vegetative state with no discernible consciousness. Resident #71 was totally dependent on one to two staff to complete all Activities of Daily Living (ADLs). Resident #71 required suctioning, tracheostomy care, invasive mechanical ventilator, intravenous medications, intravenous access, and oxygen. Resident #71 had one facility acquired unstageable pressure ulcer noted in the assessment. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #71 had four stage 3 pressure ulcers present upon admission or readmission and three unstageable pressure ulcers present upon admission or readmission. Review of Resident #71's census revealed the resident was hospitalized from 01/13/24 to 01/29/24. Review of the progress note dated 01/29/24 at 5:24 P.M. revealed Resident #71 arrived in the facility at 5:10 P.M. The resident received care at the hospital. A routine assessment was completed on arrival. The progress note did not specify any pressure ulcers identified during the routine assessment of the resident. Review of a Clarification Progress Note dated 01/31/24 at 11:05 A.M., entered by Wound Licensed Practical Nurse (WLPN) #195, revealed clarification of Resident #71's admitting skin assessment. Resident #71 exhibited pressure on the left first knuckle that is (stage 3), left thumb that is (unstageable), right heel (Deep Tissue Injury or DTI), left heel (unstageable), lower right shin area (stage 3), sacrum that is (unstageable), right lateral side (stage 3), and right upper back (stage 3). No further details about these pressure areas were included in the note. Review of the Skin Grid-Pressure dates for Resident #71 revealed there were not any skin grids completed between 01/11/24 and 02/01/24 (three days after Resident #71 was readmitted to the facility). Review of the Skin Grid-Pressure assessments for Resident #71's pressure ulcer on the right heel dated 02/01/24, 02/08/24, and 02/15/24 and completed by Wound Licensed Practical Nurse (WLPN) #195 revealed discrepancies when compared to WCNP #330's notes. The assessment on 02/01/24 revealed an unstageable pressure ulcer to Resident #71's right heel which measured 4.1 centimeters (cm) long by 6.9 cm wide by an unable to be determined (UTD) depth. The area had scant eschar (dead tissue) and was debrided. After debridement a depth of 0.4 cm was determined. There was no indication of the wound treatment recommendation. On 02/08/24, the right heel remained an unstageable pressure ulcer which measured 4.1 cm long by 6.9 cm wide by UTD depth. The area had scant eschar and was debrided. Post debridement, a depth of 0.4 cm was determined. The area consisted of 15% tendon, 80% granulation, and 5% eschar or slough. There was no indication of wound treatment recommendation. On 02/15/24, the right heel remained an unstageable pressure ulcer which measured 3.3 cm long by 3.8 cm wide by UTD depth. There was no further information related to treatment of the wound indicated. Review of WCNP #330's notes on Resident #71's pressure ulcer on the right heel dated 02/01/24, 02/08/24, and 02/15/24 revealed on 02/01/24, WCNP #330 noted the area to be an unstageable pressure ulcer which measured 4.1 cm long by 6.9 cm wide by an UTD depth. The area was debrided down to the tendon and a depth of 0.4 cm was determined post-debridement. There was moist eschar present and the area was unstable. WCNP #330 recommended anasept and oil emulsion first, then cleanse with normal saline (NS), pack the wound with alginate, apply barrier cream, cover with an abdominal (ABD) pad, wrap with kerlix. The treatment was to be completed daily and as needed. On 02/08/24, WCNP #330 noted an unstageable pressure ulcer which measured 3.6 cm long by 5.4 cm wide by UTD depth. The area had moderate gray slough and was debrided to the tendon. A post-debridement depth was not indicated. The periwound was macerated. WCNP #330 recommended to stop oil emulsion. Apply anasept first, cleanse with NS, pack with alginate, apply barrier cream, cover with ABD pad, and wrap with kerlix. Offload with heel boots daily and as needed (prn). On 02/15/24, WCNP #330 noted an unstageable pressure ulcer with visible tendon which measured 3.3 cm long by 3.9 cm wide by UTD depth. The area was 80% granular, 15% tendon, and 5% slough with a macerated periwound. The area was debrided and slough was removed. No treatment order changes were recommended. Review of the TAR dated January 2024 and February 2024 revealed a wound treatment for Resident #71's right heel was not implemented until 02/05/24 (seven days after readmission and four days after WCNP #330 completed assessment). The treatment order started on 02/05/24 and discontinued on 02/07/24, did not include to pack the wound with alginate or apply barrier cream. No treatment was administered on 02/08/24. The treatment administered from 02/09/24 through 03/05/24 was to cleanse with NS, apply anasept gel first then apply calcium alginate (not silver alginate), cover with ABD and wrap with kerlix every day shift for wound care. Review of the Skin Grid-Pressure assessments for Resident #71's pressure ulcer to her right shin dated 02/01/24, 02/08/24, 02/15/24, 02/22/24 and 02/29/24 revealed discrepancies when compared to WCNP #330's wound notes. On 02/01/24, a stage III pressure ulcer to the right shin was identified which measured 1.2 cm long by 1.4 cm wide by 0.1 cm deep. No treatment order was indicated. On 02/08/24, measurements were 1.2 cm long by 1.4 cm wide by 0.1 cm deep. On 02/15/24, measurements were 1.2 cm long by 1.4 cm wide by 0.1 cm deep. On 02/22/24, there was no indication of treatment change being recommended. On 02/29/24, measurements were 0.9 cm long by 0.9 cm wide by UTD depth. There was no indication of the area opening or a treatment change recommendation. Review of WCNP #330's wound notes for Resident #71's pressure ulcer to her right shin dated 02/01/23, 02/08/24, 02/15, 24, 02/22/24, and 02/29/24 revealed a stage III pressure ulcer area to the resident's heel was initially assessed on 02/01/24 which measured 1.2 cm long by 1.4 cm wide by 0.1 cm deep. A treatment to apply triad daily and as needed was recommended. On 02/08/24, measurements were 0.9 cm long by 1.4 cm wide by UTD depth with scabbing noted. On 02/15/24, measurements were 1.1 cm long by 1.1 cm wide by UTD depth with dry scab noted. On 02/22/24, a recommendation to apply betadine daily was recommended. On 02/29/24, measurements were 0.9 cm long by 0.9 cm wide by 0.1 cm deep. The area opened this week. A treatment to apply triad paste and cover with a silicone dressing daily was recommended. Review of the TAR dated January 2024 and February 2024 revealed no treatment orders were implemented until 02/01/24 (three days after readmission) for Resident #71's right shin. From 02/01/24 to 02/04/24, an order to apply triad, cover with ABD pad and wrap with kerlix was implemented (which did not match WCNP #330's recommended treatment). The recommendation to apply betadine daily was not implemented. The treatment ordered from 02/05/24 and discontinued on 03/05/24 was to cleanse right shin with normal saline (NS), pat dry, apply triad paste, and leave open to air every day shift. The treatment recommended on 02/29/24 was not implemented until 03/06/24. Review of the Skin Grid-Pressure assessment for Resident #71's pressure ulcer on the left first knuckle and completed by WLPN #195 dated 02/01/24 and 02/29/24 revealed discrepancies when compared to WCNP #330's wound notes. On 02/01/24, the area was identified as a Stage III pressure ulcer which measured 1.1 cm long by 0.4 cm wide by 0.4 cm deep. No treatment orders were indicated. On 02/29/24, the area measured 0.6 centimeters (cm) long by 0.8 cm wide by 0.2 cm deep. The wound was noted as improved. There was no indication of the area opening or a wound treatment change recommended. Review of the Wound Certified Nurse Practitioner (WCNP) #330's note dated 02/01/24 noted the area was initially assessed and found to be a Stage III pressure ulcer which measured 1.1 cm long by 0.4 cm wide by 0.4 cm deep. A treatment to apply triad daily and as needed and offload was recommended. On 02/29/24, Resident #71's stage III pressure ulcer on her left first knuckle measured 0.6 cm long by 0.8 cm wide by 0.2 cm deep. The area was noted to have opened this week. WCNP #330 recommended a treatment change to apply triad with a silicone dressing daily and as needed. Review of the TAR dated January 2024 and February 2024 revealed no wound treatment was implemented for Resident #71's left first knuckle until 02/05/24 (six days after readmission and four days after WCNP #330's recommendation). The treatment administered from 02/05/24 to 03/04/24 was to cleanse left first knuckle with NS, pat dry and apply triad paste, leave open to air every day shift. The treatment change recommendation made by WCNP #330 was not implemented until 03/05/24. Review of the Skin Grid-Pressure assessments for Resident #71's stage III pressure ulcer to her upper back dated 02/01/24, 02/08/24, and 02/15/24 and completed by WLPN #195 revealed discrepancies when compared to WCNP #330's wound notes. On 02/01/24, the area measured 6.1 cm long by 4.2 cm wide by 0.1 cm deep. There was no indication of a treatment order. On 02/08/24, the area measured 6.8 cm long by 3.6 cm wide by 0.1 cm deep. There was no indication of a wound treatment change being recommended. On 02/15/24, the area measured 6.8 cm long by 3.6 cm wide by 0.1 cm deep. There was no indication of a wound treatment change being recommended. Review of WCNP #330's wound notes for Resident #71's stage III pressure ulcer to her upper back dated 02/01/24, 02/08/24, and 02/15/24 revealed on 02/01/24, the area was noted to be possibly a shear skin injury. A treatment to apply silver alginate and a foam dressing on Tuesday, Thursday, and Saturday and as needed (prn) was recommended. On 02/08/24, increased drainage was noted. A recommendation to stop the foam dressing and increase to daily dressing changes was made. The treatment to apply silver alginate and cover with an abdominal (ABD) pad daily and as needed was recommended. On 02/15/24, measurements were 7.3 cm long by 3.9 cm wide by 0.2 cm deep were noted. Heavy drainage was noted. A treatment change to apply triad first, pack with silver alginate and cover with ABD pad daily and prn was recommended. Review of the TAR dated January 2024 and February 2024 revealed no wound treatment for Resident #71's upper back to apply triad paste and cover with foam was administered from 02/01/24 to 02/04/24. This treatment did not match the recommended treatment by WCNP #330. No wound treatment was administered on 02/05/24. From 02/06/24 to 02/08/24, triad paste and foam Tuesday, Thursday, and Saturday was implemented. This did not match WCNP #330's recommendation. From 02/09/24 to 03/05/24, triad paste and ABD pad daily was administered to Resident #71. This did not match WCNP #330's recommendation to add silver alginate. Review of the Skin Grid-Pressure assessments of Resident #71's unstageable pressure ulcer to her coccyx dated 02/01/24, 02/08/24, and 02/29/24 and completed by WLPN #195 revealed discrepancies with WCNP #330's wound notes. On 02/01/24, there was no indication of a wound treatment recommendation. On 02/08/24, the measurements were 3.1 cm long by 4.2 cm wide by UTD depth. On 02/29/24, the area was noted to be unstageable with 95% granular and 5% tendon. Review of WCNP #330's wound notes of Resident #71's unstageable pressure ulcer to her coccyx dated 02/01/24 revealed a treatment recommendation to pack with silver alginate, cover with foam dressing, daily and leave open to air as well as offload were made. On 02/08/24, measurements were 3.4 cm long by 4.1 cm wide and UTD depth. On 02/29/24, the area was staged as a Stage IV pressure ulcer with visible tendon. Measurements were 1.9 cm long by 2.9 cm wide by 0.3 cm deep. There was 95% granulation and 5% tendon. Review of the TAR dated January 2024 and February 2024 revealed there was not an accurate wound treatment for Resident #71's coccyx wound per WCNP #330's recommendations implemented. A treatment of calcium alginate and foam dressing was implemented from 01/30/24 to 03/05/24. The recommendation was to pack the wound with silver alginate. Additionally, there was a delay in implementing wound treatments for Resident #71's pressure areas to her left heel DTI (not implemented until 02/05/24) and lower back (received inaccurate treatment from 02/05/24 to 02/07/24 and then the recommended treatment on 02/01/24 was implemented on 02/09/24). Interview on 03/07/24 at 11:49 A.M. with WCNP #330 confirmed Resident #71's pressure ulcer areas that were identified in the discharge paperwork on 01/29/24 and identified by WLPN #195 were not fully assessed until 02/01/24. WCNP #330 confirmed treatment order recommendations would be expected to be implemented immediately. WCNP #330 confirmed she and WLPN #195 completed wound rounds together weekly and their assessments should match. Interview on 03/07/24 at 4:28 P.M. with WLPN #195 confirmed there was a delay in identifying all of Resident #71's pressure ulcer areas after she was readmitted on [DATE]. WLPN #195 confirmed the admitting nurse on 01/29/24 did not identify all of the areas. WLPN #195 confirmed she did not note wound treatment recommendations made by WCNP #330 in the resident's wound assessments. WLPN #195 also did not note any wound treatment changes recommended by WCNP #330. WLPN #195 confirmed there were delays in implementing wound treatments for Resident #71 after readmission as well as wound treatments ordered which did not match the recommendations from WCNP #330. Interview on 03/11/24 at 3:37 P.M. with the Director of Nursing (DON) revealed she did not provide any oversight or assistance with resident wounds. The DON stated WLPN #195 and WCNP #330 handled all the facility's wounds. The DON confirmed there were delays in implementing wound treatments for Resident #71 after readmission. The DON confirmed all pressure areas and non-pressure areas should have been identified by the admitting nurse and a treatment should have been started. The DON confirmed there was no evidence WLPN #195 had consulted with WCNP #330 in the resident's record. Review of the facility policy, Nursing Assessments, dated 03/01/24, revealed the policy stated, Licensed nurses ensure assigned nursing assessments are completed timely by evaluating residents as scheduled and per the resident needs. Licensed nurses collaborate with other members of the healthcare team to ensure appropriate interventions related to data collected for completion of nursing assessments are in place and documented per facility policy. Review of the facility policy, Skin Assessment, dated 09/2107, revealed the policy stated, at the time of admission/re-admission, the resident is evaluated for special needs related to skin care. Residents receive a weekly skin integrity check performed by licensed personnel. Resident response to preventative efforts is monitored and evaluated. Approaches are revised as appropriate. Areas of alteration in skin that are present, or which develop subsequently to admission, are treated according to medical direction and are conscientiously followed. Review of the facility policy, Skin Evaluation, revised 03/01/24, revealed the policy stated, Licensed nurses may collect patient data that includes the LPN's observation, measurement, and comparative analysis of a wound to a staging chart, and document the observation, measurement and comparative analysis in accordance with recognized standards of practice.

Based on closed medical record review, staff interview and review of the facility Skin Assessment policy, the facility failed to ensure accurate and on-going skin assessments (monitoring) were completed to timely identify and implement treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred on 02/01/21 when Resident #120, who was cognitively impaired and required extensive assistance to total dependence on staff for activities of daily living was found to have eight new areas of non-pressure related skin impairment upon transfer back to her previous nursing home residence which had not been identified by the facility. The resident was transferred from the facility without evidence of a comprehensive skin assessment being completed at the time of discharge. In addition, there was no evidence the facility investigated the development of these areas upon notification of them from the receiving facility to determine when or how they had occurred and to ensure timely treatment had been as implemented. This affected one resident (#120) of three residents reviewed for skin impairment. Findings include: Review of the closed medical record for Resident #120 revealed the resident was admitted to the facility on [DATE] due to testing positive for COVID-19. The resident had resided in a long term care facility prior to her admission to this facility, however that facility did not provide care for COVID-19 positive residents resulting in her transfer. Resident #120 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was transferred from the facility on 02/01/21 back to her previous nursing home residence following the completion of her isolation for COVID-19. Record review revealed the resident was cognitively impaired. Review of the admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed Resident #120 had a treatment order for an arterial ulcer to the left lateral heel to be completed daily. The treatment order was for the ulcer to be cleansed with normal saline, patted dry, and Iodosorb (sterile antimicrobial to absorb fluid, to remove exudate, slough and debris) paste was to be applied to the wound bed and covered with a clean, dry dressing daily. The resident had an order to check circulation below a cast to the right lower leg every shift. And an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the facility admission skin assessment, dated 01/21/21 at 1:59 P.M. revealed Resident #120 had no pressure ulcers or non-pressure skin impairment present. On 01/22/21 unit manager Licensed Practical Nurse (LPN) #500 entered a medication administration note indicating there was no area present to the resident's left heel. However, review of the treatment administration record (TAR) revealed staff completed a treatment to this area on 01/23/21, 01/24/21, 01/25/21, and 01/27/21. There were no corresponding assessments/description of any type of area on the four days the treatment was documented as being completed. In addition, on 01/25/21 at 6:59 A.M. a new order was obtained for a treatment to Resident #120's left heel. The order indicated the area was to be cleansed with soap and water, patted dry and a foam dressing applied every shift. There was no assessment of the area on this date completed. Review of a skin grid-non-pressure form, dated 01/25/21 at 6:53 A.M. revealed Resident #120 had a new skin tear to the left shin that measured 3.0 centimeters (cm) long, 2.0 cm wide and was less than 0.1 cm deep. A treatment order was obtained for treatment every shift. The area was re-assessed on 01/27/21 at 10:21 A.M. and measured 3.0 cm long by 2.0 cm wide with less than 0.1 cm depth. The area was described as being scabbed at that time. Review of skin grid-non-pressure form, dated 01/25/21 at 6:55 A.M. revealed Resident #120 had a new skin tear to the left heel that measured 3.5 cm long, 1.7 cm wide, and was less than 0.1 cm deep. A treatment order was obtained for treatment every shift. The area was re-assessed on 01/27/21 at 10:21 A.M. and measured 3.5 cm long, 1.7 cm wide, and was less than 0.1 cm deep. The area was described as scabbed at that time. Record review revealed no evidence the facility investigated to determine the cause or circumstances surrounding the identification of or development of the skin tears to the resident's left shin or left heel. Review of a skin grid-non-pressure form, dated 01/27/21 at 10:23 A.M. revealed Resident #120 had a skin tear to the right knee that measured 2.1 cm long, 2.0 cm wide, and was less than 0.1 cm deep. The area was scabbed and had no signs of infection. Record review revealed the resident had been admitted with this area. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 01/28/21 revealed Resident #120 had severely impaired cognition. The resident required extensive assistance of one staff member for bed mobility, toilet use and personal hygiene. Resident #120 was assessed to require extensive assistance from two staff for transfers. The MDS also revealed Resident #120 had impairment to one side of lower extremity. Review of the plan of care, dated 01/29/21 revealed Resident #120 had alteration in skin integrity as evidenced by skin tears present to left shin, left heel, and right knee. Interventions included to assess areas for size, color, and drainage as needed, weekly and as needed body checks, encourage and assist resident to elevate heels off bed as tolerated, encourage and assist resident to turn and reposition as needed, and notify physician and family of changes as needed. Review of health status note, dated 02/01/21 at 2:30 P.M. revealed Resident #120 was discharged from the facility to another long term care facility. Record review revealed no evidence of any skin assessments being completed for the resident with the exception of those noted above or at any time between 01/28/21 and 02/01/21. At the time of discharge, the resident was receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission note dated 02/01/21 at 3:00 P.M. from facility Resident #120 was discharged to revealed the resident had arterial ulcers to the left shin, top of the left foot, all five digits of her left toes, left inner ankle, left inner foot, left great toe and left heel. Review of documentation provided by the receiving nursing facility revealed an admission skin assessment, dated 02/01/21 at 7:36 P.M. which reflected Resident #120 had the following non-pressure ulcer areas present (in addition to the area to the left shin noted above): An area to the left heel that measured 5 cm long and 4.5 cm wide. The wound had clear red drainage with a black arterial ulcer in wound bed. An area to the left foot that measured 6 cm long by 2.5 cm wide. The area was scabbed with redness around it. An area to the inner left ankle that measured 3.5 cm long and 2.5 cm wide. The area was open with clear drainage and redness around it. An area to the left inner foot that measured 3 cm long and 1.1 cm wide. The area was scabbed with redness around it. An area to the second toe on her left foot that measured 1.2 cm long and 1 cm wide. The area was scabbed with redness around it. An area to the third toe on the left foot that measured 1.5 cm long and 0.8 cm wide. The area was scabbed with redness around it. An area to the fourth toe on to left foot that measured 1.5 cm long and 1.3 cm wide. The area was scabbed with redness around it. An area to the left hallux (big toe) that measured 1 cm long and 1 cm wide. The area was scabbed with redness around it. On 03/01/21 at 4:40 P.M. interview with Registered Nurse (RN) #360 revealed he had provided care for Resident #120. RN #360 stated he remembered Resident #120 had multiple bruises and skin issues when she was admitted but could not recall where the areas were or what they looked like. During the interview, RN #360 revealed the unit manager, LPN #500 was responsible for wound care for the residents on the COVID unit but stated she seemed overwhelmed with her job duties. On 03/02/21 at 10:10 A.M. interview with facility Wound Nurse #250 revealed she did not go to the COVID-19 positive unit to do wound care and therefore did not assess or provide treatment to Resident #120 during her stay in the facility (from 01/21/21 through 02/01/21). On 03/02/21 at 10:25 A.M. interview with the Director of Nursing (DON) revealed after Resident #120 was discharged on [DATE] she received a call from the receiving facility related to skin impairment to the resident's left leg. The DON stated she asked LPN #500, who was the unit manager on the unit Resident #120 resided on about the areas and the LPN denied knowledge of them. However, LPN #500 no longer worked at the facility as of this date. During the interview, the DON verified the facility failed to identify or have any assessments of the areas of skin impairment noted by the receiving facility prior to her discharge. The DON verified a skin assessment had not been completed at the time of the resident's discharge and the last documented skin assessment completed for the resident was on 01/28/21 at which time only a Stage II pressure ulcer was identified to the resident's right thigh. On 03/02/21 at 11:53 A.M. interview with LPN #310 revealed she provided care for Resident #120 but could not recall what skin issues the resident had. During the interview, LPN #310 revealed the unit manager, LPN #500 was responsible for wound management but seemed overwhelmed with her duties. On 03/02/21 at 2:07 P.M. interview with RN #345 revealed she had provided care for Resident #120 during her stay in the facility. The RN recalled completing dressing changes but could not remember what the wounds the resident had looked like or where they were. On 03/03/21 at 1:54 P.M. interview with State tested nursing assistant (STNA) #375 revealed she had cared for Resident #120 during her stay in the facility. The STNA revealed the resident would often lay curled up and would rub her left foot on the cast that was on her right leg. STNA #375 revealed she was aware some of the skin on Resident #120's left toes had come off due to her rubbing it. STNA #375 stated she reported the areas to the nurse (date not provided) but was not sure if treatments were being done. Review of the facility Skin Assessment policy and procedure, revised 09/2017 revealed at the time of admission/re-admission the resident was evaluated for special needs related to skin care. The resident received a weekly skin integrity check performed by the licensed nurse and daily skin checks were completed with activity of daily living (ADL) care. The policy included, on an ongoing basis, factors placing the resident at risk for developing an ulcer, including specific conditions, causes and/or problems, needs and behaviors were assessed and interventions for preventing development were defined and implemented in accordance with the resident's needs, goals and recognized standards of practice. This deficiency substantiates Complaint Number OH 087.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, staff interview, review of facility investigation, review of Complete Intravenous Access Services Inc. (CIAS) contracts and policies and procedures, the facility failed to prevent a resident from receiving a peripheral vascular access device (Midline intravenous catheter) without a physicians order. Actual harm occurred when Resident #1 received a Midline which was intended for Resident #2, who had the same last name. This affected one (Resident #1) of three residents reviewed for intravenous lines and labs/services through contracted agencies. A PICC line poses the risk for intravenous infection. The facility census was 129. Findings Include: Review of the medical record for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/26/19, revealed Resident #1 required total dependence on two staff for transfers and total dependence on one staff for locomotion via wheel chair. Resident #1 had a Brief Interview of Mental Status (BIMS) of 00 indicating severely impaired cognition. Review of the plan of care revealed Resident #1's cognitive function was altered/cognitively, compromised related to mentally retarded developmentally disabled (MRDD) diagnosis. He was rarely understood and rarely understands and he did not speak. Interventions included announce self and all procedures prior to starting care, be patient with resident and be consistent with daily routine. Review of physician orders [REDACTED].#1 had an order to discontinue the Midline in the right arm on 03/30/19. The medical record contained no orders to insert the Midline. Review of the medical record for Resident #2 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 03/28/19, revealed Resident #1 required total dependence on two staff for transfers and total dependence on one to two staff for care. Resident #2 had severely impaired cognition. Review of the plan of care revealed Resident #2 was at risk for complications related to current health conditions. Interventions included administer medications as ordered, complete intravenous (IV) procedures and care per facility policies, flush IV per physician orders [REDACTED]. Review of physician orders [REDACTED].#2 had and order to insert a Midline for 30 days on 03/29/19 which was documented as completed. Review of the Lippincott Nursing Center website revealed Midline catheters vary in length and are inserted in the middle third of the upper arm and advanced and placed so the catheter tip is level or near the level of the axilla and distal to the shoulder. Midline catheters are inserted by clinicians using aseptic technique, most often with the use of maximal sterile barrier precautions. Review of the nursing progress notes dated 03/29/19 for Resident #1 revealed a Midline was inserted into his right arm that was not ordered to be inserted. The physician and responsible party were both notified, and a new order was received to discontinue the Midline. Nurse notes dated 03/30/19 revealed Resident #1 was monitored regarding the incident. Attempted interviews with Residents #1 and #2 on 04/22/19 from 8:03 P.M. through 10:05 P.M. revealed both residents were not interviewable. Resident #1's PICC line site was no longer visible and his first and last name were posted outside of his door. An interview on 04/22/19 at 8:07 P.M. with Licensed Practical Nurse (LPN) #33 revealed Residents #1 and Resident #2 had the same last name and the same room number but were located on different units. Interviews on 04/22/19 at 9:05 P.M. with the Director of Nursing (DON) and Corporate Registered Nurse (RN) #34 revealed outside venders/contracted services were supposed to go to the nurses' station to verify the resident, date of birth, and orders before going to the resident's room. In this case CIAS RN #30 went into Resident #1's room without checking with the nurse or checking his name. They stated all three nurses that night LPN) #36, LPN #37 and RN #38 realized what was going on about the same time and came together to resolve the problem. Review of the witness statement, dated 04/01/19, revealed RN #38 stated CIAS RN #30 went into Resident #1's room without asking if it was the right resident. He signed the consultant service paperwork after he completed the procedure. He stated he signed it because the procedure was already done. RN #38 asked LPN #37 if Resident #1 was supposed to have a Midline and she said no. RN #38 stated that's when the facility called the CIAS company to let them know it was the wrong resident. Resident #1 was not on CIAS RN #30's assignment. Review of the witness statement, dated 04/02/19, revealed LPN #37 went into Resident #1's room around 9:45 P.M. and noted the resident had a line in his right arm. She immediately notified the physician and received a new order to remove the Midline. She stated another nurse had told her that the CIAS employee went into Resident #1's room and placed the Midline prior to getting any orders or demographics from the nurse. LPN #37 had never seen CIAS RN #30 until he returned later that evening to remove the Midline around 12:00 A.M. She stated she immediately assessed Resident #1 and notified his family via voice mail. Review of the witness statement, dated 04/02/19, revealed LPN #36 received a fax from CIAS between 8:00 P.M. and 9:00 P.M. related to a procedure that was completed on Resident #1 who was not on her side of the building (she had been waiting on her resident (Resident #2) to receive the Midline). She looked into Resident #1's chart and saw there was no order for the Midline for the resident. LPN #36 notified LPN #37 and LPN #37 and stated CIAS RN #30 had placed the Midline in Resident #1 without verifying with any staff. The facility called CIAS and notified them of the issue and the intake personnel stated that her technician must have gotten the patients confused with the same last name and room number. Review of the witness statement, dated 04/02/19, revealed State tested Nurse Assistant (STNA) #39 greeted CIAS RN #30 and asked if he needed any help. CIAS RN #30 asked where Mr. (last name stated) room was. STNA #39 pointed to his room and stated he is the first bed by the door. At that time STNA #39 continued to provide care to her other residents. She further stated she never saw CIAS RN #30 speak to any other staff until after the procedure was completed. Observations on 04/22/19 from 7:20 P.M. through 11:00 P.M. revealed all staff were observed with name tags on with large bold letters stating their titles (STNA, LPN, RN, etc.). An interview on 04/22/19 at 8:07 P.M. with LPN #33 revealed it took a long time to have the Midline removed because they had to wait on the appropriate staff (a CIAS RN) to remove the catheter. Review of the CIAS Consultant Service form revealed CIAS RN #30 completed the Midline insertion on 03/29/19 from 8:00 P.M. through 9:00 P.M. It indicated CIAS RN #30 took a time-out and observed the orders and two patient identifiers. Review of the contract for CIAS, dated 09/01/17, revealed CIAS was responsible for verifying physicians' orders and obtaining informed consent for services provided by an RN qualified in infusion therapy administration. Review of the CIAS policy titled, Vascular Access Services, undated, revealed upon arrival to the facility, the vascular access nurse would communicate with the patient's nurse or unit supervisor before entering patient care areas. It also revealed the facility nurse would provide the vascular access nurse access to the patient's medical record for review prior to performing any vascular access procedure. Review of CIAS Corrective Action Plan, dated 04/03/19, revealed CIAS Nurse #30 inserted a Midline catheter into the incorrect resident on 03/29/19. He was educated on verifying the correct resident by name by completing a time-out procedure which includes: verify, by viewing, the physician order [REDACTED]. This deficiency substantiates Complaint Number OH 671. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 04/17/19: -On 03/29/18 at 9:45 P.M., LPN #37 discovered the PICC line in Resident #1's right arm and immediately notified the physician to get an order to remove the PICC line. The resident was assessed provided treatment. -On 03/30/19 at 12:00 A.M., another CIAS RN removed the PICC line from Resident #1's right arm. -On 04/01/19, an initial audit was completed on current residents for IV line insertion. There were no other residents with orders for new IV lines to be placed by CIAS. -On 04/03/19, CIAS RN #30 was educated by the CIAS CEO on verifying physician orders [REDACTED]. -On 04/01/19 to 04/04/19, all licensed nurses were educated by the DON on verifying physician's orders [REDACTED]. The nurses' education included verifying the resident's full name, room number, date of birth, and physician's orders [REDACTED]. -On 04/04/19, 04/09/19, 04/11/19, 04/15/19 and 04/17/19, audits were conducted regarding the nurses being able to correctly verbalize the need to verify orders prior to a vender providing any procedure. No concerns were identified at time of audits.

Based on medical record review, review of the facility's policy entitled "Cardio-Pulmonary Resuscitation (CPR), " review of the policy entitled "Change of Condition," review of licensed practical nurse (LPN) #114's personnel file, review of staff in-service records and staff interview, the facility failed to provide necessary care and services when staff failed to immediately implement cardiopulmonary resuscitation (CPR) and activate emergency medical services (EMS) for one resident (Resident #500) when the resident was found without a pulse or respirations. This resulted in Immediate Jeopardy for one (Resident #500) of five residents reviewed for change in condition. The facility identified 73 residents who required full resuscitative measures in the event of a cardiopulmonary arrest. The facility census was 143 residents. On [DATE] at 11:50 A.M. the Administrator, Director of Nursing (DON), Regional Administrator #3, Regional Nurse #1 and Regional Nurse #2 were notified Immediate Jeopardy began on [DATE] at 6:52 A.M. when Licensed Practical Nurse (LPN) #114 discovered Resident #500 in his bed, nonresponsive and without pulse or respirations. LPN #114 did not initiate CPR or activate Emergency Medical Services (EMS). Resident #500 required full resuscitation (full code) with an active order initiated on [DATE] for a full code status. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions. ? On [DATE] the Administrator reviewed the policies and procedures entitled Cardio-Pulmonary Resuscitation (CPR) ([DATE]) and Change of Condition([DATE]), with the facility's Regional Director of Clinical Services and Regional Director of Nursing. No changes were recommended to the existing facility policies. ? On [DATE] the DON conducted in-services with all 89 licensed nursing staff employed by the facility either in person or via telephone on the Cardio-Pulmonary Policy and Procedure and the Change of Condition Policy and Procedure. Education was provided specifically instructing all licensed staff CPR must be initiated on all residents with a documented "Full Code status, including Hospice residents, as stated on the staff Education/In-Service sign in sheet. ? On [DATE] the DON conducted an audit of all Hospice residents to determine clear documentation of their code status. Eleven of 11 Hospice residents (Residents #1 through #11) were determined to have advanced directives in place. ? On [DATE] the DON completed audits of 146 resident medical records to determine each resident's code status. The DON identified 73 residents who were requesting to have full resuscitation (CPR) measures implemented. ? On [DATE] the DON conducted audits of 146 resident medical records for compliance with the Policy and Procedure for Change of Condition. Three residents (Resident #126, #150 and #159) were identified by the facility to have experienced a significant change. Record review revealed evidence of physician notification of the change in condition and adequate care and services for these residents in a timely manner. ? On [DATE] the DON provided a written plan to complete audits of residents with a change in condition weekly for four weeks, through [DATE] and then monthly for two months, through [DATE]. ? Review of a Disciplinary Action Form in LPN #114's personnel file revealed on [DATE] the DON disciplined LPN #114 for failure to comply with standard nursing procedures in regard to the event of [DATE] for Resident #500. The disciplinary action was acknowledged and signed by LPN #114, the LPN assigned to care for Resident #500 when the resident was found without respirations or pulse. LPN #114 failed to administer CPR, activate EMS services and notify the resident's physician. Discipline entailed a Final Written disciplinary action which left the LPN with no further disciplinary actions without termination based on review of the disciplinary action form. ? On [DATE] the surveyor interviewed six LPN's (LPN's #114, #115, #116, #117, #118 and #119). All six nursing staff demonstrated knowledge of implementation of CPR for residents with full code status including those on Hospice, and their responsibilities to ensure each resident's correct code status was checked and followed as reviewed on [DATE]. All six licensed nursing staff knew how to update a resident's code status on the report sheet and the steps to take to update oncoming staff as to the change. ? On [DATE] review of four additional closed records (Residents #600, #700, #800 and #900) of residents who exhibited acute changes in condition, between [DATE] and [DATE] revealed prompt physician notification and implementation of CPR by qualified staff in a timely manner for those residents who were a full code status. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (No actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as an insufficient amount of time had lapsed between the date of the incident of Immediate Jeopardy on [DATE] and the date of the on-site investigation on [DATE] to determine the facility had implemented ongoing audits and monitoring of residents related to change in condition as per the corrective plan developed by the facility. Findings include: Review of the medical record of Resident #500 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Hospice contract revealed Resident #500 was admitted to Hospice services on [DATE]. Review of the resident's current physician orders for [DATE] revealed Resident #500 had an active order for a full code status. Record review revealed the order had been initiated and in place since [DATE]. Review of nursing progress notes dated [DATE] at 5:11 A.M. revealed LPN #114 assessed Resident #500 to have an elevated temperature of 104.8 degrees Fahrenheit. The note indicated the LPN administered [MEDICATION NAME] 650 milligrams and [MEDICATION NAME] drops sublingually per physician order. An assessment of the resident's vital signs, also noted at 5:11 A.M., revealed the resident's pulse was 52 beats per minute, respirations were 24 per minute and blood pressure was ,[DATE]. The resident's oxygen saturation was noted as 84%. Record review revealed LPN #114 notified the Hospice nurse of the resident's condition. However, there was no evidence the resident's physician was notified of the resident's change in condition at that time. Further review revealed on [DATE] at 6:52 A.M., when LPN #114 re-entered Resident #500's room, the LPN found the resident without pulse, blood pressure or respirations. At this time LPN #114 did not administer CPR nor did the LPN call 911 for emergency transport or assist in spite of the active physician's order stating the resident as a full code. Review of the Hospice Nurse Skilled Nursing Visit Note dated [DATE] at 8:00 A.M., revealed Resident #500's time of death was documented as 6:52 A.M. on [DATE]. In an interview with LPN #114 on [DATE] at 4:53 P.M., the LPN revealed she was assigned to care for Resident #500 on [DATE]. The LPN verified she was aware Resident #500 had a full code status even though the resident was receiving Hospice services. LPN #114 verified she failed to initiate CPR or call 911 when she found Resident #500 without pulse, blood pressure or respirations. LPN #114 verified she did not administer CPR per facility policy. During the interview, the LPN indicated she had contacted the Hospice nurse on [DATE] related to the resident's change in condition. The LPN stated she thought the Hospice nurse was in communication with the resident's legal guardian and family to change the resident's code status from a full code to a Do Not Resuscitate (DNR). LPN #114 verified at the time she found Resident #500 unresponsive without a pulse or respirations on [DATE], the resident was a full code status and no changes had been made related to advance directives. A nursing progress note, dated [DATE] at 5:11 A.M. reflected LPN #114 notified the Hospice nurse of the resident's change in condition. During the interview LPN #114 also verified following the incident with Resident #500 she had received additional education related to ensuring timely physician notification for any resident assessed to have a change in condition and also the need to provide CPR to any resident who was a full code who was found nonresponsive without pulse and/or respirations. Review of a Disciplinary Action Form in LPN #114's personnel file revealed on [DATE] the DON disciplined LPN #114 for failure to comply with standard nursing procedures in regard to the event of [DATE] for Resident #500. The disciplinary action was acknowledged and signed by LPN #114, the LPN assigned to care for Resident #500 when the resident was found to be without respirations or pulse. LPN #114 failed to administer CPR, activate EMS services and notify the resident's physician. Discipline entailed a Final Written disciplinary action which left the LPN with no further disciplinary actions without termination based on review of the disciplinary action form. Review of the facility policy entitled Cardio-Pulmonary Resuscitation (CPR) dated [DATE] revealed if a resident is a "full-code" 911 is to be called. In the absence of a pulse, the policy states to begin CPR. Review of the policy and procedure entitled Change of Condition dated [DATE], revealed a change of condition included an emergence of an unstable condition. This deficiency substantiates Complaint Number OH 312.

Based on medical record review, staff interviews, and review of facility investigative reports, the facility failed to ensure a resident received an adequate level of assistance from staff during care to prevent an accident. One staff person assisted Resident #125 to turn and provide incontinence care when the resident required the assistance of two staff for activities of daily living including bed mobility. Resident #125 sustained harm as the result of a spiral fracture of the left femur. This affected one of four sampled residents (Resident #125). There were 134 residents residing in the facility. Findings include: Review of the medical record for Resident #125 revealed the resident was admitted to the facility 05/01/05. The resident had [DIAGNOSES REDACTED]. Review of nurses' notes revealed on 09/21/11 at 5:10 A.M., Licensed Practical Nurse (LPN) #140 documented he was notified by a nursing assistant that he heard a "pop" sound while turning Resident #125 during incontinence care. On arrival, the resident was seen lying on her right side in bed with a swollen area just above the left knee with minimal pink discoloration. There was no indication of pain such as crying. The resident was left in the same position until the arrival of the emergency team. Vital signs were taken: blood pressure 177/89, temperature 96.4, pulse 52, respiration 16, and oxygen saturation level 95 percent. Nine-One-One (911) was called and the resident was sent to the hospital at 5:20 A.M. The physician and family were notified. A nurse's note on 09/21/11 at 5:29 P.M. documented the resident was admitted to the hospital with [REDACTED]. On 09/22/11 at 3:25 P.M., interview with LPN #140 revealed on 09/21/11 at 5:10 A.M., State-tested Nurse Aide (STNA) #141 had come to him and stated that while he was turning Resident #125 to provide incontinence care, the resident was kicking and he heard a popping sound. LPN #140 stated he then rushed in to find Resident #125 with swelling and discoloration just above the left knee. LPN #140 confirmed STNA #141 was providing the care for Resident #125 by himself. LPN #140 also stated he thought Resident #125 required the assistance of one staff for bed mobility. On 09/22/11 at 1:30 P.M., interview with the Administrator revealed he had received Resident #125's x-ray report on 09/22/11 which stated the resident had a spiral fracture of the left femur. He stated he then felt that an investigation was needed to determine what happened. He stated he had taken statements from LPN #140 and STNA #141. The Administrator confirmed STNA #141 was the only staff in the room at the time of the popping noise heard from Resident #125's leg. Review of an annual Minimum Data Set (MDS) assessment completed on 12/20/10 and a quarterly MDS assessment completed 07/05/11 revealed Resident #125 was totally dependent upon staff for bed mobility (turning in the bed) and required two person physical assist. A care area assessment worksheet dated 12/22/10 stated the resident required total dependence for bed mobility, transfers, and toileting. It stated the resident was non-ambulatory and always incontinent of bowel and bladder. Review of a STNA assignment sheet revealed Resident #125 was incontinent and required the assistance of two staff for transfers. The STNA assignment sheet did not indicate the level of assistance required for bed mobility. Review of the plan of care dated 03/16/09 and revised 01/18/10 revealed Resident #125 had a self-care deficit related to [DIAGNOSES REDACTED]. It stated the resident could be resistive with care at times. The goal was for the resident to have her activity of daily living needs met daily. The interventions included to provide needed assistance with self care daily and assist with turning and repositioning. The plan of care did not include how many staff were needed to provide the required assistance. On 09/22/11 at 3:10 P.M., interview with the Director of Nursing revealed each resident was to have a Care Plan Cover Sheet which should be placed in the Nursing Assistant flow book to notify them of the level of assistance and number of staff required to provide activities of daily living including bed mobility. She confirmed Resident #125 did not have a Care Plan Cover Sheet. On 09/22/11 at 3:00 P.M., interview with LPN #142 revealed Resident #125 required the assistance of two staff for bed mobility and transfers. Review of the hospital x-ray report dated 09/21/11 revealed Resident #125 had a spiral fracture involving the left femoral shaft. The impression was a displaced spiral fracture, mid to distal fermoral shaft. This certification deficiency substantiates Complaint Number OH 506.

Based on observation, medical record review, pain management policy review, and staff interview, the facility failed to provide care and services to ensure proper positioning, [MEDICAL TREATMENT] shunt care, and pain management. This affected two of three Stage II sampled residents reviewed for positioning, one of one resident reviewed for [MEDICAL TREATMENT], and one of two residents reviewed for pain management (Residents #12, #124, and #211). Harm occurred to Resident #211 when the resident exhibited signs of pain and pain management interventions were not initiated. Findings include: 1. Medical record review revealed Resident #211 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission minimum data (MDS) assessment, dated 12/28/10, revealed the resident had severely impaired cognition, rarely to never understood, and did not receive pain medication. Review of the physician orders revealed an order dated 12/16/10 for extra strength Tylenol 500 milligrams (mg) as needed for pain and anxiety and [MEDICATION NAME] 5/500mg as needed for pain dated 01/05/11. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. Review of the pain rating data assessment, dated 01/04/11 at 2:07 A.M., revealed Resident #211 complained of occasional, intermittent, dull back pain that was interfering with sleep and rest. Review of the medical record revealed no documented evidence of non-pharmacological interventions or pain medication administered. On 01/05/11 at 8:25 A.M., observation of Resident #211 and interview with Licensed Practical Nurse (LPN) #50 verified the resident was nonverbal and had facial grimacing with movement LPN #50 stated that did not mean the resident was in pain. LPN #50 left the resident's room and did not administer pain medication to Resident #211. On 01/05/11 at 10:15 A.M., the resident was observed lying on her back with her feet against the mattress with no foam boots. On 01/05/11 at 10:18 A.M., State-tested Nurse Aide (STNA) #15 applied Resident #211's foam boots and verified the resident had facial grimacing and moaned when the STNA applied the foam boots. On 01/05/11 at 10:25 A.M., STNA #15 stated she informed the nurse the resident was experiencing non-verbal signs of pain. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. on 01/05/11. Review of the wound management progress note, dated 12/31/10 and 01/05/11, revealed Resident #211's pain assessment for the right and left heel pressure revealed wound pain was rated three out of 10. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. contained no documentation of administration of pain medication. On 01/05/11 at 11:10 A.M., interview with LPN #12 verified Resident #211 had not received anything for pain since admission and verified the pain assessment completed on 01/04/11 revealed the resident complained of mild back pain. LPN #12 verified there was no documentation of pain management. LPN #12 verified the plan of care did not address pain. LPN #12 stated nurses should evaluate pain with dressing changes and notify her and the physician of any changes in wounds or pain. On 01/05/11 at 11:51 A.M., during observation of coccyx pressure ulcer dressing change Resident #211 was observed to grimace and wince. LPN #50 leaned down and asked the resident if she was having pain. The resident's response was inaudible to the surveyor, and LPN #50 commented back to the resident "I know it hurts." Resident #211 was then repositioned and observed to continue to wince, grimace and her lower lip was quivering and upper torso shaking. LPN #50 verified the resident did not receive any pain medication prior to the dressing change. LPN #12 and LPN #50 left the resident in her room without administering pain medication or non pharmacological interventions for pain. Review of the MAR indicated [REDACTED].M. Review of Resident #211's plan of care entitled Unable to Express Pain, Show by Facial Grimacing, Guarding, Wincing Care Plan (dated 12/30/10) included interventions to maintain proper body alignment using pillows or roll between legs, medicate as ordered to manage pain, monitor increased level of pain and notify physician, perform pain assessments and reposition for comfort. Review of the Pain Management Policy (revised April 2002) revealed residents were to be assessed and observed for behaviors that suggest pain in residents who have cognitive impairment or who have communication problems, and offer non-medication and medication methods for relief of pain. 2. Medical Record review revealed Resident #12's minimum data set (MDS) assessment dated [DATE] identified the resident was unable to walk or transfer on her own and was unable to sit up without assistance from staff. The resident was totally dependent on staff for transportation of wheelchair and geriatric chair, was unable to balance while standing, and had no trunk control. On 01/04/11 at 7:40 A.M., 2:00 P.M., and 4:20 P.M., Resident #12 was observed sitting up in the lobby in a semi-reclined geriatric chair, with a pillow under both of her legs, and was leaning to the left side of the chair with her head raised forward. On 01/05/11 at 7:00 A.M., 9:35 A.M., 10:03 A.M., 11:25 A.M., and 12:14 P.M., Resident #12 was observed sitting up in the lobby in a semi-reclined geriatric chair, leaning to the left side of the chair with her head raised forward. On 01/06/11 at 7:10 A.M. and 8;15 A.M., Resident #12 was observed sitting up in the lobby in a semi-reclined geriatric-chair, leaning to left side of the chair with her head resting back against the chair. During observation of Resident #12, there was no evidence staff repositioned the resident for proper body alignment. On 01/06/11 at 10:03 A.M., interview with STNA #41 revealed the resident leaned when she was in her geriatric chair because the chair was too big. STNA #41 stated he had just gotten her a new one for when she got out of bed for lunch. 3. Review of Resident #124's medical record revealed the resident was diagnosed with [REDACTED]. There was no physician order for [REDACTED]. Review of the nursing care plan for Resident #124 revealed the resident was to receive [MEDICAL TREATMENT] three times a week, nursing was to assess for bruits and thrills, and the dressing was to be replaced if it would come off when not at [MEDICAL TREATMENT]. On 01/04/11 at 2:30 P.M., review of the policy and procedure for [MEDICAL TREATMENT] Resident Management (revised April 2002) revealed the facility was to assess, monitor for complications and provide adequate intervention in the management of residents receiving [MEDICAL TREATMENT]. Review of the treatment administration record for Resident #124 revealed no documentation on the treatment record for nurses to assess [MEDICAL TREATMENT] shunt dressing or check for bruits and thrills every shift. On 01/04/11 at 3:17 P.M., interview with LPN #33 revealed the care of [MEDICAL TREATMENT] shunt dressing and assessing for bruits and thrills to shunt should be documented every shift on the treatment administration record. LPN # 33 verified there was no documentation on the treatment administration record that the nursing staff had checked the dressing to the [MEDICAL TREATMENT] shunt to Resident #124's right upper extremity or that the nursing staff had assessed Resident #124's shunt for bruits and thrills.

Based on observation, medical record review, pressure ulcer policy review, skin positioning policy review, review of manufacturer's guidelines, family interview, and staff interview, the facility failed to implement and document pressure ulcer treatments and interventions for Residents #201 and #208, and the facility failed to provide care and services to a resident admitted with pressure ulcers to prevent an avoidable decline resulting in harm to Resident #211. This affected three of three Stage 2 sampled residents for pressure ulcers (Residents #201, #208, and #211). Harm occurred to Resident #211 when the facility failed to complete ordered pressure ulcer treatments, turn and reposition the resident, and use an appropriate pressure reduction mattress, resulting in a decline in an unstageable pressure ulcer wound. Findings include: 1. Medical record review revealed Resident #211 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) assessment, dated 12/28/10, revealed the resident had severely impaired cognition with short- and long-term memory problems and was not on a turning or repositioning program. On 01/03/11 at 5:46 P.M., interview with Family #20 stated staff does not come in to reposition the resident until they ask and then they have had to wait up to three hours for staff to turn and reposition the resident. Family #20 stated the staff was aware the resident had pressure ulcers. On 01/03/11 from 2:59 P.M. to 6:00 P.M., Resident #211 was observed lying on her back in the same position. On 01/05/11 at 10:15 A.M., Resident #211 was observed lying on her back with her feet against the mattress with no foam boots. At the time of the observation, State-tested Nurse Aide (STNA) #15 verified the resident did not have foam boots on and stated the resident was to wear them at all times. STNA #15 stated she was the resident's aide but did not know the last time the resident was turned. On 01/05/11 at 10:25 A.M., STNA #15 left the resident's room without repositioning the resident. The resident was observed lying on her back on 01/05/11 from 10:15 A.M. to 12:15 P.M. and again from 12:45 P.M. to 4:00 P.M. Review of the wound management progress treatment orders, dated 12/31/10, revealed an order for [REDACTED]. Review of the Pressure Tracking Log revealed Resident #211's coccyx pressure ulcer deteriorated from admission on 12/16/10. On 12/17/10, the residents coccyx pressure ulcer measured 3.0 cm (length) x 1.5 cm (width) x 0.2 cm (depth) with yellow/tan drainage. On 12/31/10, the coccyx pressure ulcer measured 4.0 cm x 2.2 cm x 0.2 cm with pale pink drainage. On 01/05/11, the coccyx pressure ulcer measured 4.0 cm (length) x 4.0 cm (width) x 3.0 cm (depth) with thick, tan/green drainage and necrotic (dead) covering. Review of the Pressure Tracking Log revealed Resident #211's right heel pressure ulcer deteriorated from admission on 12/16/10. On 12/17/10, the resident's right heel pressure ulcer measured 1.0 cm x 1.0 cm. On 12/31/10, the resident's right heel pressure ulcer measured 2.0 cm x 1.0 cm. Review of the treatment administration record (TAR) dated December 2010 revealed an order to apply skin prep to bilateral heels and cover with a dressing every other day. The TAR revealed the heel dressing was not completed on 12/21/10, 12/25/10, 12/27/10, 12/29/10, 12/31/10, 01/02/11 or 01/04/11. Review of Resident #211's December 2010 TAR revealed an order, dated 12/17/10, to cleanse the coccyx and apply [MEDICATION NAME] AG every three days. The TAR revealed the treatment was not completed on 12/29/10. Review of the January 2011 TAR revealed an order, dated 12/30/10, to cleanse the coccyx, apply Mesalt and a dry dressing daily. The TAR revealed the treatment was not completed on 01/01/11 and 01/02/11. On 01/05/11 at 10:50 A.M., interview with Licensed Practical Nurse (LPN) #12 verified the above treatments were not completed. LPN #12 stated she did not know why the treatments were not done and verified not completing the ordered pressure ulcer treatments would make the ulcers worse. On 01/05/11, observation of Resident #211's mattress revealed an Ultraform mattress. Review of the manufacturer guidelines for Ultraform IST pressure relief mattress revealed the mattress was indicated for use in the prevention and treatment of [REDACTED]. On 01/05/11 at 11:10 A.M., LPN #12 verified Resident #211's had an Ultraform mattress on her bed, and the mattress was not appropriate for a resident with unstageable pressure ulcers. Review of the POS float" heels and relieve pressure. On 01/05/11 at 10:15 A.M., interview with STNA #15 verified Resident #211 was positioned on her back applying pressure to an existing coccyx pressure ulcer, was not turned and repositioned at least every two hours, and heels were not floated to relieve pressure. Review of the nursing notes, dated 12/16/10 through 01/05/11 revealed no documented evidence of Resident #211's pressure ulcer. Review of the Skin Pressure Ulcer Policy (revised November 2006) revealed a pressure ulcer was to be evaluated daily and documented on if condition of the wound changed and intervene as needed. On 01/05/11 at 11:10 A.M., interview with LPN #12 verified the nurses' notes were silent for documentation of the resident's pressure ulcer descriptions or wound changes. On 01/05/11 at 11:51 A.M., observation of Resident #211's coccyx dressing change revealed LPNs #12 and #50 positioned the resident on the left side and removed the dressing prior to the surveyor entering the room. LPN #12 stated the dressing was removed because the resident was incontinent of stool. The coccyx peri-wound appearance was dark purple with a scant amount of bleeding at 7:00, 9:00, and 2:00 surrounding the wound. The wound bed was 75% covered with yellow and brown fibrous strands with scattered necrotic areas. Tunneling was observed at 12:00 with unknown depth. The wound had a foul odor, and no drainage was observed. LPN #12 stated the soiled dressing had a moderate thick yellow drainage. The wound size was measured at 6.0 cm x 4.0 cm x 3.0 cm with black-tan slough with tunneling at 12:00. 2. Review of Resident #208's medical record revealed the resident was admitted on [DATE] with a Stage II pressure ulcer to the right heel which measured 3 centimeters (cm) by 3 cm. Resident #208 was transferred to a local hospital on [DATE] and admitted to hospital until returning to the facility on [DATE]. Review of the admission skin assessment dated [DATE] revealed Resident #208 did have suspected deep tissue injury measuring 3 cm by 3 cm to right heel. Review of skin grids dated 12/24/10 and 12/31/10 revealed Resident #208 did have suspected deep tissue injury measuring 3 cm by 3 cm to right heel. Review of physician's orders [REDACTED]. Review of the nursing care plan for Resident #208 dated 12/10/10 revealed a problem of skin breakdown to the right heel (Stage II) and readmitted from hospital 12/17/10 with right heel at suspected deep tissue injury purple fluid filled. An approach for the problem revealed to provide treatment as ordered. Review of treatment administration record revealed that for the month of December 2010 there was no record of documentation for provision of treatment to right heel as ordered by the physician for the date of 12/21/10. For the month of January 2011, there was no record of documentation for provision of treatment to the right heel as ordered by the physician for the dates of 01/02/11 and 01/04/11. On 01/05/11 at 12:02 P.M., interview with LPN #33 verified there was no documentation on the treatment administration record Resident #208 had been provided treatment to the right heel on the dates of 12/21/10, 01/02/11, or 01/04/11. 3. Review of Resident #201's closed medical record revealed she was admitted on [DATE] with the [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] indicated the resident was admitted with a pressure ulcer to her coccyx. The skin assessment completed at the time of admission indicated the area was a suspected deep tissue injury and measured 6.5 cm x 6.5 cm. The assessment form described a suspected deep tissue injury as a purple or maroon localized area of intact skin due to damage of underlying soft tissue from pressure or shearing. A pressure ulcer risk assessment completed 10/19/10 revealed the resident was a high risk for skin breakdown scoring a nine. The assessment used identified a score of 8 or greater to be a high risk. The assessment risk indicated her risk factors were a limitation in mobility and having a poor nutritional status. She also had two predisposing diseases that increased her risk for skin breakdown. Review of the admission orders [REDACTED]. A telephone order dated 10/19/10 directed the facility to cleanse the pressure ulcer on the coccyx and apply zinc oxide to pressure ulcer every shift and as needed. A care plan was initiated on 10/27/10 for the risk of impaired skin integrity related to impaired mobility, incontinence, [DIAGNOSES REDACTED], muscle wasting and weakness, [MEDICAL CONDITIONS], adult failure to thrive and a suspected deep tissue injury present upon admission on coccyx. The goals indicated the skin would be free of breakdown and open areas would be healed without complications. Interventions included the use of barrier cream after incontinence as needed, inspect skin daily during routine care, medications as ordered, pad and protect skin, pericare after each incontinence, pillows for positioning, pressure reduction devices if ordered, skin assessments as ordered, treatments per orders and turn every two hours. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short term memory deficits and displayed depressed mood indicators. There were no behaviors identified. She required extensive assist of two with bed mobility and transfers, limited assist of one for ambulation in her room and in the corridor and mobility devices used were a walker and a wheelchair. The MDS assessment indicated her weight was 99 lbs upon admission and she had no history of weight loss. A 30-day MDS assessment dated [DATE] noted no change in her ADL assistance. She continued to require the extensive assist of two for bed mobility and transfers and was still a limited assist of one for ambulation. Her weight increased to 105 lbs at the time of the 30-day assessment. A telephone order dated 11/02/10 noted an order to apply skin prep to her left heel and to pad and protect it daily and as needed. A skin grid pressure form dated 11/2/10 confirmed the development of a Stage I pressure ulcer to the resident's left heel. A Stage I pressure ulcer is defined as a persistent area of skin redness without a break in skin that does not disappear within 30 minutes when pressure is relieved. The area measured 2.5 cm x 2.5 cm. A telephone order sheet dated 11/03/10 noted an order for [REDACTED]. physician progress notes [REDACTED]. Review of the monthly treatment administration records (TAR's) for November 2010 did not provide evidence of the resident being turned and repositioned every two hours as indicated in the plan of care. It also did not provide evidence the resident's heels were being elevated when in bed to alleviate pressure and prevent the development of the pressure ulcer. Review of the facility's Skin: Special Mattress/Bed Protocol (revised November 2006) indicated special mattresses may be required for non stageable pressure ulcers as with suspected deep tissue injuries. The facility ordered a specialty low air loss mattress on 11/03/10 which was after the development of the Stage I pressure ulcer on the left heel. On 01/07/11 at 10:15 A.M., interview with the Director of Nursing (DON) verified the Stage I pressure ulcer to the left heel developed after the resident was admitted to the facility. She stated the facility did not document turning and repositioning of the residents on the TAR's. She indicated the facility turned everyone and it was just a given that it was done. She also stated the use of pillows for positioning, as per the plan of care, would imply that the heels were elevated off the bed. The DON stated the use of the pillows would not be on the treatment record either. The DON verified the care plan does not reflect specific interventions for pressure ulcer prevention (specific timeframes for turning and repositioning, pad and protect skin without a specified site, and pillows for positioning does not state the purpose or placement of the pillows). The DON was unable to provide further documentation the care plan interventions to turn and reposition as needed, pad and protect skin, and pillows for positioning were followed.