Every finding on record at Memorial Hospital of Gardena D/P SNF

Based on observation and interview, the facility failed to:Ensure food items in walk-in refrigerator 1 were labeled and unexpired. Ensure the walk-in freezer 2 had an internal thermometer (used to check the refrigerator's inside temperature).Ensure the walk-in refrigerator 3 had an internal temperature that was within range (acceptable is 41 degrees F or lower) .This deficient practice had the potential to result in residents developing a foodborne illness (food poisoning). Findings:During a concurrent observation and interview, on 4/7/2026 at 8:48 a.m., with the Dietary Services Supervisor (DSS), an unopened cheese danish was observed unlabeled and undated, and a pack of opened hot dog buns had an expiration date of 4/4/2026 in the walk-in refrigerator 1. The DSS stated all food items should have been labeled and dated. The DSS stated all expired items should had been discarded. The DSS stated the risk of not discarding expired items and not labeling and dating food items could result in foodborne illnesses due to being possibly spoiled. During a concurrent observation and interview, on 4/7/2026 at 9:02a.m., with the DSS, there was no internal thermometer observed in walk in freezer 2 which contained a variety of meats such as chicken, fish and pork. The DSS stated the risk of not having an internal thermometer in a walk-in freezer could result in food defrosting leading to expired food.During a concurrent observation and interview, on 4/7/2026 at 9:06a.m., with the DSS, the walk in refrigerator 3 (which contained dairy products such as yogurt and milk) thermometer was observed/ read at 50 degrees Fahrenheit. The DSS stated the risk of not maintaining appropriate temperature for a refrigerator could result in expired food items.During a review of the facility's policy and procedures (P&P), titled Freshness Dating and Labeling, dated 6/2024, the P&P indicated Storage used for short-term holding of fresh, perishable and potentially hazardous food items at internal temperature of 41 degrees F or lower.During a review of the facility's policy and procedures (P&P), titled Food Purchasing and Handling, dated 6/2024, the P&P indicated Food which was prepared and not served shall be stored appropriately, clearly labeled and dated and there is a reliable thermometer in each refrigerator, freezer and in the storeroom.

Based on interview and record review, the facility failed to ensure a contingency plan (a pre-defined set of actions to be taken if an original plan fails or an unexpected event occurs) for staffing was developed and included in the Facility Assessment (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services).This deficient practice had the potential for the facility to ineffectively respond during unexpected circumstances and negatively impact resident care.Findings:During a concurrent interview and record review on 4/8/2026 at 4:34 p.m., with the Director of Nursing (DON), the Facility Assessment, dated 2/2026, was reviewed. The DON stated the Facility Assessment should be revised when there are changes in the general staffing plan, a new leadership or in the operation of the facility and was responsible in updating the Facility Assessment. The DON stated the Facility Assessment contains the operation of what the facility staff do on a day to day, but not on an emergency. The DON stated the revised Facility Assessment did not indicate the contingency plan on staffing during emergency. The DON stated it was important to include the staffing plan during emergency in the Facility Assessment to safeguard the health and safety of the residents. During a review of the facility's policy and procedure (P&P) titled, Scope of Care, dated 2/2026, the P&P did not mention the contingency plan during emergency in the Facility Assessment. During a review of Centers for Medicare and Medicaid Services (CMS), reference QSO-24-13-NH, dated 6/18/2024, titled Revised Guidance for Long-Term Care Facility Assessment Requirements, indicated the new requirements specify that the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations including nights and weekends and emergencies. The QSO-24-13-NH also indicated the facility must used this facility assessment to inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care.

Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 17 sampled residents (Resident 22).This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 22.Findings:During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own) with placement of tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), quadriplegia (loss of movement and/or sensation, to some degree, of the legs), and sepsis (a life threatening blood infection).During a review of Resident 22's MDS dated [DATE], the MDS indicated Resident 22's cognitive (ability to think and reason) skills for daily decision making were severely impaired. The MDS indicated Resident 22 was dependent (resident does none of the effort to complete the activity) on staff for oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of the CMS MDS 3.0 NH Final Validation Report with an Assessment Reference Date ([ARD] - the specific date used as the endpoint of the observation period when assessing resident's condition) of 10/20/2025, the Report indicated Resident 22's information and the value that was submitted in the database did not match (7/14/2025) for Section A (Identification Information) A1010 (Race).During a concurrent interview and record review on 4/8/2026 at 2:02 p.m., with the Minimum Data Set Nurse (MDSN), Resident 22's MDS assessment dated [DATE] and 10/10/2025), were reviewed. The MDSN stated Resident 22's MDS, dated [DATE], were not completed accurately. The MDSN stated there should have been no check mark entered on Resident 22's MDS, Section A1010 (Race) A-White. Resident 22's race was Mexican, not White. The MDSN stated she completed the MDS assessment and failed to double-check whether the information was entered correctly. The MDSN stated it was important to complete the MDS assessment of residents accurately to formulate an acceptable plan of care based on the residents' demographic and comprehensive assessment.During a review of the facility's policy and procedure (P&P), titled, Minimum Data Sheet and Care Area Assessment, dated 1/2025, the P&P indicated the MDS assessment must accurately reflect the resident's status.

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level 1 screening (a federally required preliminary screening for individuals seeking admission to a Medicaid-certified nursing facility) was conducted and resubmitted for one of two sampled residents (Resident 5), who had diagnoses of mental illness (abnormal behavior or disturbing feelings, thoughts, or actions that interfere with every day functioning) and was receiving psychotropic medications (any drug that affects brain activities associated with mental process and behavior).This deficient practice had the potential to result in Resident 5 not appropriately evaluated and not provided the necessary specialized services for mental illness.Findings:During a review of Resident 5's untitled document (front page of the chart that contains a summary of basic information about the resident), the document indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), respiratory failure (a serious condition that makes it difficult to breathe on your own), and placement of tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe).During a review of Resident 5's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/4/2026, the MDS indicated, Resident 10 was independent (decisions consistent and reasonable) with cognitive (ability to think and reason) skills in daily decision making. The MDS indicated, Resident 5 had the ability to make self-understood and understand others. The MDS indicated, Resident 5 required dependent assistance (resident does none of the effort to complete the activity) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of Resident 5's Order Summary Report (a document containing active orders), dated 4/1/2026, the Order Summary Report indicated, on 3/15/2026, the physician placed a telephone order for Resident 5 to start on Klonopin (a drug used to treat anxiety disorder (a mental health condition characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life) 1 milligram ([mg] - metric unit of measurement, used for medication dosage and/or amount) via gastrostomy tube ([GT] - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) every 12 hours as needed for anxiety. The Order Summary Report indicated, the physician placed a telephone order on 3/19/2026 for Resident 5 to start on Zoloft (a drug used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) daily (9 a.m.) via GT for depression.During a concurrent interview and record review on 4/8/2026 with the Case Manager (CM), Resident 5's PASARR Level 1 screening completed by another facility, on 5/5/2025, was reviewed. The CM stated the PASARR Level 1 screening indicated, Resident 5 had no serious mental illness diagnoses and was not on prescribed psychotropic medications. The CM stated the PASARR Level 1 screening also indicated, Resident 5's case was closed, and a PASARR level II mental health evaluation was not required. The CM stated the facility should have completed and resubmitted a new PASARR Level 1 screening under Resident Review because Resident 5 had a mental illness diagnoses of bipolar disorder, anxiety disorder, and depression and Resident 5 was prescribed with Klonopin and Zoloft. The CM stated by not resubmitting PASARR Level 1 screening, Resident 5's mental health treatment might have been neglected by the facility. The CM stated it was important to resubmit PASARR Level 1 screening immediately in order to provide mental health care and services to residents with mental illness.During a review of PASRR reference manual, dated 2/2023, the PASRR reference manual indicated, an additional requirement has been added for Nursing Facilities (NF) to promptly notify the state mental health and/or intellectual or developmental disability authority, as applicable, if there is a significant change in the physical or mental condition of an individual who is mentally ill or has an intellectual or developmental disability. This would warrant a re-evaluation to determine if a NF is still the most appropriate setting and/or if the individual could benefit from specialized services for his/her mental illness or intellectual disability.During a review of the facility's policy and procedure (P&P), titled Minimum Data Sheet and Care Area Assessment, dated 1/2025, the P&P indicated, The MDS Nurse will coordinate assessments with the preadmission screening and resident review program under Medicaid.

Based on observation, interview and record review, the facility failed to ensure the low air loss mattresses (special mattress for skin management) settings for one of eight sampled residents (Resident 7), were correct basing on the resident's weight.This deficient practice resulted in inaccurate settings and placed the resident at risk for further skin breakdown.Findings:During a review of Resident 7's untitled document (front page of the chart that contains a summary of basic information about the resident), the document indicated Resident 7 was admitted to the facility on [DATE]. Resident 7's diagnoses included acute respiratory failure (a sudden, life-threatening emergency where the lungs cannot get enough oxygen into the blood or fail to remove carbon dioxide), hypoxia (low levels of oxygen in your blood) and hypercapnia (a medical condition where there is too much carbon dioxide in your blood).During a review of Resident 7's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/31/2025, the MDS indicated Resident 7's cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 7 was dependent on staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During an observation, on 4/8/2026 at 1:19 p.m., Resident 7 was observed lying in bed on a low air loss mattress with weight settings at [PHONE NUMBER] pounds ([lb], a fundamental unit of weight and mass).During a record review, on 4/8/2026 at 3:00p.m., of Resident 7's weight, Resident 7's weight indicated Resident 7 weighed 151 lbs.During a concurrent observation and interview, on 4/9/2026 at 10:02 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 observed Resident 7's low air loss mattress settings and stated Resident 7's low air loss mattress settings were set to [PHONE NUMBER] lbs. LVN 4 stated Resident 7's low air loss mattress settings were incorrect as Resident 7 only weighed 151 lbs. LVN 4 stated the risk of inaccurate low air loss mattress settings could result in further skin breakdown.During a review of the low air loss mattress set up instructions, titled Airnest Orange, dated 2020, the set up instructions indicated to Using the soft/firm keys, set the patient comfort pressure settings by selecting the number corresponding closest to the patient's weight.

Based on observation, interview and record review, the facility failed to ensure the normal saline ([NS] - sterile solution of sodium chloride) intravenous (IV - into or connected to vein), 500 cubic centimeter ([cc] metric unit of volume) solutions, used to keep-vein-open (a continuous, very slow-rate IV infusions to prevent blood clots, drug precipitates, or obstructions from forming within an IV catheter), were not used longer than 24 hours, for two of two sampled residents (Residents 3 and 37) as indicated in its policy and procedure (P&P) titled, IV Therapy Administration.This deficient practice had the potential to placed Resident Residents 3 and 37 at risk for infection and IV therapy complications.Findings:A. During a review of Resident 3's untitled document (front page of the chart that contains a summary of basic information about the resident), the document indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your own) with placement of tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), gastrostomy tube placement (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and cerebrovascular accident ([CVA] - stroke, loss of blood flow to a part of the brain).During a review of Resident 3's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/23/2026, the MDS indicated, Resident 3's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never and rarely made decisions). The MDS indicated, Resident 3 required dependent assistance (resident does none of the effort to complete the activity) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing.During a concurrent observation and interview on 4/7/2026 at 10:44 a.m., with Registered Nurse 1 (RN 1), in Resident 3's room, Resident 3 had an IV midline (a long, flexible tube inserted into a large vein in the upper arm, with the tip resting just below the armpit, used in patients needing prolonged medication, fluid replacement, or IV therapy without requiring central venous access) on right upper arm. RN 1 stated Resident 3 had an IV fluid (fluids (F) given directly into the blood stream) of NS, 500 cc dated 4/5/2026 at 6 p.m. RN 1 stated the IVF of NS is used to keep vein open and can be used for 4 days or until it is consumed.B. During a review of Resident 37's untitled document (front page of the chart that contains a summary of basic information about the resident), the document indicated, Resident 37 was admitted to the facility on [DATE]. Resident 3's diagnoses included respiratory failure with placement of tracheostomy, GT placement, and osteomyelitis (inflammation of bone or bone marrow, usually due to infection).During a review of Resident 37's MDS, dated [DATE], the MDS indicated, Resident 37's cognitive skills for daily decision making were moderately impaired (decisions poor, cues and supervision required). The MDS indicated, Resident 37 required dependent assistance (resident does none of the effort to complete the activity) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing.During a concurrent observation and interview on 4/7/2026 at 10:48 a.m., with Registered Nurse 1 (RN 1), in Resident 37's room, Resident 37 had an IV midline on right upper arm. RN 1 stated Resident 37 had an IVF of NS 500 cc dated 4/3/2026 at 6 a.m. RN 1 stated the IVF of NS is used to keep vein open and can be used for 4 days or until it is consumed.During an interview on 4/8/2026 at 1:25 p.m., with the NM, the NM stated it was a standard of practice to use the IVF solution to keep vein open for 24 hours for the safety of the residents.During an interview on 4/8/2026 at 1:33 p.m., with the Director of Nursing (DON), the DON stated IVF should hang no longer than 24 hours because bacteria might grow in the IVF solution that would put residents at risk for infection.During a review of the facility's policy and procedure (P&P), titled IV Therapy Administration, dated 4/2026, the P&P indicated, Standardized the frequency of IV tubing set changes and ensure safe administration of IV fluids and medications. The P&P indicated small bags of IV solutions (250 cc or 500cc) should be used for keep-open IV's so that they do not hang longer than 24 hours.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 9) was free of unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) by failing to monitor resident's behavior and implement non-pharmacological interventions (intervention that does not primarily use medicine) prior to initiation of psychotropic medication.This failure had the potential to place Resident 9 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication) related to psychotropic medication use.Findings:During a review of Resident 9's untitled document (front page of the chart that contains a summary of basic information about the resident), the document indicated Resident 9 was admitted to the facility on [DATE]. Resident 9's diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your own) with placement of tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and gastrostomy tube placement (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 9's Minimum Data Set ([MDS] - a resident assessment tool), dated 3/25/2026 the MDS indicated, Resident 9's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never and rarely made decisions). The MDS indicated, Resident 9 required dependent assistance (resident does none of the effort to complete the activity) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing. The MDS indicated, Resident 9 had no potential indicators of psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality) such as hallucinations (perceptual experiences in the absences of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated, Resident 9 had no physical behavioral symptoms directed toward others such as hitting, kicking, and pushing.During a review of Resident 9's Order Summary Report (a document containing active orders), dated 4/1/2026, the Order Summary Report indicated, the physician placed a telephone order on 10/16/2025 for Resident 9 to start on Olanzapine (a psychotropic medication, used to treat certain mental/mood disorder) 5 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) daily (9 a.m.) via GT for mood disorder.During a concurrent interview and record review, on 4/9/2026 at 1:56 p.m., with the Nurse Manager (NM), Resident 9's Progress Notes from 10/9/2025 to 10/15/2025, were reviewed. The NM stated Resident 9 is on olanzapine for mood disorder manifested by agitation. The NM stated Resident 9's behavior manifestation of agitation was vague (unclear) and not specific. The NM stated there was no documentation by nursing staff to justify putting Resident 9 on psychotropic medication. The NM stated there was no behavior monitoring of Resident 9's agitation and the facility did not attempt less restrictive measures such as providing a sitter and redirection of behavior prior to utilization of psychotropic medication. The NM stated it was important to monitor and document resident's behavior for 72 hours to have concrete evidence supporting the use of psychotropic medication. The NM stated lack of adequate monitoring of behavior manifestation of psychotropic medications would be considered as an unnecessary medication.During a review of the facility's policy and procedure (P&P), titled Psychoactive Medication, dated 4/2026, the P&P indicated, When psychoactive medications are ordered, the assessment process will be utilized to assure alternative behavioral management programs have been attempted prior to the use of psychoactive medications. The P&P also indicated anti-psychotic medications will not be initiated for residents who have not used them previously unless the clinical record documents the medication is necessary to treat a specific condition and when psychoactive medications are initiated on the unit, the resident's medical record will contain completed assessments and documented interventions.

Based on observation, interview, and record review, the facility failed to remove Resident 25's one vial of expired Lispro (type of fast acting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) insulin from medication cart 5.This deficient practice placed Resident 25 at increase risk to receive expired insulin that could be ineffective in treating the resident's high blood sugar levels.Findings:During a review of Resident 25's untitled document (front page of the chart that contains a summary of basic information about the resident) the document indicated, Resident 25 was admitted to the facility on [DATE]. Resident 25's diagnoses included Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), respiratory failure (a serious condition that makes it difficult to breathe on your own), and end stage renal disease ([ESRD] - irreversible kidney failure).During a review of Resident 25's Minimum Data Set ([MDS] - a resident assessment tool), dated [DATE], the MDS indicated, Resident 25's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never and rarely made decisions). The MDS indicated, Resident 25 required dependent assistance (resident does none of the effort to complete the activity) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of Resident 25's Order Summary Report (a document containing active orders), dated [DATE], the Order Summary Report indicated, the physician placed a telephone order on [DATE] for Resident 25 to start on Lispro insulin, to inject subcutaneously ([SQ] - beneath or under the layer of the skin) every 6 hours per sliding scale (increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal): if blood sugar 150-200 = 2 units, 201-250= 4 units, 251-300= 6 units, 301-350 = 8 units, 351-400 = 10 units, greater than 400, to give 12 units and call the Medical Doctor (MD).During a concurrent observation and interview on [DATE] at 10:18 a.m., with Licensed Vocational Nurse 3 (LVN 3) in medication cart 5, one vial of expired Lispro insulin for Resident 25 was found. LVN 3 stated Resident 25's Lispro insulin was dispensed by the pharmacy on [DATE] and was opened on [DATE]. LVN 3 stated the pharmacy placed a label of beyond use date of [DATE] on Resident 25's Lispro insulin. LVN 3 stated expired medication should not be placed in the medication cart and should be discarded in the medication waste container. LVN 3 stated giving expired insulin medication would be ineffective in treating Resident 25's high blood sugar. LVN 3 stated he will re-order Resident 25's Lispro insulin to the pharmacy immediately.During an interview on [DATE] at 12:15 p.m., with the Director of Nursing (DON), the DON stated the validity of opened insulin is 30 days. The DON stated it will not make any difference for giving expired insulin medication to residents in 2 days.During a review of the manufacturer's product labeling of Lispro insulin, indicated opened Lispro insulin vials must be discarded after 28 days, even if insulin remains. Store opened vials at room temperature and keep away from direct heat/light.During a review of the facility's policy and procedure (P&P), titled Multiple Dose Medication Containers, dated 4/2026, the P&P indicated, All insulin or injectable multiple dose vials will have a 28-day expiration after initial entry. The P&P also indicated these vials dispensed by the pharmacy department will have a label stated expiration.

Based on observation and interview, the facility failed to:Ensure the Certified Nurse Assistant 1 (CNA 1) had a disposable gown on when performing direct- resident care to Resident 64, as indicated in its policy and procedures (P&P), titled Enhanced Barrier Precautions (EBP- infection control steps used in nursing homes to prevent the spread of germ-resistant bacteria) for Subacute Unit, which indicated to don (put on) gown and gloves prior to high contact care activity (hands-on tasks performed by healthcare staff involving direct contact with residents and/or immediate environment, often resulting in the transfer of multidrug-resistant organisms (MDROs) to staff clothing and hands). This deficient practice had the potential to result in cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect) of organisms from residents to staff or staff to residents.Findings: During a review of Resident 64's untitled document (front page of the chart that contains a summary of basic information about the resident), the document indicated Resident 64 was admitted to the facility on [DATE]. Resident 64's diagnoses included acute respiratory failure (a sudden, life-threatening emergency where the lungs cannot get enough oxygen into the blood or fail to remove carbon dioxide), hypoxia (low levels of oxygen in your blood) and hypercapnia (a medical condition where there is too much carbon dioxide in your blood). During a review of Resident 64's Minimum Data Set (MDS- a resident assessment tool), dated 2/23/2026, the MDS indicated Resident 64's cognitive (thinking) skills were severely impaired. The MDS indicated Resident 64 was dependent on staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an observation, on 4/7/2026 at 10:23 a.m., CNA 1 was observed rendering care to Resident 64 who had a tracheostomy (a surgical opening in the neck for an airway) connected to a cool aerosol (a medical treatment that delivers a mist of water particles [sterile water or saline] and a fixed concentration of oxygen to a patient's airway), without a disposable gown (a personal protective equipment designed to cover the body or clothing to protect against dirt or other outside contaminants). During an interview, on 4/7/2026 at 10:26 a.m., with CNA 1, CNA 1 stated he was not wearing a gown while changing Resident 64's diaper, linen and padding, and was providing oral care which included swabbing of Resident 64's tongue and brushing the resident's teeth. CNA 1 stated he should have worn a disposable gown while providing resident care to protect himself and other residents, in case of splash of body fluids. During an interview, on 4/9/2026 at 3:25 p.m., with the Infection Preventionist Nurse 2 (IPN 2), IPN 2 stated when providing patient care to residents, staff were required to wear full Personal Protective Equipment ([PPE] protective clothing, garments or equipment designed to protect the wearer or the resident from infections) to prevent any infections from spreading and to protect staff and residents. IPN 2 stated CNA must wear PPE when brushing a resident's teeth, changing residents, and when providing care due to the risk of cross contamination of organisms from residents to staff or staff to residents. During a review of the facility's policy and procedures (P&P), titled Enhanced Barrier Precautions for Subacute Unit, dated 4/2026, the P&P indicated to don gown and gloves prior to high contact care activity.

Based on observation, interview, and record review, the facility failed to observe infection control measures for four out of 27 sampled residents by failing to: 1. Sanitizing their hands between changing gloves, washing hands after cleaning the wound, and applying a clean dressing for Resident 32. 2. Sanitize hands and change gloves after cleaning the colostomy stoma (an opening in the abdomen that allows stool to pass through instead of the anus) and before putting on the new colostomy bag for Resident 38 and after cleaning the wound and before applying the treatment and dressing for Resident 38 and Resident 46. 3. Keep the urinary catheter bag off the floor for Resident 64. These failures had the potential to spread infections and illnesses amongst residents. Findings: 1. During an observation on 2/15/2025 at 3:20 p.m. in Resident's 32 room, with Treatment Nurse (TN) 2. TN 2 when inside Resident's 32 room with wound care supplies. TN 2 wash hands and applied clean gloves and removed soiled dressing from Resident 32' s sacral area. TN 2 removed gloves sanitized hands and applied clean gloves and proceeds to cleaned wound. TN 2 changed gloves and applied new gloves without sanitizing or washing hand and proceed applying new dressing and cover with foam. TN 2 removed gloves and without sanitizing or washing hands applied clean gloves and proceed to changed Resident's 32 left lower extremity scar tissue. TN 2 finished changing left lower leg dressing and changed gloves and proceed to Resident's 32 right lower extremity pressure injury. TN 2 removed dressing, sanitized hands and applied clean gloves. TN 2 clean wound and changed gloves without sanitizing hands and applied a clean dressing. During a review of Resident 32's Admission Record, the Admission Record indicated Resident 32 was admitted to the facility on [DATE] with a diagnosis that included Atrial Fibrillation (a condition where the upper chambers of the heart (atria) beat irregularly and rapidly), intracranial bleed (a bleeding that occurs within the skull, affecting the brain), and cardiomyopathy (group of diseases that affect the heart muscle, making it difficult for the heart to pump blood effectively) During a review of Resident 32's Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 1/8/2025, the MDS indicated Resident 32 was rarely/never understood and rarely/never understand. The MDS indicated Resident 32 required dependent assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 32's Treatment Administration Record (TAR) dated 2/2025, the TAR indicated Resident 32 had Sacral stage 4 pressure injury: Cleanse with normal saline [(NS) (saline is a mixture of sodium chloride and water], pat dry, apply Medihoney (help promote a moist wound environment that aids and supports autolytic debridement) cover with foam dressing every day for 30 days. During a review of Resident 32's TAR dated 2/2025, the TAR indicated Resident 32 had a left lateral lower scar tissue: cleanse with NS pat dry and apply ABD (gauze pads are used to absorb discharges) pad wrap with kerlix daily per 30 days. During a review of Resident 32's TAR dated 2/2025, the TAR indicated Resident 32 had a right lateral lower leg pressure injury: cleanse with NS pat dry and apply Silvadene (is a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of wound) cover with ABD pad wrap with kerlix daily per 30 days. During an interview on 2/16/2025 at 4:06 p.m. with the TN 2, The TN 2 stated We need to sanitized hand between changing gloves. TN 2 stated, it is important to prevent bacteria entering to the wound. TN 2 stated it is important to wash hands when we are switched from one part of the body to another to prevent contamination of wound and develop of infection. TN 2 stated I did not sanitize my hands while changing gloves TN 2 stated the policy of the facility stated to wash or sanitized hands between gloves changes. During an interview on 2/16/2025 at 5:20 p.m. with the Director of Nursing (DON) The DON stated hand hygiene is very important during wound treatment. The DON stated If hands are visible soiled the nurses need to wash hands. The DON stated if there are several wounds, TN need to sanitized hands before applying clean gloves before switching sizes. The DON stated If the TN does not change gloves or sanitized hands the resident is at risk of potential develop of an infection in the wound. During a review of the facility's policy and procedure (P&P) titled, Hand hygiene, dated 5/2023, the P&P indicated, hand hygiene indications included before touching a resident or patient, before donning (putting on) gloves when providing direct patient/ resident care. 46505 2. During a review of Resident 38's Admission Record, dated 1/3/2025, the Admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnosis of chronic respiratory failure with hypoxia (a condition when there is not enough oxygen in the tissues in the body). During a review of Resident 38's History and Physical (H&P), dated 4/24/2024, the H&P indicated Resident 38 had diagnoses of quadriplegia (a paralysis that affects all a person's limbs), multiple pressure sores present on admission (injury to skin caused by prolonged pressure to the skin), and tracheostomy (a procedure to help air and oxygen reach the lungs by creating a hole at the front of the neck). The H&P indicated Resident 38 was awake, alert, and interactive, but compromised in communication due to his tracheostomy. During a review of Resident 38's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/24/2025, the MDS section B indicated Resident 38 was able to understand and be understood by others. MDS section C indicated Resident 38 was cognitively intact. MDS section GG indicated Resident 38 had impairments on both sides of the upper extremities (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot). MDS section GG indicated Resident 38 was dependent on staff for assistance for activities of daily living such as eating, oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. MDS section GG indicated Resident 38 was dependent on staff for rolling left and right and chair to bed transfer. During a review of Resident 38's physician orders, dated 2/4/2025, the physician orders indicated Resident 38's treatment orders were to cleanse the sacral (lower back), left ischium (left lower hip), right ischium (right lower hip) stage 4 with normal saline, pat dry, apply treatment, cover with gauze and foam dressing daily. The physician orders indicated Resident 38's treatment order for the colostomy was to cleanse with normal saline, pat dry, and change bag every other day or as needed. During a review of Resident 46's Admission Record, dated 1/14/2025, the Admission Record indicated Resident 46 was admitted to the facility on [DATE] with diagnosis of respiratory failure. During a review of Resident 46's H&P, dated 1/21/2025, the H&P indicated Resident 46 was on full life support with a poor prognosis. The H&P indicated Resident 46 had osteomyelitis (bone infection), pneumonia (lung infection), and multiple pressure sores. During a review of Resident 46's MDS, dated [DATE], MDS section B indicated Resident 46 never understood and was never understood by others. MDS section C indicated Resident 46 was severely cognitively impaired. MDS section GG indicated Resident 46 had impairments on both upper and lower extremities. MDS section GG indicated Resident 46 was dependent on staff for all activities of daily living such as oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. MDS section GG indicated Resident 46 was dependent on staff for rolling left and right, chair to bed transfer, and tub and shower transfer. During a review of Resident 46's physician orders, dated 2/5/2025, the physician orders indicated Resident 46's treatment orders for the sacrum, and left and right buttocks were to cleanse with normal saline, pat dry, apply treatment, pack with gauze, and cover with dry dressing daily. During an observation on 2/16/2025 at 8:28 a.m. in Resident 38's room, Treatment nurse (TN) 3 was observed performing a colostomy change. TN 3 performed hand hygiene and put on gloves, removed the colostomy bag, cleansed with normal saline and pat dry, put on the new colostomy bag, removed trash bag and threw the trash away, and took off gloves and performed hand hygiene. TN 3 then put on new gloves and cleaned around the bag and dated the bag before taking off gloves and performing hand hygiene. During an observation on 2/16/2025 at 9:15 a.m. in Resident 38's room, TN 3 was observed performing wound care. Resident 38 had three wounds, one on the left hip, one on the right hip, and one on the sacrum. TN 3 performed hand hygiene and put on gloves, removed the dressings on the left hip, right hip, and sacrum with normal saline and covered with the wounds with gauze. TN 3 then changed gloves and performed hand hygiene, donned new gloves, cleansed the wound on the left hip with normal saline, applied treatment, and applied new dressing. TN 3 then removed gloves and performed hand hygiene before starting treatment on the sacrum. TN 3 then donned gloves, cleaned the wound with normal saline, applied treatment, and applied new dressing. TN 3 then removed gloves, performed hand hygiene, and donned new gloves. TN 3 then cleaned the wound on the right hip with normal saline, applied treatment, and applied new dressing. TN 3 then removed her gloves and performed hand hygiene. During an observation on 2/16/2025 at 10:27 a.m. in Resident 46's room, TN 3 was observed performing wound care. TN 3 performed hand hygiene, donned gloves, and removed the dressing on the sacrum and right and left buttock with normal saline. TN 3 then removed gloves, performed hand hygiene, and donned new gloves before cleaning the wound on the right buttock with normal saline and gauze, applied treatment, packed the wound, and applied the dressing. TN 3 then changed gloves and performed hand hygiene and put on new gloves. TN 3 then cleaned the wound on the sacrum with normal saline and pat dry with gauze, applied treatment, packed the wound, and applied the dressing. TN 3 then cleaned the wound on the left buttock with normal saline and pat dry with gauze, applied treatment, packed the wound, and applied the dressing. TN 3 then changed gloves and performed hand hygiene. TN 3 handled Resident 46's catheter bag and turned Resident 46. TN 3 then removed the dressing on Resident 46's back, cleansed the wound with normal saline and pat dry, put-on treatment and foam dressing. TN 3 then changed gloves and performed hand hygiene and put on new gloves. TN 3 removed the dressing on Resident 46's left hip, cleaned the wound with normal saline and pat dry, put treatment on the wound, packed the wound, and covered the wound with dressing. TN 3 then removed the gloves and performed hand hygiene. During an interview on 2/16/2025 at 1:27 p.m. with TN 3, TN 3 stated she would put on the gloves before the treatment, remove the dressing using normal saline to make it easier to come off and to clean it and cover the wound with gauze. TN 3 stated she would then change gloves and use hand sanitizer before putting on new gloves. TN 3 stated because she used normal saline to remove the dressing, the wound is already clean so she did not have to change gloves, but she would clean the wound again with normal saline and gauze and then put on the dressing. TN 3 stated for changing the colostomy bag, only one pair of gloves would be used, and they did not have to change gloves between cleaning the site and putting on the new bag. During an interview on 2/16/2025 at 2:15 p.m. with the Infection Preventionist (IP), the IP stated gloves and hand hygiene are supposed to be performed at the beginning of the wound care and between each wound. The IP stated new gloves and hand hygiene are required between each step of the wound care. The IP stated gloves and hand hygiene are required after removing the dressing, after cleaning the wound, and before putting on the new dressing. The IP stated for changing the colostomy bag, new gloves and hand hygiene are required after removing the bag, after cleaning the stoma (an opening), and before putting on the new bag. The IP stated if gloves are not changed, the nurse can contaminate clean supplies and can contaminate the wound. During an interview on 2/16/2025 at 5:37 p.m. with the Director of Nursing (DON), the DON stated using normal saline to remove the dressing was not considered cleaning the wound and removing the dressing is considered dirty. The DON stated the nurse would have to remove gloves and perform hand hygiene and put on new gloves before cleaning the wound because after removing the dressing, the gloves were dirty and before putting on new dressings because after cleaning the wound, the gloves were dirty. The DON stated if gloves were not changed and hand hygiene was not performed between the steps of wound care, the wound can get infected. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene, dated 5/2023, the P&P indicated hand hygiene was indicated before contact with a wound, before handling clean supplies, after contact with wounds, and after removing a dirty dressing and before applying a new dressing. During a review of Policy and Procedures (P&P) titled Prevention of Catheter Associated Urinary Tract Infections dated January 2024, indicated foley catheter should be maintained unobstructed urine flow, ensure there are no dependent loops in tubing and use bedsheet clip to keep tubing from falling off bed. The P&P also indicated to 44294 3. During a review of Resident 64's Admission Record, the Admission Record, indicated Resident 64's was admitted to the facility on [DATE]. During a review of Resident 64's History and Physical (H&P), dated 1/18/2025, H&P indicated Resident 64's diagnoses included history of pneumonia ([PNA] infection of one or both lungs caused by bacteria, viruses, or fungi) and hypertension (high blood pressure.) During a review of Resident 64's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 1/23/25, the MDS indicated Resident 64 was not able to understand and be understood by others. The MDS indicated Resident 64's was dependent with oral hygiene, toileting, shower/bath, dressing, putting on/off footwear and personal hygiene. The MDS indicated Resident 64 had an indwelling catheter (thin, flexible tube that drains urine from the bladder). The MDS indicated Resident 64 was always incontinent of bowel. During a review of Resident 64's Care Plan dated 1/17/2025, indicated Resident 64 had a foley catheter and the interventions were to keep catheter patent and in proper position. During a concurrent observation on 2/15/2025 at 4:29 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated the foley bag was on the floor and she did not know how long it had been on the floor. VLN 2 stated having the foley bag on the floor could have led to urinary tract infection for the Resident 64 and it should be placed below the bladder and off the floor. During a concurrent record review on 2/15/2025 at 4:29 p.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated that the care plan dated 1/17/2025 indicated to keep catheter patent and in proper position which meant no, kinks, below the bladder and not on the floor to prevent bladder infections. During a review of Policy and Procedures (P&P) titled Prevention of Catheter Associated Urinary Tract Infections dated January 2024, indicated foley catheter should be maintained unobstructed urine flow, ensure there are no dependent loops in tubing and use bedsheet clip to keep tubing from falling off bed. The P&P also indicated to always keep the collecting bag below the level of the bladder and off the floor.

Based on observation, interview and record review, the facility failed to ensure two of 27 sampled residents (Resident 5 and Resident 32) received care in accordance with the facility's policies and procedures (P&P) by failing to: 1. Implement turning interventions for Resident 5. 2. Provide wound care as ordered by the physician for Resident 32. These deficient practice had the potential for the resident to acquire new pressure ulcers and/or worsen current pressure ulcers. Findings: 1. During a review of Resident 5's Admission Record, the Admission Record, indicated Resident 5's was admitted to the facility on [DATE]. During a review of Resident 5's History and Physical (H&P), dated 5/18/2024, H&P indicated Resident 5's diagnoses included cerebrovascular accident ([CVA] a medical emergency that occurs when blood flow to the brain is suddenly cut off) and hypertension (high blood pressure.) During a review of Resident 5's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 10/12/24, the MDS indicated Resident 5's was able to understand and be understood by others. The MDS indicated Resident 5's required supervision with eating, shower/bath, dressing, and moderate assistance with oral hygiene, toileting hygiene, putting on/off footwear and personal hygiene. The MDS indicated Resident 5's was incontinent of bowel. The MDS indicated Resident 5's was at risk of developing pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time) and one unhealed pressure injury. During a review of Resident 5's Care Plan dated 5/18/2024, indicated Resident 5's had a high risk for skin breakdown and interventions indicated to reposition Resident 5's every 2 hours to promote circulation. During a review of Resident 5's Progress Note Inquiry dated 2/16/2024, indicated new blister on left trochanter and left posterior thigh fluid fill blister. During a review of Resident 5's Braden Scale (a medical tool used to assess a patient's risk of developing pressure ulcers) dated 10/9/2024 indicated Resident 5's total scale was 10. The scale indicated anything greater than 12 represented high risk. During a concurrent observation with Licensed Vocational Nurse (LVN 1) on 2/15/2025 at 8:16 a.m. Resident 5's was turned towards the window (left side.) During a concurrent observation with LVN 1 on 2/15/2025 at 9:35 a.m. Resident 5's was turned towards the window (left side.) During a concurrent observation with LVN 1 on 2/15/2025 at 11:00 a.m. Resident 5's was turned towards the window (left side.) During a concurrent observation and concurrent interview with Restorative Nurse Assistant (RNA 1) on 2/15/2025 at 12:42 a.m. Resident 5's was turned towards the window (left side.) RNA 1 stated Resident 5's should have been facing the door (turned to the right side), but she was not. During an interview on 2/16/2025 at 2:13 p.m. with LVN 1, LVN 1 stated from 8:16 a.m. to 11:00 a.m. there were no staff members entering the Resident 5's room to change her position. LVN 1 stated Resident 1 developed blisters could have been a result of her being laying on the same side for more than four hours. 45657 2. During an observation on 2/15/2025 at 10:20 a.m. in Resident's 32 room. Resident 32 was laying on the bed, awake, unable to communicate with dressings on both lower extremities. During a concurrent observation and interview on 2/15/2025 at 3:20 p.m. in Resident's 32 room, with Treatment Nurse (TN) 2. TN 2 when inside Resident's 32 room with wound care supplies. TN 2 wash hands and applied clean gloves and removed soiled dressing from Resident 32' s right lower lateral leg open pressure injury. TN 2 clean wound with normal saline [(NS) (saline is a mixture of sodium chloride and water] pat dry and TN 2 proceed to apply a dry foam with no Silvadene ointment (is a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of wound) as order in the Treatment Administration Record (TAR). TN 2 stated yes the order is to apply Silvadene. TN 2 stated I forgot I will get the ointment right now and applied it. TN 2 reach for the Silvadene ointment, washed her hands and applied gloves and proceed to applied Silvadene to right lower lateral leg. TN 2 was observed applying a foam to the wound not an ABD (gauze pads are used to absorb discharges) pad as ordered in TAR. TN 2 stated I will get an ABD pad and applied to wound as ordered. TN 2 applied ABD pad and wrap the wound with Kerlix (a brand of gauze bandage rolls that are used to dress wounds). During a review of Resident 32's Admission Record, the Admission Record indicated Resident 32 was admitted to the facility on [DATE] with a diagnosis that included Atrial Fibrillation (a condition where the upper chambers of the heart (atria) beat irregularly and rapidly), intracranial bleed (a bleeding that occurs within the skull, affecting the brain), and cardiomyopathy (group of diseases that affect the heart muscle, making it difficult for the heart to pump blood effectively) During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 was rarely/never understood and rarely/never understand. The MDS indicated Resident 32 required dependent assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 32's TAR dated 2/2025, the TAR indicated Resident 32 had a right lateral lower leg pressure injury: cleanse with NS pat dry and apply Silvadene cover with ABD pad wrap with kerlix daily per 30 days. During an interview on 2/16/2025 at 10:11 a.m. with TN 2, TN 2 stated the wound treatment doctor comes to see the residents once a week and will place a wound care order for 30 days. TN 2 stated the doctors orders must be followed as prescribed. TN 2 stated nurses are not allowed to switched order for treatments. TN 2 stated if orders are not followed Resident 32 can be at risk for a decline in wound healing and wound can get worse. TN 2 stated before I started with my treatments, I need to check the doctors' orders and make sure I used the right dressing for Residents. TN 2 stated yesterday 2/15/2025, I did not check the orders. TN 2 stated I got confused with so many orders. During an interview on 2/16/2025 at 5:31 p.m. with the Director of nursing (DON), the DON stated TN 2 need to reviewed orders before they started with wound care and follow doctors orders. The DON stated the doctors' orders will indicate what type of material and medications are used for wound care. The DON stated the danger of not following doctors' orders is the wound getting worse. During a review of Policy and Procedures (P&P) titled Wound Care Policy and Procedure dated October 2022, indicated the objective of the facilities P&P was to develop a plan of care for prevention of pressure ulcers to patients determined to be at risk and provide guidelines for individualized treatment. The P&P further indicated interventions applied to all bedbound patients that require maximum assist every two hours turning and all other patients while in bed. During a review of the facility's P&P titled, Wound care, dated 1/2025, the P&P indicated, when patient with a wound use protocol for stage 1 and 2, call MD for consult orders for pressure injuries stage 3 and 4 and all types of wounds.

Based on observation, interview and record review, the facility failed to: 1. Ensure food items were labeled with received and used dates in the dry storage area and two refrigerators. 2. Ensure expired foods were not stored in the kitchen and accessible to be used in food preparation in accordance with food service safety. These failures had the potential to place the residents at risk for developing a foodborne illness. Findings: During a concurrent observation and interview on [DATE] at 11:43 a.m. at entrance of the kitchen observed shelves with plastic containers containing single serve lemon juice bags, 1 container with single serve ranch dressing bags, 1 container with single serve Italian dressing bags, 1 container with single serve grape jelly, 1 container single serve pack syrups, 1 container with single serve ketchup bags and 1 contain with single serve mayonnaise bags. Outside the plastic containers were not label with receiving or used by dated. The Kitchen Supervisor (KS) stated, I do not know the expiration date of these products. The KS stated the expiration date comes in the original box. The KS stated when I pour this product in the containers, I did not put the received or used by date. The KS stated. I understand it is important to know until when these products can be used by. The KS stated it is important ant to avoid give residents any expired food. The KS stated Residents can be at risk of getting sicker. During an observation on [DATE] at 12:30 p.m. in shelves next to cooking area were observed dry chiles containers with exp dated of [DATE], ground cardamom powder exp dated [DATE], poultry season powder exp dated [DATE], crushed spearmint exp dated [DATE], shitake mushrooms powder exp dated [DATE], cream of mushroom soup cans x 2 exp dated [DATE], crush red pepper exp dated [DATE], dark Chile powder exp dated [DATE], basil leaves exp dated [DATE], couscous box exp dated [DATE], and uncooked dry lasagna exp dated [DATE]. During a concurrent observation and interview on [DATE] at 12:40 p.m. in Refrigerator #1 were observed shelves with bags of bread with no receiving or used by dated. The Director of Nutritional Services (DNS) stated yes, I understand the bread should be dated as well. During an observation on [DATE] at 12:45 p.m. in Refrigerator #4 were observed shelves with frozen chicken patties with no receiving or used by dated. During an interview on [DATE] at 3:41 p.m. with the DNS the DNS stated food items are delivered to the kitchen three times a week. The DNS stated we have a staff member who oversees receiving and storage the items. The DNS stated the food will be removed from the original boxes and storage on the shelves. The DNS stated every food item received needed to be label with receiving date before storage. The DNS stated yes the products needs to have the used by and expiration date. The DNS stated it is important to do it because we will know when the item will expire. The DNS stated the risk for residents receiving expired food items can be high or low depends on the food consumed. The DNS stated it can possibly cause foodborne symptoms in residents. During a review of the facility's policies and procedures (P&P) titled Freshness Dating and Labeling, dated ,d+[DATE] the P&P indicated all foods will be dated for freshness and food safety. Delivery: Upon delivery of food items, if not already dated, it is the responsibility of the purchasing agent or individual checking the delivery foods to date the items with the current date.

Based on observation, and interview, the facility failed to: 1.Implement turning interventions in accordance with the facility's policies and procedures (P/P) for one of 27 sampled residents (Resident 5.) This deficient practice resulted in delayed turning for Resident 3 which resulted in a blister on left trochanter (hip joint) and two blisters on left thigh. Findings: During a review of Resident 5's Admission Record, the Admission Record, indicated Resident 5's was admitted to the facility on [DATE] with the diagnoses including cerebrovascular accident ([CVA] a medical emergency that occurs when blood flow to the brain is suddenly cut off) and hypertension (high blood pressure.) During a review of Resident 5's History and Physical (H&P), dated 5/18/2024, H&P indicated Resident 5's diagnoses included cerebrovascular accident ([CVA] a medical emergency that occurs when blood flow to the brain is suddenly cut off) and hypertension (high blood pressure.) During a review of Resident 5's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 10/12/24, the MDS indicated Resident 5's was able to understand and be understood by others. The MDS indicated Resident 5's required supervision with eating, shower/bath, dressing, and moderate assistance with oral hygiene, toileting hygiene, putting on/off footwear and personal hygiene. The MDS indicated Resident 5's was incontinent of bowel. The MDS indicated Resident 5's was at risk of developing pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time) and one unhealed pressure injury. During a review of Resident 5's Care Plan dated 5/18/2024, indicated Resident 5's had a high risk for skin breakdown and interventions indicated to reposition Resident 5's every 2 hours to promote circulation. During a review of Resident 5's Progress Note Inquiry dated 2/16/2024, indicated new blister on left trochanter and left posterior thigh fluid fill blister. During a review of Resident 5's Braden Scale (a medical tool used to assess a patient's risk of developing pressure ulcers) dated 10/9/2024 indicated Resident 5's total scale was 10. The scale indicated anything greater than 12 represented high risk. During a concurrent observation with Licensed Vocational Nurse (LVN 1) on 2/15/2025 at 8:16 a.m. Resident 5's was turned towards the window (left side.) During a concurrent observation with LVN 1 on 2/15/2025 at 9:35 a.m. Resident 5's was turned towards the window (left side.) During a concurrent observation with LVN 1 on 2/15/2025 at 11:00 a.m. Resident 5's was turned towards the window (left side.) During a concurrent observation and concurrent interview with Restorative Nurse Assistant (RNA 1) on 2/15/2025 at 12:42 a.m. Resident 5's was turned towards the window (left side.) RNA 1 stated Resident 5's should have been facing the door (turned to the right side), but she was not. During an interview on 2/16/2025 at 2:13 p.m. with LVN 1, LVN 1 stated from 8:16 a.m. to 11:00 a.m. there were no staff members entering the Resident 5's room to change her position. LVN 1 stated Resident 1 developed blisters could have been a result of her being laying on the same side for more than four hours. During a review of Policy and Procedures (P&P) titled Wound Care Policy and Procedure dated October 2022, indicated the objective of the facilities P&P was to develop a plan of care for prevention of pressure ulcers to patients determined to be at risk and provide guidelines for individualized treatment. The P&P further indicated interventions applied to all bedbound patients that require maximum assist every two hours turning and all other patients while in bed.

Based on observation, interview and record review, the facility failed to: 1. Ensure one of 27 sampled residents (Resident 4), was properly assessed for dry and crusty (rough or thickened texture) skin on his left palm. This deficient practice resulted in lack of or delay in care for Resident 4 and potential risk for skin breakdown. Findings: During an observation on 2/15/2024 at 8:25 a.m. in Resident's 4 room. Resident 4 was laying on the bed and unable to verbally communicate. Resident 4's left hand was closed with very dry skin white in color and rough. During a review of Resident 4's admission record, the admission record indicated Resident 4 was admitted on [DATE], with diagnoses that included cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain), tracheostomy (allows air to pass into the windpipe to help with breathing.), and coronary artery disease (a condition where the arteries that supply blood to the heart become narrowed or blocked.) During a review of Resident 4's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 12/2/2024, the MDS indicated Resident 4 was rarely/never understood and rarely/never understand. The MDS indicated Resident 4 required dependent assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 4's TAR dated 2/2025, the TAR did not indicate Resident 4 had a left palm treatment order. During a concurrent observation and interview on 2/16/2025 at 9:52 a.m. with Treatment nurse (TN) 2 TN 2 was observed washing Resident's 4 right hand with water and soap. the skin to tear and keep moisten. It is important to check the skin daily. TN 2 proceeds to applied ammonium lactated lotion (indicated for the treatment of dry, scaly skin) to the right palm. TN 2 observed Resident's 4 left palm and stated the skin looks dry and is at risk for a skin breakdown. TN 2 stated skin assessments are done weekly in every shower day. TN 2 stated yes the left palm is with very dry skin. TN 2 stated I will call the doctor to get an order to applied same lotion to the left palm. TN 2 stated, it is important to keep the skin moist to prevent skin breakdown and assess the skin every day. During an interview on 2/16/2025 at 4:35 p.m. with TN 2, TN 2 stated I called the doctor, and he told me to apply same lotion to the left palm. TN 2 stated in the left hand I was not putting any lotion because I did not call the doctor. During an interview on 2/16/2025 at 5:31 p.m. with the Director of Nursing (DON), the DON stated nurses need to assess and monitor wounds. The DON stated it is very important to assess Residents skin every day. The DON stated if any issues find with skin, nurses need to call the doctor and documented a changed of condition. The DON stated nurses need to follow the treatment doctor recommended. The DON stated, it is not acceptable that nurses do not assess Resident skin every day. During a review of the facility's policy and procedure (P&P) titled, Change in Resident Conditions, dated 4/2013, the P&P indicated, routine medical changes, all symptoms and unusual signs will be communicated to the physician promptly. This included a minor change in physical and mental behavior. During a review of the facility's P&P titled, Scope of Care, dated 1/2025, the P&P indicated, methods used to assess and meet patient needs: Re-assessment ongoing assessment in collaboration with IDT. Extent to which level of care of services meets patient's needs: skilled wound care treatment.

Based on observation, interview, and record review, the facility failed to: 1. Ensure that the facility staffed sufficient Certified Nurse Assistant (CNAs) to administer and provide nursing services in a timely manner for one out of 27 sampled residents (Resident 5) The deficient practice resulted in delayed care for Resident 5. Findings: During a review of Resident 5's Admission Record, the Admission Record, indicated Resident 5's was admitted to the facility on [DATE]. During a review of Resident 5's History and Physical (H&P), dated 5/18/2024, H&P indicated Resident 5's diagnoses included cerebrovascular accident ([CVA] a medical emergency that occurs when blood flow to the brain is suddenly cut off) and hypertension (high blood pressure.) During a review of Resident 5's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 10/12/24, the MDS indicated Resident 5's was able to understand and be understood by others. The MDS indicated Resident 5's required supervision with eating, shower/bath, dressing, and moderate assistance with oral hygiene, toileting hygiene, putting on/off footwear and personal hygiene. The MDS indicated Resident 5's was incontinent of bowel. The MDS indicated Resident 5's was at risk of developing pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time) and one unhealed pressure injury. During a review of Resident 5's Care Plan dated 5/18/2024, indicated Resident 5's had a high risk for skin breakdown and interventions indicated to reposition Resident 5's every 2 hours to promote circulation. During a review of Resident 5's Progress Note Inquiry dated 2/16/2024, indicated new blister on left trochanter and left posterior thigh fluid filled blister. During a review of Resident 5's Braden Scale (a medical tool used to assess a patient's risk of developing pressure ulcers) dated 10/9/2024 indicated Resident 5's total scale was 10. The scale indicated anything greater than 12 represented high risk. During a concurrent observation with Licensed Vocational Nurse (LVN 1) on 2/15/2025 at 8:16 a.m. Resident 5's was turned towards the window (left side.) During a concurrent observation with LVN 1 on 2/15/2025 at 9:35 a.m. Resident 5's was turned towards the window (left side.) During a concurrent observation with LVN 1 on 2/15/2025 at 11:00 a.m. Resident 5's was turned towards the window (left side.) During a concurrent observation and concurrent interview with Restorative Nurse Assistant (RNA 1) on 2/15/2025 at 12:42 a.m. Resident 5's was turned towards the window (left side.) RNA 1 stated Resident 5's should have been facing the door (turned to the right side), but she was not. During an interview on 2/16/2025 at 2:13 p.m. with LVN 1, LVN 1 stated from 8:16 a.m. to 11:00 a.m. there were no staff members entering the Resident 5's room to change her position. LVN 1 stated not having enough CNAs was one of the problems the facility ha during the weekends and that the blisters Resident 1 developed could have been a result of her being laying on the same side for more than four hours. LVN 1 stated residents suffer from the lack of CNAs. During an interview on 02/16/25 01:56 p.m. with CNA 1, CNA 1 stated the facility was short staffed on weekends and the patients were not getting proper care. CNA 1 stated, sometimes we are not able to turn residents. CNA 1 stated the residents were at risk of skin breakdown due to the lack or missing of turning every two hours. During an interview on 2/16/2025 at 2:13 p.m. with Director of Nursing (DON), DON stated the facility did not have a contract for registry and she could not give a reason on why. DON stated they did not have a strong pool of CNA's the lack of CNAs in the facility could lead to delayed in care, turning and basic care of the residents. During a review of Policy and Procedures (P&P) titled Subacute Staffing Policy and Procedure dated January 2022, indicated Subacute will provide 24 hours nursing care for residents as required by the Department of Health Care Services. It also indicated Core staffing may be augmented as census and acuity changes.

Based on observations and interviews, the facility failed to: 1. Provide one of 27 sampled residents (Resident 38) a special call light system to use. This failure caused Resident 38 to feel frustrated and helpless. Findings During a review of Resident 38's Admission Record, dated 1/3/2025, the Admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnosis of chronic respiratory failure with hypoxia (a condition when there is not enough oxygen in the tissues in the body). During a review of Resident 38's History and Physical (H&P), dated 4/24/2024, the H&P indicated Resident 38 had diagnoses of quadriplegia (a paralysis that affects all a person's limbs), multiple pressure sores present on admission (injury to skin caused by prolonged pressure to the skin), and tracheostomy (a procedure to help air and oxygen reach the lungs by creating a hole at the front of the neck). The H&P indicated Resident 38 was awake, alert, and interactive, but compromised in communication due to his tracheostomy. During a review of Resident 38's Minimum Data Set (MDS, a resident assessment tool), dated 1/24/2025, the MDS section B indicated Resident 38 was able to understand and be understood by others. MDS section C indicated Resident 38 was cognitively intact. MDS section GG indicated Resident 38 had impairments on both sides of the upper extremities (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot). MDS section GG indicated Resident 38 was dependent on staff for assistance for activities of daily living such as eating, oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. MDS section GG indicated Resident 38 was dependent on staff for rolling left and right and chair to bed transfer. During an observation on 2/15/2025 at 10:26 a.m. in Resident 38's room, a call bell was on the bedside table on the resident's left side. During a concurrent observation and interview on 2/15/2025 at 4:58 p.m. with Resident 38, Resident 38 stated he was not able to use the call bell at the bedside because he could not use his arms. Resident 38 gestured towards the call bell but was not able to reach the call bell. Resident 38 stated if his family was not with him, the nurses would not come and if his family was not with him, he would have to yell for help, and it was hard to yell for help and he felt frustrated. Resident 38 stated he had to yell for 45 minutes the previous night before he received help. During an interview on 2/16/2025 at 1:36 p.m. with Resident 38's family member, Resident 38's family member stated the nurses had issues with Resident 38 yelling for him but Resident 38 had no way to get in contact with the nurses. Resident 38's family member stated Resident 38 was not able to use the call bell and the nurses do not respond to Resident 38 yelling. Resident 38's family member stated the facility did not offer an alternative to the call bell. During an interview on 2/16/2025 at 2:24 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 38 was not able to use the call bell because Resident 38 was very stiff and could not extend his arm to reach the call bell. LVN 3 stated the call light system had been broken for three years and because Resident 38 could yell, LVN 3 stated he would stay nearby Resident 38's room so that he could hear Resident 38 yell. During an interview on 2/16/2025 at 5:17 p.m. with the Director of Nursing (DON, the DON stated the call lights are broken so they use call bells at the bedside. The DON stated if a resident could not use a call bell, they rely on the family members and the staff doing hourly rounding to see if the residents were in any distress or if the residents needed suctioning. During a subsequent interview on 2/16/2025 at 7:07 p.m. with the DON, the DON stated it was not appropriate for residents to have to yell for care. The DON stated the purpose of the call bell was to let someone know the resident was calling for help and for the attention of the nurse. The DON stated if the resident could not reach the call bell, then the family would have to use the call bell, but if there were no family available, then the nursing staff would have to do more hourly rounding. The DON stated Resident 38 yelling is him trying to get help. During a review of the facility's policy and procedure (P&P), titled Nurse Call System Failure Protocol, dated 7/2010, the P&P indicated if the length of down time was extensive, notify the administrative nursing supervisor to evaluate the situation for additional staff and engineering would assist nursing in providing temporary hand operated bell to each patient in the affected area and if repairs are beyond the scope of the hospital engineering department, the engineering director and or designee would contact the facility approved vender to provide immediate service and repairs to the nurse call system.

Based on observation, interview, and record review, the facility failed to ensure the residents who were admitted to the facility with intact skin did not develop a pressure ulcer ([PU], injury to skin and underlying tissue resulting from prolonged pressure on the skin or bony prominences) for three of three sampled residents (Residents 163, 40, and 38). The facility failed to: 1. Ensure Resident 163's did not develop a Stage III PU (Full thickness tissue loss) to the right buttocks after the admission to the facility. 2. Ensure the nursing staff monitored Resident 163 skin condition to identify development of a PU to the right buttock at the earlier stage to prevent development of a Stage III PU. 3. Ensure the nursing staff implemented Resident 163's care plan titled Skin Integrity by ensuring the resident will not have a skin breakdown. 4. Ensure nursing staff turned and repositioned Resident 40 every two hours to prevent a deep tissue pressure injury ([DTPI] a serious form of pressure injuries defined as purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) from reopening. 5. Ensure the nursing staff turned and repositioned Resident 38 every two hours as care planned to prevent the resident from developing a Stage II pressure ulcer to the left gluteal fold (a horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks). These deficient practices resulted in Resident 163 acquiring a Stage III PU, the reopening of Resident 40's DTPI, and Resident 38 developing Stage II pressure ulcer to the left gluteal fold. Findings: a. During a review of Resident 163's Face Sheet (Admission Record), the Face Sheet indicated, Resident 163 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), multiple fractures (partial or complete break of a bone), and gunshot wound. During a review of Resident 163's Minimum Data Set ([MDS] a standardized assessment and care screening tool) assessment, dated 1/4/2024, the MDS indicated, Resident 163 had severely impaired cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 163 was dependent to staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS Section M (Skin Conditions) indicated, Resident 163 was at risk for developing a pressure ulcer and had one unhealed Stage III to a sacral (tailbone) area. The MDS indicated Resident 163 was incontinent of bowel and had a condom catheter (sheath-like device that is placed around the penis and secured with adhesive or a strap) for a sacral ulcer management. During a review of Resident 163's Admission Assessment, dated 12/23/2023, the Admission Assessment indicated Resident 163 was admitted with a Stage III pressure ulcer to a sacral area. During a review of Resident 163's Occupational Therapy Evaluation form, dated 12/23/2023, the Occupational Therapy Evaluation Form indicated Resident 163 was totally dependent for bed mobility. During a review of Resident 163's Braden Scale (tool commonly used in healthcare to assess and document a resident's risk for developing pressure ulcers) form, dated 12/24/2023, 12/30/2023, 1/7/2024, and 1/14/2024, the Braden Scale form indicated Resident 163 had very limited sensory perception (ability to respond meaningfully to pressure-related discomfort), was constantly moist, bedfast (confined in bed), completely immobile, was receiving nutrition via a gastrostomy tube ([GT] a soft tube surgically inserted into the stomach through the abdomen) and had a problem in friction and shear. The Braden Scale indicated, Resident 163 had a score of nine (total score of 12 or less represent high risk), indicating the resident was high risk for developing a pressure ulcer. During a review of Resident 163's Daily Assessment Inquiry under Certified Nursing Assistant (CNA) Documentation from 12/23/2023 to 2/7/2024, the Daily Assessment Inquiry indicated there were no documentation of Resident 163 having a pressure ulcer on a right buttock. During a review of Resident 163's Progress Notes Inquiry from 12/23/2023 to 2/6/2024, the Progress Notes Inquiry, indicated there were no documentation of Resident 163 having a pressure ulcer to a right buttock. During a review of Resident 163's Sub-Acute Nursing Weekly Summary dated 12/25/2023, 1/1/2024, 1/8/2024, 1/22/2024, 1/29/2024, and 2/5/2024, the Sub-Acute Nursing Weekly Summary, indicated there were no documentation of Resident 163's having a pressure ulcer to a right buttock. During a review of Resident 163's Wound Photographic Documentation-Nursing, dated 2/8/2024, the Wound Photographic Documentation-Nursing indicated Resident 163 had a Stage III pressure ulcer to the right buttock, which was not present on admission. Resident 163's Stage III pressure ulcer to the right buttock was measured 2.5 centimeters ([cm] unit of measurement) in length, 3.0 cm in width, and 0.1 cm in depth, and documented to have a scant (minimal) amount of serosanguineous (fluid containing both blood and blood serum [clear liquid part of the blood after blood cells have been removed]) fluid with no odor. During a concurrent observation and interview on 2/9/2024 at 9:21 a.m. with Treatment Nurse 1 (TN 1) in Resident 163's room, TN 1 was observed conducting a wound care treatment to Resident 163's pressure ulcer on the right buttock. The wound bed was observed to have an adherent yellow slough (dead tissue, usually cream or yellow in color) dark gray skin and pink tissue, with indistinct (not sharply outlined or separable) wound margins (edge). The Peri wound (tissue surrounding the wound) was noted to have deep purple skin discoloration. TN 1 stated Resident 163's Stage III pressure ulcer to the right buttock was acquired at the facility. TN 1 stated she identified Resident 163 having a Stage III pressure ulcer to the right buttock on 2/7/2024. TN 1 stated she did not document about it and did not notify Resident 163's physician (MD 1) until the next day on 2/8/2024. TN 1 stated she was overwhelmed with other tasks on 2/7/2024 and that was the reason why she did not document about newly identified Resident 163's pressure ulcer and did not called MD 1. TN 1 stated she did not follow the standard of practice by not reporting Resident 163's Stage III pressure ulcer to the right buttock to MD 1 in a timely manner. TN 1 stated she had seen Resident 163's on several occasions soiled (dirty) with urine because his condom catheter was dislodged. TN 1 stated Resident 163 had only one Stage III pressure ulcer to the sacral area upon admission. TN 1 stated she did not observe Resident 163's developing redness, blister, or any skin damage to his right buttock until 2/7/2023 when he developed a Stage III pressure ulcer to his right buttock. TN 1 stated Resident 163 had no skin maintenance treatment order to the right buttock prior to identification of a Stage III pressure ulcer. During an interview on 2/9/2024 at 10:23 a.m. a Certified Nursing Assistant 2 (CNA 2) stated she was giving a bed bath (bathing a patient who is confined to bed and cannot have the physical and mental capability of self-bathing) to Resident 163 every time she was assigned to care for Resident 163. CNA 2 stated, she did not observe Resident 163 had a new pressure ulcer. CNA 2 stated she documents in the flowsheet of a resident's electronic health record if a resident noted with skin issues including bed sore, redness, and skin tear. During an interview on 2/9/2024 at 10:33 a.m. the Registered Nurse 2 (RN 2) stated protecting and monitoring the condition of Resident 163's skin was important for preventing development of a pressure ulcer and identifying a pressure ulcer earlier so it can be treated at the early stage and not to let it to get worse. RN 2 stated she was not aware Resident 163 developed a Stage III pressure ulcer to his right buttock. RN 2 stated the licensed nurses need to check resident's skin when completing the Nursing Weekly Summary and report it to the supervisor when areas of concern identified. During a concurrent interview and record review on 2/9/2024 at 2:25 p.m. with Infection Preventionist Nurse (IP 1), Resident 163's Subacute Pressure Injury Weekly Report dated 12/24/2023 and 1/28/2024 were reviewed. IP 1 stated Resident 163 had only one pressure ulcer Stage III to the sacral area. IP 1 stated it was important to identify the presence of a pressure ulcer and its stages early so nurses can implement the necessary interventions. During a concurrent interview and record review on 2/9/2024 at 3:00 p.m. with Director of Nursing 1 (DON 1), Resident 163's care plan titled Skin Integrity, dated 12/27/2023, was reviewed. The care plan problem indicated, Potential for impaired skin integrity related to impaired mobility, incontinence, fragile skin, history, or current pressure ulcer, and on anticoagulant therapy. The care plan goals included the following: 1. To maintain Resident 163's skin integrity as evidenced by intact skin daily for next three months. 2. Resident 163 will be free from skin breakdown daily for next three months. 3. There will be no further sacral pressure ulcer deterioration daily for the next three months. The DON stated the facility failed to prevent Resident 163's pressure ulcer development to the right buttock and failed to identify this pressure ulcer prior its progression to a Stage III. The DON stated a Stage III pressure ulcer can develop fast but not right away. The DON stated with proper care treatment and interventions and early detection of a pressure ulcer Resident 163's new Stage III pressure ulcer to the right buttock could had been avoided. During a review of facility's policy and procedure (P&P) titled, Dignity, Patient/Resident, dated 9/2023, the P&P indicated, the facility will provide, in accordance with Federal law requirement, every resident with the care and quality of life sufficient for them to attain and maintain their highest practicable physical, emotional, and social well-being. During a review of facility's policy and procedure (P&P) titled, 'Change in Residents Condition, dated 11/2023, the P&P indicated, the licensed nurse in charge will notify the physician immediately of any sudden or serious change in residents condition manifested by a marked change in physical or mental behavior. 46144 b. During a review of Resident 40's Admission Record (Face Sheet), the Admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), seizures (a sudden, uncontrolled body movements due to abnormal electrical activity in the brain), and diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). During a review of Resident 40's Minimum Data set ([MDS] a standardized assessment and care screening tool), dated 11/30/2023, the MDS indicated, Resident 40's cognitive (ability to learn reason, remember, understand, and make decisions) skills for daily decision making were severely impaired. The MDS indicated Resident 40 was dependent on staff for activities of daily living (ADL) including toileting, hygiene, and showering. During a review of Resident 40's Admission assessment dated [DATE], the Admission Assessment indicated the resident had the following: 1. Left heel undetermined (UTD) skin injury. 2. Sacral pressure ulcer Stage III. 3. Right lateral malleolus UTD skin injury. 4. Right buttock UTD skin injury. During a review of Resident 40 's care plan for Impaired Skin Integrity dated 8/18/2023, the care plan indicated a goal for the resident was to maintain intact skin daily for the next three months (until next care plan evaluation). One of the care plan interventions was to reposition the resident every two hours. During a review of Progress Note Inquiry dated 9/21/2023 completed by a Wound Consultant, the Progress Note Inquiry indicated Resident 40's left heel was assessed as unstageable pressure ulcer and measured 1.0 cm by 0.8 cm. The Wound Consultant documented recommendation for intervention to promote pressure ulcer healing included heel off loading, heel protector, and turning and repositioning the resident. During a review of Resident 40's Physician's Orders, dated 2/1/2024, Physician's Orders indicated the order to cleanse left heel DTPI with Normal Saline solution, pat dry. Apply Betadine and cover with dry dressing daily. During a review of Wound Photographic Documentation/Nursing dated 2/1/2024, the Wound Photographic Documentation indicated Resident 40 had DTPI to left heel measured 1.0 cm in length by 1.5 cm in width. During an observation on 2/6/2024 from 11:09 a.m. until 4:00 p.m. (a total of five hours), Resident 40 was observed in bed on a left side facing the window. During an observation on 2/7/2024 from 9:17 a.m. until 4:15 p.m. (a total of seven hours), Resident 40 was observed in bed on a left side facing the window. During an observation on 2/8/2024 from 8:15 a.m. until 12:15 p.m. (four hours) Resident 40 was observed lying on the left side facing the window. During a concurrent observation and interview on 2/8/2024 at 12:15 p.m. with Restorative Nurse Assistant (RNA 1) in Resident 40's room, Resident 40 was observed in bed lying on a left side facing the window. Resident 40 was observed to have a heel protector (a soft cushion covering the heel) on the left heel. Resident 40's left heel had a sock on inside the heel protector. RNA 1 confirmed Resident 40 was facing the window and lying on the left side of his body. RNA 1 stated Resident 40 should be facing the door at 12:00 p.m. RNA 1 stated Resident 40 should be repositioned from side to side every two hours to prevent a pressure ulcer from developing, to help with blood circulation (the flow of blood through the heart and blood vessels), and to prevent DTPI to have a recurrent pressure ulcer. During a review of Resident 40's Repositioning Schedule, date unknown, the Repositioning Scheduled indicated Resident 40 should be turned (repositioned) every two hours. During a concurrent observation and interview on 2/8/2024 at 12:30 p.m. with Infection Preventionist (IP 1), in Resident 40's room, Resident 40 was lying on the left side facing the window. IP 1 stated Resident 40 had a sock on and a heel protector. IP stated if the resident is not turned every two hours, even though there is a heel protector on the heel, the resident can develop a pressure ulcer to the skin. IP 1 stated it was 30 minutes passed the time for Resident 40 to be repositioned on the right side and facing the door. IP 1 stated we should be following the reposition schedule every two hours. IP 1 stated it was important to reposition Resident 40 as scheduled to prevent a pressure ulcers development. During a concurrent interview and record review on 2/8/2024 at 3:54 p.m. with the Director of Nursing (DON 2) Resident 40's Progress Notes Inquiry, dated 9/21/2023 were reviewed. The Progress Notes Inquiry indicated Resident 40 had to have heels offloading (not bearing weight) as one of the interventions to promote DTPI healing. The DON 2 stated its important to reposition a resident every two hours to prevent pneumonia (a condition that inflames the air sacs in one or both lungs). The DON 2 stated repositioning Resident 40 every two hours and offloading the left heel would help healing proceed of Resident 40's left heel DTPI. During a concurrent interview and record review on 2/9/2024 at 2:02 p.m. with the Registered Nurse (RN1) Resident 40's Progress Notes Inquiry, dated 9/21/2023 were reviewed. The Progress Notes Inquiry indicated Resident 40 interventions to promote healing to a left heel included offloading. RN 1 stated the left heel had DTPI. RN 1 stated the recommendation were to offload the left heel. RN 1 stated it was important to offload the left heel to prevent skin breakdown and to promote DTPI healing. RN 1 stated by not following the Wound Consultant's recommendations to offload Resident 40's left heel the pressure ulcer on a heel can continue to breakdown further and could become infected. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcer Assessment, Treatment and Prevention, dated 7/2019, the P&P indicated, preventive measures used to prevent further breakdown of the skin and did not disclose to offload heels. The P&P did not disclose to turn the Residents every two hours. During a review of the facility's P&P titled, Pressure Ulcer Assessment, Treatment and Prevention, dated 7/2019, the P&P indicated that upon admission to the facility each resident shall have a total body check by a licensed nurse for the presence of pressure injuries or risk to develop a pressure injury. The resident care plan will include preventive equipment used to help prevent further ulcer breakdown. DTI is a skin injury resulted from intense or prolonged pressure and shear force at the bone muscle interface. 48712 c. During a review of Resident 38's Face Sheet, the Face Sheet indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, persistent vegetative state (condition of not being aware), respiratory failure (unable to breath on your own), and diabetes (high blood sugar). During a review of Resident 38's Admission assessment dated [DATE], the Admission Assessment indicated the resident had intact skin. During a review of Resident 38's MDS dated [DATE], the MDS indicated Resident 38 was dependent on staff to reposition from side to side. The MDS indicated Resident 38 was at risk for pressure ulcer development. During a review of Resident 38's care plan for Impaired Skin Integrity (date illegible), the care plan indicated Resident 38 had the potential for impaired skin integrity related to impaired mobility, weight loss, and steroid therapy. The care plan indicated the staff would reposition the resident every two hours and assess skin condition daily. During a review of Resident 38's Braden Scale Highest (a lower score represents a higher risk), dated 10/18/2022, indicated Resident 38 scored 10. During a concurrent interview and record review on 2/8/24 at 12:05 p.m. with TN 1, Resident 38's Wound Management form dated 8/31/23 was reviewed. The Wound Management indicated Resident 38 had a new pressure ulcer to the left gluteal fold (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks) acquired on 8/31/23. TN 1 stated Resident 38 acquired a pressure ulcer because the resident was immobile. TN 1 stated Resident 38 had to be repositioned every two hours and there was no medical reason why the resident could not be repositioned. During a review of Resident 38's Physician's Orders Report dated 8/31/2023, the Physician's Orders Report indicated an order for Hydrogel (medication that promotes wound healing) with dry dressing to the left gluteal fold pressure ulcer to be done daily. During a review of Resident 38's Physician's Orders Report dated 2/1/2024, the Physician's Orders Report indicated an order to continue Hydrogel with dry dressing to the left gluteal fold pressure ulcer daily. During an interview on 2/8/24 at 12:28 p.m. CNA 1 stated residents were turned every two hours to prevent a pressure ulcer development. CNA 1 stated bed sores (pressure ulcers) are preventable. During an observation on 2/9/24 from 8:10 a.m. until 2:07 p.m. (six hours) Resident 38 was in bed in a supine (on the back) position. During an observation on 2/9/24 at 8:20 a.m. TN 2 observed performing wound care and measuring the pressure ulcer of the left gluteal fold. The pressure ulcer measured 1.5 cm x 1.5 cm and assessed as a Stage II pressure ulcer. During a concurrent interview and record review on 2/9/24 at 11:25 a.m. with RN 2, a wound evaluation (pressure ulcer) order dated 9/1/2023 was reviewed. RN 2 stated it was the responsibility of the treatment nurse to notify the wound nurse of a new pressure ulcer by entering a wound evaluation order. During a review of the facility's P&P titled, Turning and Repositioning, dated 6/2018, the P&P indicated staff will turn and reposition residents every two hours and as needed.

b. During a review of Resident 36's Admission Record (Face Sheet), the Admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), renal failure (one or both kidneys no longer function well on their own), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Resident 36's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/12/2023, the MDS indicated, Resident 36's cognition (ability to learn reason, remember, understand, and make decisions) skills Resident 36 was oriented to year, month, year, and could recall questions that were previously asked. The MDS indicated, Resident 36's oral and dental status did not have mouth discomfort or difficulty with chewing. During an observation and interview on 2/8/2023 at 9:40 a.m. with Resident 36, in resident room, Resident 36 opened mouth and had missing and broken teeth. Resident 36 stated he had not seen a dentist for a few years. Resident 36 stated now that he can eat food it is uncomfortable to chew the food because of his broken teeth. Resident 36 stated it makes him feel sad that he had not been seen by a dentist to correct his broken and missing teeth. During a concurrent interview and record review on 2/9/2024 at 10:25 a.m. with Minimum Data Set Coordinator (MDS) 1, Resident 36's Dental Service Note, dated 4/30/2022 was reviewed. The Dental Service Note indicated, on 4/30/2022 dentist recommendation to have Resident 36 to be referred to an oral surgeon to remove teeth and pain medication when needed. MDS 1 stated a care plan should have been set up to address the dentist recommendations. MDS 1 stated the care plan would have consisted of interventions to address the missing teeth and comfort. MDS 1 stated Resident 36 's care plan would be implemented. MDS 1 stated after the care plan is implemented to check if the interventions were effective. MDS 1 stated Resident 36 had missing teeth and difficulty chewing it could had affected his nutrition and put Resident 36 at risk for weight loss. During a concurrent interview and record review on 2/9/2024 at 10:25 a.m. with Infection Preventionist (IP) 1, Resident 36's Dental Service Note, dated 4/30/2022 was reviewed. The Dental Service Note indicated, on 4/30/2022 dentist recommendation to have Resident 36 to be referred to an oral surgeon to remove teeth and pain medication when needed. IP 1 stated Resident 36 had missing and broken teeth. IP 1 stated a care plan needed to be set up to address if Resident 36 were to have discomfort and difficult chewing. IP 1 stated it is important to have a care plan for Resident 36 to make sure the Resident is comfortable and not having issues with chewing his food. During a review of the facility's policy and procedure (P&P) titled, Assessment and Care Planning, dated 2/2019, the P&P indicated, To identify resident needs and to provide a data base to be used in planning the comprehensive nursing care to meet resident's individual needs and to assist the resident reaching high level of independence possible .The assessment identifies risk factors associated with possible functional decline and the resident's objective for maintaining or improving.

Based on observation, interview and record review, the facility failed to; 1. Ensure the physician was promptly notified when one of one sampled resident (Resident 163), had a change of condition (a change in resident's normal, physical, mental, or behavioral state). Resident developed full-thickness skin loss potentially extending into the subcutaneous tissue layer (stage 3 pressure ulcer) on the right buttock. A physician notification was made on 2/8/2024 (1 day after the initial identification of the pressure ulcer). This deficient practice had the potential for a delay in care and intervention of Resident 163's Stage 3 pressure ulcer Findings: During a review of Resident 163's Face Sheet, the Face Sheet indicated, Resident 163 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), multiple fractures (partial or complete break of a bone), and gunshot wound. During a review of Resident 163's Minimum Data Set ([MDS] resident assessment and care screening tool) assessment, dated 1/4/2024, the MDS indicated, Resident 163 was severely impaired with cognitive skills for daily decision making (ability to think and reason). The MDS indicated, Resident 163 was dependent to staff in oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. Section M (Skin Conditions) of the MDS indicated, Resident 163 was at risk for developing pressure ulcers and had one unhealed stage 3 pressure ulcer. During a review of Resident 163's Admission Assessment, dated 12/23/2023, the Admission Assessment indicated, Resident 163 was admitted with stage 3 pressure ulcer on sacral area. During a review of Resident 163's Braden Scale (tool commonly used in healthcare to assess and document a resident's risk for developing pressure ulcers), dated 12/24/2023, 12/30/2023, 1/7/2024, and 1/14/2024, the Braden Scale indicated Resident 163 had very limited sensory perception (ability to respond meaningfully to pressure-related discomfort), constantly moist, bedfast (confined in bed), completely immobile, adequate nutrition/on tube feeding and had a problem in friction and shear. The Braden Scale indicated, Resident 163 had a total score of 9, indicating resident was high risk for developing pressure ulcers. During a review of Resident 163's Wound Photographic Documentation-Nursing, dated 2/8/2024, the Wound Photographic Documentation-Nursing indicated, Resident 163 had stage 3 pressure ulcer on right buttock, not present on admission, wound size is 2.5 centimeters (cm, unit of measurement) in length, 3 cm in width, and 0.1 cm in depth, scanty amount of serosanguineous (type of wound drainage), and no odor. During a concurrent observation and interview on 2/9/2024 at 9:21 a.m. with Treatment Nurse 1 (TN 1) in Resident 163's room, TN1 observed doing wound care treatment on Resident 163's pressure ulcer on right buttock. The wound bed was observed with adherent yellow slough, dark gray skin and pink tissue, wound margins indistinct. Peri wound noted with deep purple skin discoloration. TN 1 stated Resident 163's stage 3 pressure ulcer on right buttock was acquired in the facility and identified the pressure ulcer on 2/7/2024 and did not document and notify the Medical Doctor (MD 1) until the next day on 2/8/2024. TN 1 stated she was overwhelmed with other tasks on 2/7/2024 and that was the reason why she did not document and called MD 1. TN 1 stated she did not follow the standard of practice by not reporting the pressure ulcer stage 3 on right buttock to the physician in a timely manner. During an interview on 2/9/2024 at 4:48 p.m. with MD 1, MD 1 stated he was notified Resident 163's new stage pressure ulcer on right buttock by TN 1 on 2/8/2024 and not on 2/7/2024. MD 1 stated he thinks Resident 163's new stage 3 pressure ulcer on right buttock had been there but he doesn't want to speculate. During a review of facility's policy and procedure (P&P) titled, 'Change in Residents Condition, dated 11/2023, the P&P indicated, Any sudden or serious change in residents condition manifested by a marked change in physical or mental behavior will be communicated to the physician immediately. The licensed nurse in charge will notify the physician.

Based on interview and record review, the facility failed to: 1.Ensure the comprehensive Minimum Data Set ([MDS] resident assessment and care screening tool) assessment for one of fifteen sampled residents (Resident 51) was completed within the required timeframe. This deficient practice had the potential to result in Resident 51 not receiving proper care and treatment. Findings: During a review of Resident 51's Face Sheet, the Face Sheet indicated, Resident 51 was admitted to the facility on [DATE], with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), hypoxia (not enough oxygen), and hypercapnia (when you have too much carbon dioxide in your blood). During a review of Resident 51's MDS assessment, dated 8/21/2023, the MDS assessment, indicated Resident 51's had a Brief Interview for Mental Status (BIMS) score of 8 which indicated Resident 51's cognitive skills for daily decision making was moderately impaired. During a concurrent interview and record review on 2/7/2024 at 3:27 p.m. with MDS 1, Center for Medicare/Medicaid Services (CMS) Validation Report, dated 8/21/2023 was reviewed. The CMS Validation Report of Resident 51's MDS assessment indicated a warning message of assessment completed late for this admission assessment (A0310A, coded as 1), Z0500B (The data on this column contains the date that the Registered Nurse Assessment Coordinator signed the assessment as complete), was more than 13 days after A1600 (Recent admission entry date). MDS 1 stated Resident 51's MDS admission assessment should had been completed on 8/21/2023 since Resident 51 was admitted to the facility on [DATE] but the facility completed Resident 51's admission assessment on 8/26/2023. MDS 1 stated residents MDS assessment should be completed 14 days, quarterly, yearly and if there is a significant change in residents health status. MDS 1 stated she follows the Resident Assessment Instrument ([RAI] is the official instructional guide for completing MDS) manual for completing the MDS assessment. MDS 1 stated it was very important to submit and complete MDS assessment in a timely manner as required by law in order to formulate appropriate plan of care to residents. During a review of facility's policy and procedure (P&P) titled, CMS's RAI Version 3.0 Manual, dated September 2010, the P&P indicated, Federal statute and regulations require that residents are assessed promptly upon admission (but not later than day 14) and the results are used in planning and providing appropriate care to attain or maintain the highest practicable well-being.

Based on observation, interview, and record review, the facility failed to ensure four of 15 sampled residents (Residents 3, 5, 8 and 14) received pain relief medication prior to wound care. -Residents 3 and 5 were not medicated on a consistent basis, prior to daily wound care. - Resident 8 exhibited sign and symptom of pain during wound care observation and the resident did not receive pain relief medication prior to the wound care. -Resident 14, was receiving daily wound treatment for [REDACTED]. Resident 14 was not pre-medicated for pain prior to wound care for 63 out of 145 days. The failure to medicate the residents prior to wound care resulted in Resident 8 exhibited sign and symptom of pain and discomfort and had the potential to cause pain and discomfort to Residents 3, 5, and 14. The facility also failed to ensure two of 15 sampled residents (Residents 3 and 10), and two randomly selected residents (Residents 17 and 18) were assessed for rashes, including skin assessment of the neck underneath the tracheal ties and tracheal gauze padding. This deficient practice had the potential to result in unnecessary discomfort for the residents, and for worsening skin condition. Resident 10, who had chronic itching as a result of abrasions on the right cheek, left forearm and right lower leg, was not assessed and re-assessed as needed. One of the care plan approaches was to treat the resident's itching with [MEDICATION NAME] (anti-itch medication), and observe for effectiveness of the treatment. However, the care plan did not indicate alternative interventions. Resident 17, who was identified with generalized body rashes for over one year, had a dermatologist consult. However, there was no indication the resident's rash was being assessed on a regular basis by the subacute staff, or that the resident was seen by a dermatologist in a timely manner. Resident 18, who was in a persistent vegetative state and had generalized body rashes for over seven months, was not being assessed on a regular basis by the subacute staff. Additionally, the resident was not evaluated by a dermatologist in a timely manner. Findings: 1. On January 22, 1016 at 6 p.m., during the initial tour of the subacute unit, Resident 8 was observed lying on a low air loss mattress (a special mattress that promotes wound healing, and relieves pressure on the body surface), and was breathing through a tracheotomy (a tube that is inserted into the trachea, or windpipe, for purposes of breathing, and removal of lung secretions), that was connected to a ventilator (a machine that assists in breathing, or completely breathes for someone). Resident 8's eyes were partially open, and did not appear to be focusing. Resident 8 was receiving tube feeding formula through a gastrostomy tube (GT- a tube that is surgically inserted through the abdominal wall into the stomach for purposes of feeding and medication administration), and had an indwelling urinary catheter (tube to drain urine from the bladder) that was draining cloudy urine. A review of Resident 8's clinical record indicated Resident 8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly Minimal Data Set (MDS- a written resident assessment tool), dated January 22, 2016, indicated Resident 8 was in a persistent vegetative state (describes a condition during which a person in a coma may have some improvement, with automatic functions like breathing, heart-rate regulation, and sleep, as well as some brain-stem function, like eye opening or making sounds), was unable to walk or to talk, and was totally dependent on staff for all of her daily living needs. The section that addressed pain management, indicated the resident had not been on a pain management regimen, that the resident received PRN (whenever necessary) pain medication, and received non- medication intervention for pain. A review of Resident 8's physician order, dated January 3, 2016, indicated to cleanse the sacral pressure ulcer (buttocks area) with normal saline solution, apply Santyl ointment (a product that works by helping to break up and remove dead skin and tissue), and cover with dry dressing daily for 30 days. A review of a physician order, dated April 1, 2015, indicated to administer [MEDICATION NAME] (Tylenol) 650 milligrams (mg) every four hours via [DEVICE] as needed for pain. A review of Resident 8's care plan, dated January 22, 2016, indicated Resident 8 was totally dependent with self care and bed mobility, and to monitor for signs and symptoms of pain using the face, legs, activity, cry, consolability (FLACC) scale or Baker-Wong Scale (measurements used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain. The scale is scored in a range of 0-10 with 0 representing no pain, and 10 representing severe pain), and to give pain medications as ordered. A review of Resident 8's Medication Administration History Report for November 7, 2015-January 23, 2016, indicated Tylenol was not administered prior to wound care on the following dates: In October 2015: 3, 4, 8, 9, 10, 19-21, 23, 26-29, and 31 (14 days) In November 2015: 8, 12, 15, 25, 27, 29 and 30 (7 days) In December 2015: 2, 5-9, 12, 14, 17, 18, 22-25, 27, 28 and 31 (17 days) In January 2016: 2, 6, 11, 14, 19, and 20 (6 days) On January 23, 2016 at 4:05 p.m., during an observation of Resident 8's wound care, Licensed Vocational Nurse (LVN 1) prepared the wound care supplies, then changed the resident's [DEVICE] dressing. LVN 1 sanitized her hands, donned a clean pair of gloves, and removed the old sacral dressing, irrigated the wound with normal saline solution, then wiped the wound dry with gauze. LVN 1 then applied Santyl ointment applied A&D ointment (a skin protectant) around the edges of the wound, covered the wound with gauze dressing, then taped the dressing in place. During the treatment, Resident 8 appeared to be awake, and was observed to have facial grimacing. Both LVN 1 and Certified Nursing Assistant (CNA 1), who was assisting with repositioning the resident, would periodically state, It's okay, and LVN 1 stated several times, We're almost done. A review of Resident 8's MAR indicated [REDACTED]. On January 23, 2016 at 4:40 p.m., an interview was conducted with LVN 1 and LVN 2 (medication nurse), both LVNs stated Resident 8 should be pre-medicated for pain prior to her daily wound care. On January 23, 2016 at 4:50 p.m., during an interview with CNA 1, when asked if Resident 8 was able to respond, CNA 1 stated the resident was able to respond at times by facial expression, and would sometimes attempt to indicate her needs by moving her eyes. 2. On January 26, 2016 at 11:10 a.m., Resident 14 was observed lying on a low air loss mattress, was non-responsive, and was breathing through a [MEDICAL CONDITION] that was connected to a ventilator. Resident 14 had contractures (shortening of the muscle tissue, causing the muscle to become highly resistant to stretching, and can lead to permanent disability) of both the upper and lower extremities, and was receiving tube feeding formula through a [DEVICE]. A review of Resident 14's clinical record indicated Resident 14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 14's MDS, dated [DATE], indicated the resident was in a persistent vegetative state, received tube feeding formula through a gastrostomy tube, and was totally dependent on staff for all daily living needs. The MDS also indicated the following pressure ulcers: - Coccygeal (tailbone) site Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar-dead tissue-may be present. Often includes undermining and tunneling) - Left heel Stage IV -DTI of right heel (deep tissue injury- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) - Left buttock: Stage II (partial thickness skin loss) - Left first and fourth toes: Stage III (full thickness tissue loss) A review of Resident 14's physician order, dated June 11, 2012, indicated to administer [MEDICATION NAME] (pain reliever) 650 mg via [DEVICE] every four hours PRN (as necessary) for pain. Review of Resident 14's care plan for comfort, with review date of December 21, 2015, indicated alteration in comfort related to pain, secondary to presence of pressure ulcers and contractures of both upper and lower extremities. Approaches included gentle handling, and to give medication as ordered and needed. A review of Resident 14's Medication Administration History Report indicated Resident 14 was not pre-medicated for pain prior to wound care on the following months and days: - In October 2015: 3, 4, 8, 9, 10, 19-21, 23, 26-29, and 31 (14 days) - In November 2015: 1-4, 5, 6, 7, 9-12, 13, 15, 17, 18, 23, 27-29, and 30 (20 days) - In December 2015: 3, 6, 8, 9, 10, 14, 16-18, 22, and 23 (11 days) - In January 2016: 2, 5, 6, 9-11, 19, and 20 (8 days) On January 26, 2016 at 11:45 a.m., during an interview with LVN 5, she stated that she will ask the medication nurse which residents were scheduled to receive wound care, then would medicate those residents approximately one hour prior to the treatment. On January 27, 2016 at 8:45 a.m., during an interview with CNA 4, CNA 4 stated Resident 14 was able to respond by moving her right arm, then stated that during wound care, whenever she assisted the treatment nurse with holding and repositioning the resident, she could feel the resident's right arm tense up when the resident's coccygeal pressure ulcer was being treated. On January 27, 2016 at 10:55 a.m., an interview was conducted with Pharmacist 1 and Pharmacist 2 at the same time. Pharmacist 1 stated the wound care nurse attended the monthly IDT (interdisciplinary team) meetings, and if there was any indication that a resident required pain medication, it would be discussed with the IDT members. Pharmacist 2 further stated the subacute unit did not have a pain management program in place, and that the pharmacy department relied on the nursing staff to keep them informed regarding a resident's status. There was no discussion in IDT regarding Residents 8 and 14. Pharmacist 1 stated that he would have to evaluate each resident individually in order to determine whether a resident revealed any non-verbal signs or symptoms of pain during wound care treatment. He would then address that resident's physician regarding the resident's pain medication needs. Pharmacist 2 then stated that he will start a conversation with the physicians and the IDT members regarding individualizing pain management for residents on the subacute unit. On January 27, 2016 at 2:05 p.m., an interview was conducted with MD 1 (subacute unit medical director). MD 1 stated that he assesses a resident for any potentially painful conditions, then would order around the clock pain treatment, assess the resident after two weeks, then keep that plan if there was improvement. As the interview with MD 1 continued, MD 1 indicated the subject of pain was discussed during the IDT meetings, but may not always be documented in the IDT meeting notes. MD 1 then stated that he will put a pain management plan together, and will give a lecture on pain management for the subacute staff. An online article on the National Pressure Ulcer Advisory Panel website (http://www.npuap.org/wp-content/uploads/2012/01/Pieper_2009_Feb1.pdf), titled, Pressure Ulcer Pain: A Systematic Literature Review and National Pressure Ulcer Advisory Panel White Paper, and dated February 2009, indicated the following: Pressure ulcer pain needs to be assessed and treated because it has widespread physical and psychosocial implications for the patient .Pressure ulcer pain may be caused by tissue trauma from sustained loads (refers to pressure at the site of the ulcer, adequacy of blood supply, and infection), inflammation, damaged nerve endings, dressing changes, debridement (the process of removing nonliving tissue from pressure ulcers, burns, and other wounds), operative procedures, and other treatments. The skin has more sensory nerves than any other body organ. As the pressure ulcer cellular damage expands, chemicals are released that irritate nociceptive (the encoding and processing of harmful stimuli in the nervous system) nerve (endings) .The ulcer erodes through tissue planes (layers) and destroys nerve terminals. As peripheral nerves regenerate, the nocioceptive nerve terminals send out immature sprouts of nerve tissue that may be hypersensitive to both noxious (hurtful, injurious) stimuli, and non-noxious stimuli (stimuli that is not painful or annoying) . Pain, particularly acute pain, is also a stimulus to the stress response thus, at the cellular level (the most basic structural units of the human body), [MEDICAL CONDITION] (inadequate amount of oxygen) may develop because of limited painful breathing and peripheral [MEDICATION NAME] ([MEDICATION NAME] of blood vessels, which may result in decrease of flow of blood) and impede wound healing . (Studies of pressure ulcer pain have shown that) the most frequently used descriptors by pressure ulcer stage were: tender, hurting, sore (Stage II); burning, tender, hurting, sore (Stage III); and tender, hurting, sharp, sore, wretched (Stage IV) .Persons with either Stage III or Stage IV pressure ulcers had significantly more pain than persons with other wounds . Pain assessment scales . have been used in research to measure pressure ulcer pain .Clinicians should have a high index of suspicion of pressure ulcer pain in patients, including those who cannot respond . 3. During a treatment observation for Resident 3's pressure ulcer- stage IV on the sacrococcyx area, on January 24, 2016, at 9:10 a.m., Registered Nurse (RN 2) stated she had medicated Resident 3 prior to treatment. A review of Resident 3's physician monthly order date January 8, 2016, indicated Tylenol 650 milligrams (mg) via [DEVICE], every 4 hours, as needed for pain. A recap notation dated January 8, 2016 indicated to monitor for signs and symptoms of pain prior to treatment daily using the FLACC (Face, Legs, Activity, Cry, Controllability scale or FLACC scale is a measurement used to assess pain between the ages of 2 months and 7 years or individuals that were unable to communicate their pain. The scale is scored in a range of 0-10 with 0 representing no pain), or Wong-Baker Wong scale (uses faces to assess for pain from 0 -10 with 0 representing no pain, for children and/or individuals that were unable to communicate their pain). A review of Resident 3's Care Area Assessment (CAA) Analysis Report dated January 14, 2016, indicated the category of Pain was triggered due to Resident 3's history of episodes of generalized pain, especially when turning and repositioning, as evidenced by facial grimacing. The report indicated to continue to monitor the resident for signs and symptoms of pain using FLACC/Baker Wong Scale, and to give pain medication as ordered. A review of a care plan titled, Comfort related to Generalized Pain and Lower Bilateral Extremity [MEDICAL CONDITION], dated January 7, 2016, indicated the resident's goal express need for medication by 90 days. The staff's interventions included to assess for non verbal signs of pain, and use pain management flow sheet - FLACC/Baker Wong Scale. During an interview on January 27, 2016, at 11 a.m., with CNA 6, CNA 6 stated when she turns Resident 3, she observes for facial expressions and reports any concerns to the licensed nurse. CNA 6 was unable to state if she reported facial expressions for the past two days. A review of Resident 3's Medication Administration History Report dated January 9, 2016 through January 26, 2016 indicated there was no documentation Resident 3 was assessed for pain prior to provision of wound care. There was no documented evidence that the FLACC scale or Baker Wong Scale were used per the care plan and the CAA Analysis Report. According to the National Pressure Ulcer Advisory Panel (NPUAP): Pressure Ulcer Pain- A Systematic Literature Review and NPUAP White Paper, dressing change and wound treatment were among the most painful times for an individual with a pressure ulcer. Pressure ulcer pain should be should be assessed by the bedside clinician. Pain medication should be administered on a schedule that maximizes the resident's ability to be comfortable during pressure ulcer treatment. 4. A review of the clinical record indicated Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS an assessment and care plan tool) dated December 14, 2015 indicated Resident 5 in a vegetative state. She was totally dependent on the staff for her activities of daily living (ADL), that included transfers, dressing, personal hygiene, and bathing. The MDS further disclosed Resident 5 had bilateral upper, lower extremity functional limitation in range of motion, and had a Stage IV pressure ulcer. During the initial tour on January 22, 2016, at 6:10 p.m., RN 4 stated Resident 5 was total care,ventilator dependent, and had a pressure ulcer on her sacral area. A review of the physician's monthly orders,dated January 2016, indicated to administer [MEDICATION NAME] (Tylenol) 650 mg/20.3 ml via [DEVICE], every 6 hours as needed for pain. A review of the Daily Assessment Inquiry Nutrition 2 Enteral Note, dated 01/26/16, and timed at 8:26 a.m., indicated due to worsening sacral decubitus A review of the January 2016 Medication Administration History Report indicated that [MEDICATION NAME] was administered to Resident 5 on the following dates and times: 01/14/16, at 10:17 a.m., 01/15/16, at 9:32 a.m., 01/18/16, at 9:15 a.m., 01/23/16, at 9:25 a.m., 01/24/16 at 9:02 a.m., 01/25/16, at 12:47 p.m. However, there was no documented pain scale assessment, only documented as complete pain relief. The CAA Analysis Report, dated 06/14/15, indicated pain was triggered due to episodes of generalized pain, especially when turning and repositioning as evidenced by facial grimacing and protective body guarding. The report also indicated that the nursing staff was to monitor for signs and symptoms of pain using either the FLACC pain assessment scale, or the Baker Wong Scale, and to administer pain medication as ordered. There was no documented evidence the staff used either pain assessment method per the CAA Analysis Report, prior to administration of the medication. According to the National Pressure Ulcer Advisory Panel (NPUAP): Pressure Ulcer Pain- A Systematic Literature Review and NPUAP White Paper, dressing change and wound treatment were among the most painful times for an individual with a pressure ulcer. Pressure ulcer pain should be should be assessed by the bedside clinician. Pain medication should be administered on a schedule that maximizes the resident's ability to be comfortable during pressure ulcer treatment. 5. During a treatment observation of Resident 3's sacro-coccygeal pressure ulcer, Stage IV on January 24, 2016, at 9:10 a.m., the resident, who was on a ventilator,was repositioned onto her left side by Licensed Vocational Nurse (LVN 6). RN 2 conducted the treatment. There was gauze padding underneath the resident's [MEDICAL CONDITION] (trach -a plastic tube that is inserted into a surgically- created opening into the trachea, or airway, for purposes of breathing and management of lung secretions) ties. The resident's right neck and shoulder skin underneath the resident's tracheal ties, appeared to be thick, dry, scaly, and discolored. When questioned about the observaation, LVN 6 lifted the gauze underneath the tracheal ties, stated it was dry skin, then peeled off a small piece from the shoulder area. When asked who was responsible for reporting changes or concerns, LVN 6 stated the CNAs were to report any changes they observed while providing care, to the licensed staff. RN 2 stated the skin assessments were documented in the weekly nursing summary. During an interview on 01/23/16, at 10:30 a.m., RN 3 stated the licensed nurses were responsible for conducting resident assessments, including the neck area, on a daily basis, including each time tracheal care was performed. A review of the clinical record indicated Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS an assessment and care plan tool) dated 01/14/16 indicated Resident 3 was totally dependent on the staff for activities of daily living which included mobility, transfers, dressing, personal hygiene, and bathing. The MDS further disclosed Resident 3 had bilateral upper and lower extremity functional limitation in range of motion. During a interview on January 24, 2016 at 9:40 a.m., CNA 5 stated she was not aware Resident 3 had dryness around her neck area, and that she reported any changes to the team leader or treatment nurse. At 11:55 a.m., RN 1 stated the licensed nurses were responsible for conducting daily body checks, including during tracheal care. A review of the Daily Assessment Inquiry- Daily Integument dated January 18, 2016, through January 23, 2016, indicated no [MEDICAL CONDITION] noted and/or no new [MEDICAL CONDITION]. An entry dated January 24, 2016, and timed at 11:15 p.m., indicated, New order for A&D ointment for dryness. There was no indication where the A&D ointment was to be applied. A review of the weekly Nursing Summary, dated January 12, 2016, and completed by the 7 p.m.- 7 a.m. shift, indicated the resident's skin status was normal. During a concurrent interview and review of the daily resident census, on January 26, 2016, at 11:55 a.m., RN 1 and RN 3 were asked which staff were responsible for conducting resident assessments when a resident was being bathed. RN 3 indicated from the daily census sheet, which residents were to receive a shower that day, which included Resident 3, then stated that the bath trolley lift had not been working since January 4, 2016 (21 days), therefore, the CNAs were doing shampoo and bed baths. RN 1 stated the licensed nurses do daily skin assessments and were responsible to provide trachea care. During an interview on 01/27/16, at 8:50 a.m., Respiratory Therapist (RT 1) stated that the licensed nursing staff performed routine tracheal care. RT 1 also stated that the RT conducted an assessment of the [MEDICAL CONDITION], including whether [MEDICAL CONDITION] were too tight, and for any redness or inflammation, and reports any concerns to the licensed nurses. A review of a facility's policy and procedure titled, [MEDICAL CONDITION] Site Care, dated June 2011, indicated the purpose of the policy was to prevent loss of skin integrity at the tracheotomy site. The procedure included to remove the old dressing and to cleanse the area around the tracheal tube. 6. During an observation on 01/25/16, at 10:40 a.m., Resident 10 was wearing a hospital gown and pants, had a hand splint on his left arm, and was in a geri chair (a wheelchair that offers more comfort and support than a regular wheelchair), was taken to the activities room by CNA 2 and another CNA. Resident 10 had dried blood and scratch marks on his left shoulder that extended down to his wrist, and dried blood was observed on the resident's gown. Scratches were also observed on the resident's scalp. When questioned regarding the resident's scratched areas, CNA 2 stated they apply lotion. A review of the clinical record indicated Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment and care plan tool) dated 11/09/15, indicated Resident 10 required extensive to total staff assistance for all activities of daily living, and had functional limitation in range of motion to the upper extremities. A review of an Admission Assessment Inquiry Wound Report indicated the following dates and assessments: - April 28, 2015: Abrasions to the resident's right cheek, multiple abrasions the left forearm, and an abrasion on the right lower leg. - August 29, 2015: Left cheek scratches- apply [MEDICATION NAME] ointment for 30 days. - September 7, 2015: Cleanse right forearm scratch, apply [MEDICATION NAME] and cover with dry dressing for 30 days. A review of a care plan titled Chronic Itching (Scratch Marks), On and Off, at risk for scratch marks due to resident scratches self, and dated April 28, 2015, indicated the care plan goal was to provide relief from the itching, and for the itching to resolve after intervention was given. The approaches included to observe for effectiveness, and if not resolved, to report to the physician. The care plan re-evaluation dates included 07/28/15, 10/28/15, 01/28/16, and 03/28/16. There was no documented evidence the physician was informed of the resident's scratches, and no documented indication that alternative approaches were implemented for the 10 month period. A review of the Interdisciplinary Team Conference Skin review, dated 01/12/16, and completed by the RN, indicated that any alteration in skin integrity and/or recommendations to change treatment were to be documented as N/A (not applicable). There was no documentation regarding Resident 10's recurring scratches and/or recommendations or alternate approaches. The Nursing Weekly Summary dated 01/15/16, 01/01/16, 12/25/15, 12/18/15, 12/04/15, 12/01/15, and 11/05/15 indicated Skin Status included normal skin color and turning and depositing. The comments did not indicate any scratches. During interviews on 01/26/16, between 10:25 a.m. and 10:45 a.m., CNA 5 stated Resident 10 usually scratched his arms, back, legs, and feet, depending on his mood. When asked how long the resident had been scratching, CNA 5 stated, For over four months. CNA 5 further stated she reported the resident's scratches to the charge nurse and treatment nurse. Restorative Nursing Assistant (RNA)1 stated she had observed Resident 10 with on and off scratches for about two to three months. A review of the physician's monthly orders for January 2016, indicated an order, dated May 4, 2015, for [MEDICATION NAME] (an [MEDICATION NAME] that is used to treat sneezing, runny nose, and itching) 50 milligrams (mg) via gastro tube (an opening into the stomach to allow for nutritional feedings), as needed for itching. There were other orders to apply lotion for skin maintenance every day. 7. A review of Resident 17's face sheet indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated the resident was able to understand others,and was sometimes able to make himself understood. The resident required assistance from the staff for his ADL care that included transfers, dressing, eating, personal hygiene, and bathing. The MDS also indicated the resident had functional limitation in bilateral range of motion to his upper and lower extremities. Reviews of care plans titled: 1. Chronic Itching due to Dry Skin dated 05/02/15 indicted the resident's goals included would have relief and resolve after intervention given every 3 months. The interventions included observe for effectiveness and if not report to physician. 2. Body Rash (short term care plan) dated 08/02/15 indicated the interventions included treatment as ordered and call the physician for any changes. This short term care plan was updated on 09/02/15,10/02/15, and on 11/03/15. The interventions were treatment renewed with [MEDICATION NAME] cream daily. 3. Generalized Body Rashes (short term care plan) dated 12/03/15 and updated 01/03/16 indicated treatment as ordered monitor for any signs and symptoms of infection, update the physician of any changes in condition, and treatment to be continued for 30 days. Reviews of physician's orders [REDACTED]. During an interview on 01/26/16, at 3:45 p.m., RN 3 stated the physician stated Resident 17 had seasonal rashes. A review of a Progress Note Inquiry dated 01/26/16, at 3:07 p.m. and 3:46 p.m., indicated the physician was notified and he stated Resident 17 had a dermatology consult in 2014, the rashes had been resolved, as the rashes come and go. In addition, the licensed nurse informed the physician that Resident 17 did not have rashes but the skin appeared to have fungus, flaky, desquamation (shedding of the outer layers of the skin), and purplish discoloration to both hips and buttocks. The nurses notes further indicated that the physician had stated , There is no need for a derm consult today, apply moisturizing cream and use [MEDICATION NAME] cream as ordered. The licensed nurse called the physician, described the resident's rashes, and asked if another treatment order could be initiated. The physician stated, The rashes had been on and off- just moisturizer on both elbows, there is no need to change the treatment or introduce a new order to the elbow sites. At end of conversation the physician reiterated to leave the order as is. During an observation on 01/26/16, between 1:10 p.m. and 1:25 p.m., Resident 17 was lying on his bed, on his right side and back area. Areas of discoloration, peeling skin, and dry flakes patches noted on his bed sheets. Scattered scab formations were also observed. The skin on the resident's right elbow was dry, with areas of thick, raised skin. RN 4 stated Resident 17 had generalized body rashes including his lower extremities, and that the staff applied the same treatment to all affected areas. RN 4 further stated the licensed nurses should be specific in describing the rashes. LVN 7 stated a physician had examined Resident 17 and stated generalized rashes on both extremities. Perspiration attribute to rashes and using a diaper did not help. The Daily Assessment Inquiry -Intergumentary dated 01/25/16 at 3 p.m., indicated, Nurse to obtain measurements and take photos. A review of the Nursing Weekly Summary, dated 01/22/16, 7 a.m. -7 p.m. shift, indicated Resident 17's skin was dry, normal skin color, and normal temperature. There was no documentation regarding the presence of rashes. During an interview on 01/27/16, at 9:50 a.m., RN 1 stated the licensed nurses document skin rashes on the daily assessment inquiry under the Braden Scale form and on the treatment sheet. During an interview on 01/17/16, at 1 p.m., RN 5 stated that the LVNs were to inform her if the treatments were ineffective, and she would then communicate the information to the attending physicians. RN 5 further stated there would be more inservices for description of rashes. Durin

Based on record review and interview, the facility staff failed to ensure the safety of one of one sampled resident from injury when a certified nursing assistant (CNA) repositioned/turned the resident in bed (Resident A). When Certified Nursing Assistant (CNA) 1 turned Resident A on her right side, the upper side rail of the bed was up but was not in a locked position. As a result, the upper side rail went down, while Resident A fell off the bed, landed on the floor, and caused her to have a swelling (bump) and a cut on the left side of the forehead. Ice pack was applied on the affected area and the resident received treatment of [REDACTED]. Findings: On April 2, 2015, an unannounced visit was made at the skilled nursing unit of the acute care hospital to investigate an entity reported incident regarding Resident A's fall. Resident A's clinical record was reviewed. The face sheet indicated Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly minimum data assessment (MDS, assessment tool) dated March 2, 2015, indicated the resident was comatose (person exhibits a complete absence of wakefulness and is unable to consciously feel, speak, hear, or move). Resident A required total assistance from the staff for activities of daily living such as bed mobility, transfers, ambulation, dressing, personal hygiene, and bathing. Resident A had limitation in range of motion to her upper and lower extremities. According to the quarterly MDS, Resident A required a one person assists in bed mobility and had weakness in her upper and lower extremities. A review of the care plan titled, At risk for fall, dated February 2, 2015, indicated Resident A would remain free from injury. A review of the care plan titled, Self Care Deficit, dated March 2, 2015, indicated Resident A's needs would be met. The interventions included placing both side rails up when in bed as ordered. A review of the facility letter to the Department dated March 19, 2015, indicated Resident A fell from the bed while care was being delivered. The CNA placed the upper right hand rail in place. The upper hand rail did not lock into place. When the resident was turned on her side, she (the CNA) reached for the side rail. The side rail went down and the resident could not be held by the CNA from the other side of the bed. The resident fell on to the floor. The resident was noted to have small laceration and edema (swelling) to her forehead. A review of the care plan titled, Actual fall, dated March 16, 2015, indicated Resident A had a bump with a small open area on the left side of the forehead. Interventions included providing the treatment as ordered, doing neuro checks, and checking the side rails are up and locked at all times. The Physician order [REDACTED]. The Treatment Record dated from March 16, 2015 to March 24, 2015, indicated the resident received daily treatment to the left side of the forehead (a total of 8 days). The Progress Note Inquiry dated March 16, 2015 at 12:06 p.m., indicated that at 10:25 a.m., Resident A fell on to the floor, was lying on her back by the bed in the presence of a CNA. The resident sustained [REDACTED]. There was a small amount of bleeding and there was swelling on the surrounding area of the cut. Ice pack was applied. Neuro check (an ongoing neurological assessment to monitor the resident's condition) was done. The physician was notified at 10:40 a.m., and ordered a CT (computed tomography, uses X-rays to make picture of structure inside the body) scan of the brain with no contrast and X-ray series (spine, hip and shoulders). Resident A was sent to the X-ray department in the acute care hospital. The CT scan of the brain dated March 16, 2015 dictated at 1:08p.m., indicated at 11:54 a.m., Resident A was at the imaging department of the acute care hospital, as an outpatient visit, and underwent a CT Scan of the brain, non-contrast. The CT scan report indicated there was mild tissue swelling on the left frontal (forehead) area. There was no acute intracranial bleed (a blood vessel within the skull is ruptured). During an interview on April 2, 2015 at 11:28 a.m., CNA 1 stated the upper right side rail went down when she turned the resident on her right side (window side). CNA 1 stated she could not hold the resident from the other side of the bed (door side). According to CNA 1, the resident fell to the floor because the upper right side rail did not lock into place. During an interview on April 2, 2015 at 11:46 a.m., Registered Nurse (RN) 1 stated CNA 1 was supposed to wait for CNA 2 to assist in turning the resident. During an interview on December 29, 2015 at 10 a.m., CNA 1 stated she checked the upper right side rail was up. CNA 1 could not explain how she checked the upper right side rail for proper locking when placed in the up position. During the concurrent interview, Employee 1 (chief nursing officer) stated CNA 1 failed to check the upper right side rail to ensure was locked into place.

Based on observation, interview, and record review, the facility staff failed to ensure 1 of 15 sampled residents (Resident 7) was safe from injury, when Resident 7 was placed in a shower trolley (gurney) and the safety belt had a hole a size of a quarter and snapped open resulting in Resident 7 falling off the shower gurney, landed on the floor, and caused her to have an open wound on the left side of the forehead with bleeding. Resident 7 went to the emergency room for a computerized tomography scan (CT scan combines a series of X-ray views taken from many different angles and computer processing to create cross-sectional images of the bones and soft tissues inside your bodyscan of the head with contrast for a evaluation). The CT scan result showed Resident 7 had a 5 millimeter (mm) right frontal convexity (means curving out or extending outward) subdural hematoma (collection of blood outside the brain). This deficient practice caused Resident 7 to have a 5 mm right frontal convexity subdural hematoma and an open area on the left frontal part of the head. Subdural hematoma symptoms are not noticeable immediately and may not appear for several weeks. The common symptoms of a subdural hematoma included inability to speak, weakness, and loss of consciousness or coma. The possible complications included brain herniation which is severe pressure on the brain that could cause coma and death (National Library of Medicine, National Institutes of Health). Also, Resident 7 received Norco (an narcotic analgesic) for pain after the incident and received treatment by cleaning the open area with normal saline solution, applying bacitracin ointment to the open area, and cover with dry dressing daily for 30 days. Findings: During the initial tour of the facility with Registered Nurse (RN) 3, on October 14, 2014, at 10 a.m., Resident 7 was lying in her bed and her hands were in a flexion position. RN 3 stated that Resident 7 had contractures (chronic loss of joint motion) to her upper and lower extremities and a left hand soft restraint to prevent pulling out her tube feeding. On October 15, 2014, at 11:05 a.m., Resident 7's clinical record was reviewed. The face sheet indicated Resident 7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), a standardized assessment and care planning tool dated April 21, 2014, indicated the resident was comatose (person exhibits a complete absence of wakefulness and is unable to consciously feel, speak, hear, or move). Resident 7 required total assistance from the staff for activities of daily living such as bed mobility, transfers, ambulation, dressing, personal hygiene, and bathing. Resident 7 had limitation in range of motion to her upper and lower extremities. The Change of Condition MDS dated [DATE], indicated Resident 7 had a fall with injury since admission. During an interview on October 17, 2014 at 8:10 a.m., the MDS Coordinator reviewed the electronic medical record. She stated Resident 7 was a one person assist for bed mobility and was identified with upper and lower extremity weaknesses. A review of the care plan titled, "High Risk for Falls" dated April 10, 2014 at 4:47 a.m., indicated Resident 7 would not have episodes of fall every shift. The interventions included providing a safe and hazard free environment. According to a facility's "Event Report" documentation, Resident 7 had a fall incident on June 2 at 9:15 a.m. Resident 7 was on the shower gurney, in her room and was waiting for her bed to be made. The shower trolley (gurney) belt snapped opened and Resident 7 slipped from the shower gurney. Resident 7 had a head injury to her left forehead area with some swelling. Certified Nursing Assistant (CNA) 3 stated the strap belt was secured on the gurney. CNA 3 stated Resident 7 was lying on the shower gurney and was about 2 feet away from her bed. While the other CNA was preparing the bed, CNA 3 was standing on the right side of the gurney with Resident 7. The shower gurney "belt snapped open" and Resident 7 slipped off the gurney. Resident 7 was able to move her upper and lower extremities without facial grimacing. Resident 7 was noted with an open skin measuring 4.0 centimeters by 4.0 centimeters on the left side of her fore head with some bleeding. The bleeding was controlled with pressure. Resident 7 remained awake but was nonverbal and was noted with slight facial grimaces when affected area was touched. Resident 7 was medicated for pain. The family member and the physician were notified. During a telephone interview on November 4, 2014, at 10 a.m., CNA 3 stated that she was assigned as a "shower person." She stated she took Resident 7 on the shower trolley to be showered and the licensed nurse ventilated the resident via the ambu bag (an ambu bag is a manual medical device used to provide assisted ventilation to people who are either not breathing or having trouble breathing. The ambu bag consists of a bag, adapter, one way value, and a mask. The ambu bag needs to be compressed to force a volume of air into the lungs). CNA 3 notified the other CNA to change Resident 7's bed. Upon returning to Resident 7's room, the other CNA was changing the linens on the resident's bed. The licensed nurse connected Resident 7 to the ventilator and left the room. CNA 3 stated she waited on the right side of the gurney by Resident 7. CNA 3 stated, "I used two belts. I saw the belt come loose." When the surveyor asked which belt, CNA 3 stated the top belt came loose as Resident 7 turned and fell to the floor. "I screamed. I couldn't do anything. The resident fell to the floor." CNA 3 immediately examined the belt. The surveyor asked what was wrong with the belt. CNA 3 stated there was a hole in the belt about the size of a quarter. During an interview on October 17, 2014 at 7:15 a.m., the clinical director of the sub acute unit stated the shower gurney was taken out of service due to the straps were "worn out." She stated she told CNA 3 to inform her when such things like an equipment was worn out or broken. The clinical director further stated had the CNA reported to her that the shower gurney belt had a hole, the gurney would have been replaced with the new gurney. The clinical director said, "Yes, Resident 7's fall was avoidable." The clinical director stated there was no policy and procedure for the use of the shower trolley (gurney). A review of the facility's policy and procedure titled, "Shower,Tub Bath Ventilator Dependent Resident," effective date April 2013, indicated the purpose of the policy and procedure was to safely provide an out of bed shower for ventilator dependent resident and to ensure safe transport of the ventilator dependent resident, but the policy did not include procedures on the safe use of the shower trolley (gurney) or a safety inspection of the shower gurney. A review of the physician orders [REDACTED]. Cleanse with normal saline open area on the left frontal part of the head, apply bacitracin ointment, and cover with dry dressing daily, for 30 days. The treatment record dated June 2, 2014, indicated Resident 7 received treatments daily with cleaning the open area with normal saline solution, applying bacitracin ointment, and covering with dry dressing daily, for 30 days. A review of a Progress Note Inquiry dated June 2, 2014, at 5:45 p.m., indicated Resident 7 was given Norco (narcotic analgesic used for the relief of moderate to moderately severe pain) at 9:43 a.m. and at 5:20 p.m. The physician orders [REDACTED]. A review of the CT scan without contrast dated June 2, 2014, at 4:10 p.m., indicated Resident 7 had a 5 millimeter (mm) right frontal convexity subdural hematoma.