Every finding on record at Miami Nursing Center, LLC

Based on record review and interview, the facility failed to ensure resident medication administration records and controlled drug count sheets accurately recorded the disposition of medications for 3 (#1, 7, and #8) of 6 sampled residents reviewed for medical record accuracy.The DON identified 19 residents at the facility were prescribed narcotics.Findings:An undated policy titled Procedure for Administration, read in part, Each dose of medication will be properly recorded in the resident's medication administration record . If the cma [sic] is unable to administer a resident medication for any reason, he/she is to notify the charge nurse immediately.1. A physician order for Res #1, dated 02/09/26, showed the resident was to be administered one Norco (opioid pain relief medication) 10-325 mg tablet every four hours as needed for pain.A MAR for Res #1, dated 02/2026, was compared to the resident's individual narcotic record, dated 01/24/26 to 02/26/26, for hydrocodone (pain medication) 10-235 mg tablets. The comparison showed the following discrepancies and missing medication destruction notations.a. On 02/09/26, the narcotic record showed four doses of the medication were administered to Res #1. The MAR on that date showed two doses were administered to the resident. There was no documentation on the individual narcotic record any of the unaccounted for tablets had been destroyed.b. On 02/10/26, the narcotic record showed five doses of the medication were administered to Res #1 and one dose was wasted. The MAR on that date showed three doses were administered to the resident. There was no documentation on the narcotic record the one unaccounted for tablet had been destroyed.c. On 02/11/26, the narcotic record showed five doses of the medication were administered to Res #1. The MAR on that date showed four doses were administered to the resident. There was no documentation on the narcotic record the one unaccounted for tablets had been destroyed.d. On 02/12/26, the narcotic record showed five doses of the medication were administered to Res #1. The MAR on that date showed four doses were administered to the resident. There was no documentation on the narcotic record the one unaccounted for tablet had been destroyed.e. On 02/13/26, the narcotic record showed five doses of the medication were administered to Res #1. The MAR on that date showed four doses were administered to the resident. There was no documentation on the narcotic record the one unaccounted for tablet had been destroyed.f. On 02/18/26, the narcotic record showed five doses of the medication were administered to Res #1. The MAR on that date showed four doses were administered to the resident. There was no documentation on the narcotic record the one unaccounted for tablet had been destroyed.g. On 02/19/26, the narcotic record showed five doses of the medication were administered to Res #1. The MAR on that date showed four doses were administered to the resident. There was no documentation on the narcotic record the one unaccounted for tablet had been destroyed.h. On 02/20/26, the narcotic record showed five doses of the medication were administered to Res #1. The MAR on that date showed three doses were administered to the resident. There was no documentation on the narcotic record any of the unaccounted for tablets had been destroyed.On 02/20/26 at 2:40 p.m., Res #1 stated they kept track of when they took their pain pills. They stated when they had the opportunity to compare their notes to the facility's narcotic records, the narcotic records were not accurate.2. A physician order for Res #7, dated 02/03/26, showed the resident was to be administered one Ativan (antianxiety medication) 1mg tablet at bedtime.A MAR for Res #7, dated 02/2026, was compared to the resident's narcotic record, dated 02/06/26 to 02/25/26, for Ativan 1mg tablets. The comparison showed the following discrepancies and missing medication destruction notations.a. On 02/06/26, the narcotic record showed one dose of the medication was administered to Res #7. The MAR on that date showed one dose of the medication had been refused by the resident. There was no documentation on the narcotic record of the refused tablet had been destroyed.b. On 02/07/26, the narcotic record showed one dose of the medication was administered to Res #7. The MAR on that date showed one dose of the medication had been refused by the resident. There was no documentation on the narcotic record of the refused tablet had been destroyed.c. On 02/08/26, the individual narcotic record showed one dose of the medication was administered to the Res #7. The MAR on that date showed one dose of the medication had been refused by the resident. There was no documentation on the individual narcotic record of the refused tablet had been destroyed.d. On 02/09/26, the narcotic record showed one dose of the medication was administered to Res #7. The MAR on that date showed one dose of the medication had been refused by the resident. There was no documentation on the narcotic record of the refused tablet had been destroyed.e. On 02/10/26, the narcotic record showed no medication was signed out for that date. The MAR on that date showed Res #7 was administered the one medication that was ordered.f. On 02/14/26, the narcotic record showed one dose of the medication was administered to Res #7. The MAR on that date showed one dose of the medication had been refused by the resident. There was no documentation on the narcotic record of the refused tablet had been destroyed.g. On 02/15/26, the narcotic record showed one dose of the medication was administered to Res #7. The MAR on that date showed one dose of the medication had been refused by the resident. There was no documentation on the narcotic record of the refused tablet had been destroyed.h. On 02/21/26, the narcotic record showed one dose of the medication was administered to Res #7. The MAR on that date showed one dose of the medication had been refused by the resident. There was no documentation on the narcotic record of the refused tablet had been destroyed.i. On 02/22/26, the narcotic record showed one dose of the medication was administered to Res #7. The MAR on that date showed one dose of the medication had been refused by the resident. There was no documentation on the narcotic record of the refused tablet had been destroyed.j. An undated entry on the narcotic record (immediately below the entry for 02/24/26) showed one dose of the medication was administered to the Res #7. The MAR showed on 02/25/26, one dose of the medication had been refused by the resident. There was no documentation on the narcotic record of the refused tablet had been destroyed.3. A physician order for Res #8, dated 06/03/24, showed the resident was to be administered two tramadol (opioid pain relief medication) 50 mg tablets every six hours as needed for pain.A MAR for Res #8, dated 02/2026, was compared to the resident's narcotic record, dated 06/03/24 to 02/25/26, for tramadol 50 mg tablets. The comparison showed on 02/12/26, two tramadol 50 mg tablets had been administered to Res #8 on the narcotic record. The MAR showed no doses of tramadol were documented as being administered to the resident on that date. There was no documentation on the individual narcotic record of the tablets had been destroyed.On 02/26/26 at 2:15 p.m. CMA #1 stated when a medication was refused by a resident, the CMA and the nurse were supposed to initial next to the entry on the count sheet and that would indicate the pill was destroyed.On 02/26/26 at 2:23 p.m., LPN #1 stated when a resident refused a controlled medication, the person attempting to administer the medicine was to go to their nurse with the medicine. They stated the nurse and the other person destroy the medication together and both initial on the count sheet next to the entry to indicate it was destroyed.On 02/27/26 at 8:19 a.m., RN #1 observed the 02/2026 MARs and narcotic records for Residents #1, 7, and #8. They stated each of the documents were not accurate and showed pills had been signed out but there was no documentation they were administered or destroyed. They stated they were not aware the CMAs were not telling the nurse when a resident had refused a controlled medication. They stated they were supposed to notify the nurse and then destroy the medication together.On 02/27/26 at 8:28 a.m., CMA #2 observed the 02/2026 MARs and narcotic records for Residents #1, 7, and #8. They stated each of the documents were not accurate and showed pills had been signed out but there was no documentation they were administered or destroyed. They stated all refused controlled medication were supposed to be taken to the charge nurses by the CMA and destroyed together. They stated both then initial next to the entry on the count sheet to indicate the medication was destroyed.On 02/27/26 at 8:50 a.m., CMA #1 observed the 02/2026 MARs and narcotic records for Residents #1, 7, and #8. They stated each of the documents were not accurate and showed pills had been signed out but there was no documentation they were administered or destroyed. CMA #1 stated they had just learned about the process of taking refused medications to the charge nurse on 02/26/26. They stated previous to 02/26/26 they had been destroying the medication by themselves and had not alerted the charge nurses.On 02/27/26 at 9:03 a.m., the DON stated some of the CMAs had not been following procedure to alert the charge nurses of refused narcotics. They stated nurses must be informed of refused medications and the CMA and nurse must destroy the medication together and sign off on the narcotic record.

Based on record review and interview, the facility failed to provide an environment free from abuse for 1 (#5) of 3 sampled residents whose clinical records were reviewed for abuse. The DON identified 68 residents resided in the facility. Findings:A quarterly assessment, dated 12/10/25, showed Resident #5 was moderately impaired in cognition with a BIMS score of 7, had diagnoses of non-Alzheimer's dementia, depression, and hoarding disorder; displayed verbal and physical behaviors directed toward others, and rejected care. A state reportable incident report, dated 12/10/25, showed CNA #1 accused CNA #3 (an employment agency employed CNA) of abusing Resident #5 by pinning the resident's arms behind their back and dragging the resident to a chair to sit. CNA #3 let go of the resident's arms, but grabbed the resident's wrist and squeezed. The incident report showed CNA #1 asked CNA #3 to leave. The incident report showed CNA #3 verbally antagonized Resident #5 by telling them to punch, hit, and beat the crap out of CNA #1 before CNA #3 left the room. The incident report showed Resident #5 initially claimed their arms ached all over, but soon denied any pain or discomfort and denied staff the opportunity to assess the resident for further injury. The incident report showed CNA #3 was suspended for the remainder of their shift. CNA #3 was removed from the schedule and their employment agency informed of the allegation. A witness statement signed by CNA #1, dated 12/10/25, showed three CNAs (CNA #1, CNA #2, and CNA #3) entered the resident's room to provide personal care and get the resident ready for bed. The statement showed Resident #5 approached CNA #1, grabbed, and squeezed the neck of CNA#1. CNA #1 asked CNA #3 to distract the resident by talking to them so Resident #5 would quit squeezing the neck of CNA #1. The statement showed CNA #3 had the resident's arms pinned by their back and CNA #3 used that leverage to move the resident to a chair located in the room. The statement showed CNA #1 asked CNA #3 to stop holding the resident's arms behind their back because they were hurting the resident. The statement showed CNA #3 then grabbed Resident #5 by the wrist and squeezed. The statement showed CNA #1 and CNA #2 again asked CNA #3 to stop. The statement showed CNA #3 let go of the resident's wrist and began to leave the room but stopped to verbally antagonize the resident, telling the resident to punch, hit, and beat the crap of CNA #1 and CNA #2. The statement showed Resident #5 then slapped CNA #1 across the face and began to hit CNA #1 and CNA #2 with their fist. The statement showed that after CNA #3 left the room, Resident #5 calmed and allowed CNA #1 and CNA #2 to aide them in their care. The statement showed Resident #5 complained their arms hurt all over. A witness statement signed by CNA #2, dated 12/10/25 at 10:54 p.m., showed CNA #2 attempted to aide Resident #5 in changing their brief and clothes. The statement showed Resident #5 resisted care and fought the 3 CNAs, told them to leave their room, and they would change their own brief and clothing. The statement showed as CNA #2 went to leave the room, Resident #5 walked behind them. The statement showed CNA #2 continued to encourage the resident to enter the bathroom and accept help in changing their brief and clothing. The statement showed CNA #3 grabbed the resident's pants and pulled them down, then grabbed the resident from behind, and told CNA #1 and CNA #2 to remove the resident's pants. The statement showed CNA #1 and CNA #2 instructed CNA #3 they could not force the resident to change their brief and clothing and to stop restraining the resident. The statement showed CNA #3 held the resident by their arms behind their back and pulled the resident into a chair. The statement showed the resident yelled for help and for CNA #3 to stop. The statement showed CNA #2 pleaded with CNA #3 to stop and told CNA #3 they could only coax the resident into changing their brief ,but the resident had the right to refuse and there was nothing they could do if the resident refused. The statement showed CNA #3 released the resident and the resident again instructed the CNA #1, CNA #2, and CNA #3 to leave their room. The statement showed the resident agreed to assistance with changing their brief and clothing, but then the resident repeatedly struck CNA #1 and CNA #2. The statement showed CNA #1 and CNA #2 asked CNA #3 to distract the resident so CNA #1 and CNA #2 could finish providing care to the resident while the resident was distracted. The statement showed CNA #3 held the resident down by the wrists where the resident could not move. The statement showed CNA #1 and CNA #2 were afraid the resident would get hurt and informed CNA #3 of their concerns. CNA #3 then released the resident. The statement showed the resident returned to striking CNA #1 and CNA #2 as CNA #1 and CNA #2 attempted to provide care. CNA #1 and CNA #2 again requested CNA #3 to distract the resident and CNA #3 held Resident #5 down. The statement showed CNA #1 and CNA #2 then asked CNA #3 to leave. The statement showed CNA #3 antagonized the resident by encouraging the resident to hit CNA #1 and CNA #2 as they attempted to provide care. The statement showed Resident #5 held CNA #1 by the back of the neck and struck CNA #1 in the face with their hand and their shoe. The statement showed that after CNA #3 left the room, Resident #5 calmed down and allowed CNA #1 and CNA #2 to complete the resident's care.On 12/22/25 at 4:30 p.m., CNA #1 stated they provided care to Resident #5 on 12/10/25 and witnessed CNA #3 abuse Resident #5. CNA #1 stated they were assigned to provide care to Resident #5. CNA #1 stated Resident #5 frequently resisted care and could be verbally and physically combative. CNA #1 stated it was often easier to have help in the room to aide with care and provide a diversion for the resident. CNA #1 stated they requested assistance from CNA #2 and CNA #3 to help Resident #5 prepare for bed. CNA #1 stated Resident #5 held the back of their neck and squeezed while the CNA #1 tried to provide care. CNA #1 stated they asked for help from CNA #3 who was in the room along with CNA #2. CNA #1 stated CNA #3 grabbed the resident's arms, twisted them behind the resident's back, and pulled the resident backwards to a chair in the room. CNA #1 stated they told CNA #3 they could not do that and to release the resident's arms. CNA #1 stated they continued to try to provide care and Resident #5 hit CNA #1 in the face with their hand and in the head with their shoe. CNA #1 again asked CNA #3 to help, wanting the CNA to distract the resident. CNA #1 stated CNA #3 grabbed the resident's wrist and squeezed. CNA #1 stated they again told CNA #3 they could not do that and to let the resident go. CNA #1 stated they asked CNA #3 to leave the room, but instead, CNA #3 told Resident #5 to strike out at the staff and to punch, hit, and beat the crap out of CNA #1. CNA #1 stated Resident #5 continued to strike at staff until CNA #3 left the room. CNA #1 stated once CNA #3 left the room, Resident #5 calmed and cooperated with preparing for bed. CNA #1 stated they attended a recent in-service on abuse, but could not recall if it was a month ago or longer. On 12/22/25 at 4:50 p.m., CNA #2 stated the whole situation was very odd because of the way CNA #3 was acting. CNA #2 stated CNA #3's actions were abusive when CNA #3 restrained Resident #5's arms behind their back and pulled them to a chair. CNA #2 stated CNA #3 abused Resident #5 when CNA #3 antagonized the resident by encouraging the resident to verbally and physically strike out at CNA #1 and CNA #2. CNA #2 stated they recently received an in-service on abuse and knew the facility had 2 hours to report abuse. On 12/23/25 at 3:15 p.m., the DON stated the facility routinely trained their staff on abuse and neglect with their most recent two in-services on abuse dated 11/28/25 and 12/11/25. The DON stated CNA #3 was an agency aide who had worked at the facility for the last month without incident. The DON stated the agency who employed CNA #3 performed background checks on the employees and provided a copy of the background check for CNA #3. The DON stated CNA #3 did not provide a statement and did not return their calls. The DON stated the facility provided an orientation packet to all agency staff which provided them answers to frequently asked questions, copies of policies related to abuse and neglect, and a skills check. The DON stated the facility kept a copy of the orientation packet once completed. The DON stated they were not able to find the orientation packet for CNA #3.

Based on observation, record review, and interview, the facility failed to minimize the risk of spreading infection for 1 (#6) of 1 sampled resident exposed to COVID-19. The DON identified six residents and seven facility staff members who contracted COVID-19 since 12/01/25. Findings:On 12/12/25 at 12:35 p.m., Resident #6 was observed in their room with their roommate, Resident #5. Resident #5 was in their bed and Resident #6 was standing beside their own bed. Neither resident was wearing a mask. There were no barriers between the two residents. There were no visible signs of isolation gowns, gloves, masks used within the room, such as biohazard bags of used gowns, gloves, and masks present. Resident #6's room did not have signage for isolation on or around the resident's door and no personal protective equipment (mask, gloves, gown, etc.) was stored near the entrance to their room. On 12/12/25 at 12:40 p.m., Resident #6 exited their room and walked with their walker down to the lobby area near the front office and nurses' station. Resident #6 did not have on an isolation mask. Nursing staff were observed to pass Resident #6 in the hall and lobby area. None of the staff working on the hall with the resident were observed to wear isolation masks while in the hallway and none were observed to encourage Resident #6 to wear a mask while Resident #6 was in the hallway or ask Resident #6 to return to their room. A quarterly assessment, dated 11/30/25, showed Resident #6 was severely impaired in cognition with a BIMS score of three, exhibited no behaviors, and ambulated with a walker.A care plan, dated 11/30/25, showed Resident #6 required supervision/assistance with all decision making. A nurse's progress note, dated 12/11/25, showed Resident #6 removed isolation signage from their door and personal protective equipment basket from outside of their door. A nurse's progress note, dated 12/12/25, showed Resident #6 continued to remove signage off their door and biohazard bins from their room. A lab report, dated 12/16/25, showed Resident #6 was negative for COVID-19. On 12/12/25 at 12:35 p.m., LPN #1 stated Resident #6 resided in the same room as Resident #5. LPN #1 stated Resident #5 was in isolation for COVID-19 but Resident #6 was not in isolation and could come and go from the room as they wished. On 12/12/25 at 12:45 p.m., the DON stated Resident #5 was not part of the facility's initial COVID-19 exposure testing performed on 12/01/25. the DON stated Resident #5 tested positive for COVID-19 on 12/10/25 while out of the facility for an appointment. The DON stated on 12/10/25, Resident #6 tested negative for COVID-19 and was given the option to move to another room while Resident #5 isolated in their room or remain in the room with Resident #5 in isolation. The DON stated Resident #6 decided to remain in their room with Resident #5 in isolation. The DON stated Resident #6 would remove the isolation signs, move the isolation carts from on and around their room's door, and the biohazard containers from their room. The DON stated the facility informed Resident #6 they needed to wear a mask when they left their room, but it was the resident's right to decline to wear a mask and their right to leave their room whenever they wished.

On 09/08/25 an IJ situation was determined to exist related to involuntary seclusion for 1 (#1) of 3 sampled residents reviewed for involuntary seclusion. Resident #1 was told they had to eat at a table in another room alone due to their behavior. On 09/09/25 at 2:15 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 09/09/25 at 2:25 p.m., the facility administrator and the DON were notified of the IJ situation and provided a copy of the IJ template. On 09/09/25 at 5:30 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal read in part, At 2:57pm on 9/9/2025 the DON and Care plan coordinator met with resident #1. Advised resident #1 that beginning with evening meal on 9/9/2025 she would be offered 3 locations for her meals to be taken. She could choose between main dining room, smaller dining room, or her room to have meals. Resident # 1 was agreeable to this plan. It was never the facility's intention to make resident #1 feel isolated, the facility never informed resident #1 that she had to eat alone. Facility was trying to provide alternate location for meals in a quieter setting as she self-reports that large groups or loud environments cause her to be upset. An alert has been added to EMR for resident #1 that she will be able to choose where she would like to take meals. Staff will ask resident #1 prior to each meal where she would like meal served. Care plan will be updated to reflect that resident is able to choose her dining locations. Resident #1s dietary card has been updated to reflect that meals may be taken at location of resident's choice. Facility will not ask any other resident to receive meals in small dining room unless resident requests to do so. The facility has reviewed all current residents and no other residents were identified as being secluded in any manner. In the future the facility will not seclude a resident exhibiting behavior problems that may be detrimental to other residents. If resident #1 or any other resident exhibits disruptive behaviors staff will attempt to de-escalate situation. If resident is removed from area a staff member will remain with them until behaviors have resolved. All nursing staff will receive in-service training on the above by midnight 9/9/2025. If any nursing staff is unable to be present in person they will receive in-service via phone.On 09/10/25 at 9:30 a.m., after review of the in-service records and staff interviews, the administrator and DON were informed the IJ had been removed as of 09/09/25 at 12:00 a.m.The deficient practice remained at an isolated level with the potential for minimal harm. Findings: Based on observation, record review and interview the facility failed to prevent involuntary seclusion for 1 (#1) of 3 sampled residents reviewed for involuntary seclusion.The DON identified 69 residents resided in the facility. On 09/08/25 at 12:02 p.m., Resident #1 was observed sitting alone at a table facing the wall in the day room eating lunch away from other residents. Resident #1 had a BIMS of 15 and is cognitively intact as shown in the resident's quarterly MDSResident #1 electronic medical records shows they had diagnosis which includes lymphedema, dementia with agitation, depression, epilepsy, type 2 diabetes and asthma.On 09/08/25 at 12:02 p.m., Resident #1 stated they were told by the administrator they had to eat in the day room alone so they do not disturb anyone else. Resident #1 stated they would rather be in the dining room. It makes them feel like a child being chastised. On 09/08/25 at 3:00 p.m., CMA #1 stated Resident #1 causes chaos in the dining room. They don't like to eat with certain people. On 09/08/25 at 3:15 p.m., LPN #1 stated that for several weeks in a row Resident #1 had outbursts in the dining room. They were moved from the dining room scenario to see if things were calmer.On 09/08/25 at 3:28 p.m., the director of nurses stated Resident #1 was causing disturbances in the dining room. The director of nurses stated they were trying to find a compromise for everyone involved by moving Resident #1 to the other room. 09/08/25 at 4:00 p.m., the administrator stated Resident #1 disrupts activities and meals. The administrator told the resident they cannot be disruptive during meal times. The administrator stated they have to look out for the other residents too. The administrator stated Resident #1 could go to the dining room as long as they were not disruptive.

On 08/12/25 an Immediate Jeopardy (IJ) situation was determined to exist related to pain management during wound care for 1 (#27) of 4 sampled residents reviewed for pain.On 08/13/25 at 1:00 p.m., the OSDH was notified and verified the existence of the IJ situation. On 08/13/25 at 1:39 p.m., the facility administrator and DON were notified of the IJ situation and provided a copy of the IJ template. On 08/13/25 at 5:20 p.m., an acceptable plan of removal was submitted to the OSDH. The plan of removal read in part, a pain assessment was completed on Resident #27 at 3:00 p.m., on 08/13/25. PCP [primary care physician] for Resident #27 was contacted and a new order for Tramadol, an analgesic, was obtained. Staff will offer PRN [as needed] pain medication approximately 30 minutes prior to wound care. Care plan for Resident #27 will be updated accordingly. For all other residents a new pain assessment will be completed by 12:00 p.m., tomorrow (08/14/25). All employees will be in-serviced on pain management including recognition of pain (verbal and non-verbal signs) by midnight 08/13/25. If employee is unable to come in person for training they will receive training over the phone and then in person training prior to the beginning of their next shiftOn 08/14/25 at 3:30 p.m., the administrator and the DON were informed the IJ had been removed as of 08/14/25 at 12:00 p.m., when all components of the plan of removal had been completed. On 08/14/25 interviews were conducted with a total of 14 employees who worked different shifts in the nursing department. The employees verified they had been in-serviced regarding the components documented in the plan of removal and that they understood the information. The deficiency remained at an isolated level with the potential for more than minimal harm.Based on observation, record review and interview the facility failed to assess, monitor, and intervene for pain for 1 (#27) of 4 sampled residents reviewed for pain. The DON identified four residents with wounds.Findings:On 08/12/25 at 1:14 p.m., during wound care, Resident #27 was observed grimacing, stiffening, and stated Ow, Ow!. LPN #1 did not stop the wound care or address Resident #27's pain. An undated policy titled Policy and Procedure for Pain Identification and Treatment, read in part, It is the policy of this facility to identify the presence of pain in residents and to implement treatment strategies in an effort to alleviate or minimize pain, consistent with the resident's goals, while assisting the resident to maintain a high level of functioning as possible and to maintain or improve his/her quality of life.A medical diagnosis list, dated 06/12/25, showed Resident #27 admitted to the facility with diagnoses which included type 2 diabetes, Alzheimer's disease, peripheral vascular disease and hypertension. A pain assessment form dated 06/30/25 showed the resident did not have pain at that time. An entry assessment dated , 07/30/25, showed Resident #27 had a BIMS score of 5 and was severely cognitively impaired.A wound care order, dated 08/02/25, read in part, Apply gentian violet solution [antiseptic to treat skin infections] to amputated surgical incision on right foot, coccyx, and to right heel topically every shift for wound care. Clean wound with normal saline, pat dry, apply with sterile cotton tip applicator gentian violet to wound bed, leave open to air. The treatment administration record showed from 8/02/25 through 08/12/25 the resident had not been assessed for pain during wound care for 35 missed opportunities. On 08/12/25 at 3:20 p.m., LPN #1 stated they had not assessed Resident #27 for pain prior to wound care of the coccyx. LPN #1 stated they did not know if Resident #27 had medication ordered for pain. LPN #1 stated they should have stopped the wound care when Resident #27 voiced they were in pain. LPN #1 stated they did not know why they did not stop, and it was wrong.On 08/13/25 at 8:08 a.m., CNA #1 stated Resident #27 exhibits pain with wound care. CNA #1 stated they clinched their teeth and sometimes they moaned.On 08/13/25 at 8:34 a.m., CNA #2 stated Resident #27 has pain during wound care. CNA #2 stated they tensed up and sometimes yelled out or would tell them not to do wound care because it hurt.On 08/13/25 at 11:03 a.m., Resident #27 stated they had pain every time wound care was done. They stated their pain was an 8 on a scale of 1 to 10.On 08/13/25 at 4:03 p.m., the DON stated they did not know why Resident #27 did not have pain medication ordered.

Based on observation, record review, and interview, the facility failed to:ensure opened containers in the reach in refrigerator were properly labeled; andensure the top of the oven was free of grime and debris. The DON identified 65 residents received meals prepared in the kitchen.Findings:On 08/06/25 at 10:00 a.m., a tour of the kitchen was conducted. The following observations were made:a. an opened gallon container of orange drink, an opened 48-ounce container of grape juice, an opened 48-ounce container of prune juice, and an opened 46-ounce container of thickened lemon water were observed in the reach in refrigerator. None of the open containers were labeled with the date they were opened, andb. the top of the oven was covered with debris and the walls above the oven were coated with sticky brown substance.An undated facility policy titled Refrigerated Storage, read in part, The opened unused portions of packaged foods should be dated to ensure they are used first.An undated facility policy titled Cleaning schedules showed the oven and the walls should be cleaned weekly.On 08/06/25 at 10:55 a.m., dietary aide #1 stated once items were opened, they should be labeled with the date they were opened.On 08/11/25 at 11:09 a.m., the dietary manager stated they were new and not aware opened items in the reach in cooler were supposed to be labeled with the date they were opened. They stated the oven and the area around it should be thoroughly cleaned.

Based on record review and interview, the facility failed to ensure a facility assessment included residents with wounds and the training and competency required to treat wounds.The DON identified four residents with wounds resided in the facility.Findings: A Facility-Wide Assessment, reviewed 07/30/25, did not address residents with wounds in the facility. The assessment did not address training and competency for staff regarding wounds. On 08/14/25 at 12:53 p.m., the administrator was asked why the facility assessment did not address wounds in the facility. They stated, That is something we will add to that. The administrator was asked why the facility assessment did not address wound training. They stated, We will take care of that immediately.

Based on record review and interview, the facility failed to ensure training was provided for staff on wound care.The DON identified four residents had wounds in the facility.Findings: A Facility-Wide Assessment, reviewed 07/30/25, did not address training and competency regarding wound care for residents with wounds. Review of employee records did not show employees were trained and competent in wound care. On 08/14/25 at 12:55 p.m., the DON stated they did not know if they had a specific way to determine nurses were competent in identifying and treating wounds.

Based on record review and interview, the facility failed to ensure an advance directive was offered to 1 (#30) of 1 sampled resident reviewed for advance directives.The DON identified 69 residents resided in the facility.Findings: A quarterly assessment, dated 05/19/25, showed a BIMS of 15 which indicated Resident #30 was cognitively intact for daily decision making. The assessment showed diagnoses which included neurogenic bladder and quadriplegia. Review of the clinical record showed no advance directive acknowledgement to indicate Resident #30 had been offered an opportunity to develop an advanced directive. On 08/11/25 at 4:28 p.m., the DON was asked to provide an advance directive acknowledgement for Resident #30. On 08/12/25 at 7:52 a.m., the DON stated they did not find an advance directive acknowledgement for Resident #30. An advance directive acknowledgement was not provided for Resident #30 by the end of the survey.

Based on observation, record review and interview, the facility failed to notify of a room change for 1 (#3) of 1 sampled resident reviewed for notification of change.The DON identified 69 residents resided in the facility.Findings: On 08/12/25 at 9:00 a.m., Resident #3 was observed to have been moved to another room. An undated facility document titled Policy and Procedure for Notification of Change, read in part, Except in a medical emergency or when a resident is incompetent, this facility will consult with the resident immediately and notify the resident's physician, and if known, the resident's legal representative or interested family member within 24 hours when there is .a change in room or roommate assignment (said notice shall include cost of transferring resident's telephone, if applicable). Review of clinical progress notes for Resident #3 showed no notification was made to a representative regarding a room change. A quarterly assessment, dated 07/07/25, showed a BIMS of 00, which indicated Resident #3 was severely impaired for daily decision making. The assessment showed diagnoses which included heart failure, hypertension, cerebrovascular accident, and seizure disorder. A facility Notice of Room or Roommate Change form, dated 08/10/25, provided by the DON, showed it was for a room change and had no documented reason for a room change. The form showed a scribble mark for a resident's signature with the nurse's printed name below the resident's scribble mark. On 08/12/25 at 9:36 a.m., the DON stated Resident #3 was moved over the weekend to another room. They stated notification should have been made prior to the move and documented in the clinical record. The DON stated Resident #3 had been moved to accommodate another resident's request due to an issue with their roommate. On 08/12/25 at 10:39 a.m., the representative of Resident #3 stated they were not made aware of the move for Resident #3 until Monday 08/11/25 after Resident #3 had been moved. They stated the facility did not ask. The representative stated the facility called them and told them they had moved Resident #3.

Based on record review and interview, the facility failed to ensure unnecessary psychotropic medications were not administered to 1 (#74) of 5 sampled residents reviewed for unnecessary medications.The DON identified 57 residents received psychotropic medications in the facility.Findings: An admission record showed Resident #74 admitted to the facility on [DATE] and had diagnoses which included dementia, anxiety disorder, and post-traumatic stress disorder. A minimum data set assessment had not been completed and a BIMS was not established. A physician's order, dated 08/04/25, showed to administer Risperdal (an antipsychotic) 1 mg one tablet by mouth at bedtime related to dementia unspecified severity with other behavioral disturbance. A physician's order, dated 08/06/25, showed to administer Risperdal 0.5 mg one tab by mouth at bedtime related to dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety for 14 days. The order had an end date of 08/20/25. A review of the August 2025 medication administration record showed Risperdal 0.5 mg was not administered on 08/06/25 and was to be on held on 08/07/25 and 08/08/25. On 08/11/25 at 2:07 p.m., Resident #74 stated they did not know why they were taking Risperdal. They stated they did not want the facility to give them that medication. On 08/11/25 at 2:18 p.m., the DON stated Resident #74 came to the facility from a geriatric psychiatric hospital. They stated the Risperdal was a medication the facility would try to get Resident #74 off of due to an inaccurate diagnosis. The DON stated the nurse practitioner wrote an order on 08/06/25 to decrease the Risperdal to 0.5 mg, but the nurse did not discontinue the 1 mg Risperdal order. They stated Resident #74 received both the 1 mg and 0.5 mg Risperdal over the weekend. The DON stated the Risperdal 1 mg was an unnecessary medication.

Based on observation, record review, and interview, the facility failed to ensure nurses were competent in identifying and assessing pain during wound care for 1 (#27) of 4 sampled residents reviewed for wound care.The DON identified four residents had wounds in the facility.Findings: On 08/12/25 at 1:14 p.m., during wound care, Resident #27 was observed to grimace, stiffen their body, and stated Ow, Ow!. LPN #1 was observed to not stop the wound care or address Resident #27's pain. Review of employee files did not show training was completed for wound care.On 08/12/25 at 3:20 p.m., LPN #1 stated they had not assessed Resident #27 for pain prior to wound care. They stated they did not know if Resident #27 had medication ordered for pain. LPN #1 stated they should have stopped the wound care when Resident #27 voiced they were in pain. They stated they did not know why they did not stop and it was wrong.On 08/14/25 at 12:55 p.m., the DON stated they did not know if they had a specific way to ensure the nurses were competent in identifying and treating wounds.

Based on record review and interview, the facility failed to provide catheter care as ordered for 1 (#5) of 3 sampled residents reviewed for catheter care. The DON reported the census was 67. Findings: A physician's order, dated 01/30/25, showed staff were to cleanse the area around the suprapubic catheter and the catheter tubing with soap and warm water or normal saline every shift. An annual assessment, dated 02/19/25, showed Res #5 had a BIMS score (a test for cognition) of 15, which was indicative of being cognitively intact for daily decision making. The assessment also showed Res #5 had an indwelling urinary catheter. A treatment administration record, dated 05/2025, showed for the first 17 days of May out of 51 opportunities to provide catheter care it was completed 31 times. The record showed the resident refused 16 times and there was no documentation of catheter care on the evening shift on 05/06/25, the night shift on 05/07/25, or the day shift on 05/10/25. On 05/20/25 at 10:45 a.m., Res #5 stated CNAs never performed catheter care on them. They also stated only one nurse routinely performed catheter care on them and the other nurses did not even ask if they wanted it done. On 05/21/25 at 10:35 a.m., LPN #1 stated Res #5 did not want them to provide care. LPN #1 stated if there was no one else available to provide care they charted Res #5 refused, but they did not go into Res #5's room and ask them. On 05/20/25 at 2:25 p.m., the DON stated nurses should not document the resident refused care if they did not offer the care.

Based on record review and interview, the facility failed to ensure the accuracy of medical records for 1 (#5) of 3 sampled residents reviewed for catheter care. The DON reported the census was 67. Findings: A physician's order, dated 01/30/25, showed staff were to cleanse the area around the suprapubic catheter and the catheter tubing with soap and warm water or normal saline every shift. An annual assessment, dated 02/19/25, showed Res #5 had a BIMS score (a test for cognition) of 15, which was indicative of being cognitively intact for daily decision making. The assessment also showed Res #5 had an indwelling urinary catheter. A Documentation Survey Report V2, dated 05/2025, showed CNA #1 documented they had performed catheter care on Res #5 on 05/05/25, 05/09/25, and 05/16/25. The report also showed CNA #6 had documented they had performed catheter care on Res #5 on 05/07/25, 05/08/25, 05/14/25, and 05/21/25. On 05/21/25 at 9:30 a.m., CNA #6 stated they did not go into Res #5's room. They also stated they did not perform catheter care on Res #5. CNA #6 stated they documented the catheter care was complete because they assumed the nurse had done it. On 05/21/25 at 10:40 a.m., CNA #1 stated they did not perform catheter care on Res #5 on 05/05/25, 05/09/25 or 05/16/25. On 05/21/25 at 1:50 p.m., the DON stated if the CNAs did not perform catheter care they should not have documented they did.

Based on record review and interview, the facility failed to provide written notice of a room change for 1 (#4) of 3 sampled residents reviewed for room changes. The DON reported the census was 67. Findings: An undated facility policy titled Policy and Procedure for Notification of Changes, read in part, The facility will also notify the resident, and if known, the resident's legal representative or interested family member within 48 hours when there is a change in room or roommate assignment. A resident list report, dated 10/16/24, showed Res #4 resided in room [ROOM NUMBER] bed A. A quarterly assessment, dated 03/15/25, showed Res #4 had a BIMS score (a test for cognitive function) of 0, which was indicative of severe impairment for daily decision making. A resident list report, dated 05/15/25, showed Res #4 resided in room [ROOM NUMBER] bed A. A review of Res #4's medical record did not show Res #4 or their representative had been notified in writing of the room change. On 05/20/25 at 2:25 p.m., the DON stated they did not have documentation showing Res #4 or their representative was given any notice of the room change.

Based on record review and interview, the facility failed to provide imaging services as ordered for 1 (#5) of 3 sampled residents reviewed for imaging services. The DON reported the census was 67. Findings: A physician's order, dated 12/29/24, showed Res #5 had a chest x-ray on 12/29/24. A nurse note, dated 12/29/24 at 7:33 p.m., showed Res #5 informed the nurse they were supposed to have a chest x-ray on 12/27/24 and they never got it. The note also showed the administrator was contacted and they confirmed Res #5 was supposed to have an x-ray on 12/27/24. An annual assessment, dated 02/19/25, showed Res #5 had a BIMS score (a test for cognition) of 15, which was indicative of being cognitively intact for daily decision making. The assessment also showed Res #5 had an indwelling urinary catheter. On 05/20/25 at 10:45 a.m., Res #5 stated they were supposed to have a chest x-ray on 12/27/24 and they did not get it until 12/29/24. On 05/20/25 at 1:50 p.m., the DON stated Res #5 should have had an x-ray on 12/27/24, but the nurse did not put in the order. The DON also stated Res #5 did not get the x-ray until 12/29/24.

Based on record review and interview, the facility failed to ensure appropriate hand hygiene was performed during catheter care for one (#1) of three residents reviewed for catheter care. The DON identified five residents with catheters in the facility. Findings: An undated facility policy titled Procedure for Indwelling Urinary Catheters, read in part, .Catheter care will be provided periodically throughout the day .Staff will assist the resident to [their] room, provide privacy and provide care consistent with techniques that prevent cross contamination . Resident #1 had diagnoses which included quadriplegia and neuromuscular dysfunction of the bladder. On 10/17/24 at 10:32 a.m., catheter care was observed for Resident #1. CNA #1 was seen to don gloves, cleanse around the area of the catheter and without changing gloves or performing hand hygiene, then touched the resident's table and computer keyboard. LPN #1 was observed to don gloves, cleanse the area around the catheter with a 4x4, place the soiled 4x4 in the trash can, touch the side of the trash can with their gloved hand, and then place a clean dressing on the catheter site without changing gloves or performing hand hygiene. On 10/17/24 at 10:45 a.m., CNA #1 stated they should have performed hand hygiene and changed gloves before moving from dirty to clean areas. On 10/17/24 at 10:55 a.m., LPN #1 stated they should have changed gloves before placing the clean dressing on Resident #1. On 10/17/24 at 2:15 p.m., the DON stated gloves should be changed during catheter care when moving from soiled to clean areas.

Based on observation and interview, the facility failed to: a. provide for the residents' dignity for three (#55, #4, and #50) of three residents observed for full visual privacy and for two (#50 and #26) of two residents observed with signage to always keep the residents' door open; and, b. provide enough dishware to allow for meals to be served without use of disposable containers and/or cutlery. The DON identified 73 residents in the facility. Findings: 1. Resident #55 had diagnoses which included dysphagia. On 07/15/24 at 10:28 a.m., there was no privacy curtain observed to provide privacy for the middle bed of a three-bed bedroom. On 07/15/24 at 10:30 a.m., stated they had episodes of incontinence. The resident stated the staff closed the door but there was no curtain to provide full visual privacy from the two roommates. On 07/17/24 at 3:30 p.m., CNA #6 stated the staff pulled the door closed and pulled the curtains around bed A and bed C but did not have a curtain to pull for B bed to provide full visual privacy for the resident. - Resident #4 had diagnoses which included PTSD and depression. On 07/16/24 at 3:18 p.m., there was no privacy curtain observed to provide privacy for the middle bed of a three-bed bedroom. On 07/16/24 at 3:20 p.m., Resident #4 stated they did not have privacy in their own room. They stated they did not have a curtain to pull for visual privacy and their roommates frequently yelled out day and night which made her feel as though they had no privacy at all. On 07/17/24 at 3:30 p.m., CNA #6 stated the staff pulled the door closed and pulled the curtains around bed A and bed C but did not have a curtain to pull for B bed to provide full visual privacy for the resident. On 07/22/24 at 6:15 p.m. the DON stated they had not noticed the lack of privacy curtains for the middle bed in the rooms in the rooms with three residents. The DON stated the staff would not be able to provide full visual privacy for those without a curtain. The DON stated they would have expected the nursing staff to have notified the housekeeping supervisor and the DON of the missing privacy curtains. - Resident #50 had a diagnosis which included anoxic brain damage. An Annual Assessment, dated 04/15/24, documented Resident #50 had severe cognitive impairment. On 07/16/24 at 12:32 p.m., there was a sign on the door stating to keep the door open at all times. The resident's bed was closest to the door and the privacy curtain was observed pulled around the bed and pinned low and to the wall beside the door with a tack, leaving a gaping open area above the tack to observe the resident. Facility residents were observed to stand at the door and to look in at the resident from over the privacy curtain. Resident #50 was observed laying in bed, flat on their back, with their hospital gown up around their chest and their abdomen, pelvic/pubic area, and legs exposed for viewing. On 07/22/24 at 2:45 p.m., LPN #5 stated they were to keep the door open at all times to allow staff to check on the resident frequently. The LPN stated they pinned the privacy curtain to the wall because the curtain track did not reach all the way to the wall, which left the resident visible to others. On 07/22/24 at 3:00 p.m., the DON stated they provided privacy by keeping the curtain pinned to the wall but since that did not work they would try other options to limit the resident's exposure. The DON stated they would need to get a longer curtain track. - Resident #26 had diagnoses which included dementia. On 07/15/24 at 10:00 a.m., a sign on the door to Resident #26 read to keep door always open to allow for Resident #26 to be observed in bed. On 07/22/24 at 6:15 p.m. the DON stated Resident #26 had frequent falls and one intervention was to keep the door open at all times to allow for frequent observations. The DON stated the resident did not seem to mind having their door open but the DON could see how the signage on the door might be construed as a dignity issue. 2. On 07/15/24 at 07:40 a.m., cook #1 was observed to plate food in styrofoam containers. [NAME] #1 stated there were some residents who would write or otherwise mark up the dishware and there were other residents who would poke one another with their cutlery. The cook stated to help mitigate the behaviors, some residents received their meals in styrofoam containers and some residents who received plasticware to eat with instead of the standard cutlery. On 07/15/24 thru 07/19/24 and on 07/22/24, meals were observed to be served with side dishes/deserts in styrofoam containers. On 07/22/24 at 2:10 p.m., the dietary manager stated the facility did not have enough bowls to serve all side items to the residents and the lids for the bowls were expensive. The dietary manager stated the kitchen staff used small styrofoam container to serve the side items. 46703

Based on record review and interview, the facility failed to ensure residents were not charged separately for services paid for by Medicare/Medicaid for one (Resident #174) of four residents who were charged room and board during covered periods of stay and for four (#8, #44, #55, and #174) of four residents charged for administrative supplies and whose monies were managed in the Resident Trust. The BOM identified 38 residents with funds in the Resident Trust. Findings: Resident #174 had diagnoses which included depression. On 07/19/24 at 10:30 a.m., the Trust Transaction History for Resident #174 was reviewed and compared to the facility's monthly billing statements from admission to 07/19/24 with BOM and Administrator #2. The transaction history and facility statements documented the following: February 2024 facility statement documented a charge of $2015.00 for Medicaid pending stay from 01/19/24 to 01/31/24 which left a balance due of $2015.00; Resident #174 trust transactions with posting dates of January thru February 2024: - 01/22/24 balance of $95.47 in trust account; - 01/29/24 $24.00 purchase for a trust balance of $71.47; - 02/05/24 $44.00 purchase for a trust balance of $27.47; - 02/16/24 $10.00 cash deposit for trust balance of $37.47; - 02/16/24 $10.00 withdrawal for a trust balance of $27.47; The March 2024 facility statement documented a forwarded balance due of $2015.00 and the following transactions: - 01/19/24 $2015.00 payment for facility stay 01/19/24 through 01/31/24. - 02/16/24 $490.00 cash payment by Resident #174; - 03/13/24 $3800.00 charge for room and board charges for 03/13/24 through 03/31/24 which left a monthly balance due of $3310.00. The Resident #174 trust transactions with posting dates of March 2024: - 03/01/24 deposit of $552.00 for a trust balance of $579.47; - 03/04/24 payment to facility of $447.00 for a trust balance of $102.47; - 03/22/24 February interest accrued of $0.00 for a trust balance of $102.47; - 03/26/24 $37.91 store purchase for a trust balance of $64.56; The April 2024 facility statement documented a forward balance due of $3310.00 and the following transactions: - 03/07/24 $477.00 facility payment; - 03/13/24 $1400.00 payment for room and board charges for 03/13/24 thru 03/19/24 which left a monthly balance due of $1433.00. The Resident #174 trust transactions with posting dates of April 2024: - 04/03/24 $477.00 facility payment for a trust balance of $(-412.44); - 04/03/24 deposit of $552.00 for a trust balance of $139.56; - 04/19/24 $104.42 store purchase for a trust balance of $35.14; - 04/24/24 $3.25 purchase to order new checks to draw on Resident Trust funds for a trust balance of $31.89. The May 2024 facility statement documented a forward balance due of $1433.00 and the following transactions: - 04/10/24 $1431.00 payment (no description of payment documented) - 04/10/24 $954.00 charge (listed as payment); - 01/19/24 $477.00 liability charge due for 01/19/24 through 01/22/24; - 02/01/24 $477.00 liability charge due for 02/01/24 through 02/05/24; - 03/20/24 $2400.00 payment for room and board charges for 03/20/24 through 03/31/24; - 04/04/24 $477.00 liability charge due for 04/01/24 through 04/08/24; and - 05/01/24 $236.00 liability charge due for 05/01/24 through 05/06/24 (liability charge change due to an adjustment in liability to cover other insurance premiums) which left a balance due of $223.00. The Resident #174 trust transactions with posting dates of May 2024: - 05/03/24 $44.00 purchase for a trust balance of $(-12.11); - 05/03/24 $72.00 insurance premium for a trust balance of $(-84.11); - 05/03/24 $236.00 facility payment for a trust balance of $(-320.11); - 05/03/24 $110.00 insurance premium for a trust balance of $(-430.11); - 05/03/24 deposit of $552.00 for a trust balance of $121.89; - 05/03/24 $59.00 insurance premium for a trust balance of $62.89; The June 2024 facility statement documented a forward balance due of $223.00 and the following transactions: - 05/13/24 $236.00 payment - 06/01/24 $236.00 liability charge for 06/01/24 through 06/03/24 which left a balance due of $223.00. The Resident #174 trust transactions with posting dates of June 2024: -06/03/24 $552.00 deposit for a trust balance of $614.89; - 06/04/24 $44.00 store purchase for a trust balance of $570.89; - 06/04/24 $59.00 insurance premium for a trust balance of $511.89; - 06/04/24 $223.00 facility payment for a trust balance of $288.89; - 06/04/24 $110.00 insurance premium for a trust balance of $178.89; - 06/04/24 $72.00 insurance premium for a trust balance of $106.89; - 06/20/24 $67.51 store purchase for a trust balance of $39.38; and, - 06/27/24 $5.00 cash withdrawal for a trust balance of $34.38. The July 2024 facility statement documented a forward balance due of $223.00 and the following transactions: - 06/13/24 $223.00 payment - 07/01/24 $236.00 liability charge for 07/01/24 through 07/08/24 which left a balance due of $236.00. The Resident #174 trust transactions with posting dates of July 2024: - 07/03/24 $236.00 facility payment for a trust balance of $(-201.62); - 07/03/24 $552.00 deposit for a trust balance of $350.38; - 07/03/24 $110.00 insurance premium for a trust balance of $240.38; - 07/03/24 $72.00 insurance premium for a trust balance of 168.38; and - 07/03/24 $59.00 insurance premium for a trust balance of $109.39. On 07/19/24 at 11:15 a.m., the BOM stated the resident had discharged from the facility and would receive the remaining funds of $109.38 still in the Resident Trust, plus any accrued interest, within 30 days of their discharge. On 07/19/24 at 11:30 a.m., the BOM stated they enter charges on a resident's account based on their instructions from corporate. The BOM stated the resident would have paid the $490.00 for their estimated portion of the cost of the facility charges and once the actual amount was determined, their account should have been credited the difference. The BOM stated the resident did not have a payment due for January 2024. They stated the resident was charged $477.00 for their stay for February 2024. The BOM stated the resident started a skilled nursing stay toward the end of February and would not have incurred a room and board charge for their stay in March 2024. The BOM stated the facility resumed charging Resident #174 at a rate of $477.00 per month in April 2024, when the resident discharged from skilled services. The BOM stated there were adjustments which lowered the facility charges in May, June, and July to allow for insurance premiums for vision, hearing, and dental insurance coverage. The BOM stated Medicaid covered all of the charges for January and the resident should not have been charged for January 2024 room and board. The BOM stated Medicare covered the skilled days starting 02/02/24 and ending 04/03/24 and the resident should not have been charged for room and board in March 2024. The BOM stated the the billing errors were entered at the corporate level and the facility accounting of the resident's Trust was correct based on the information they received. On 07/19/24 at 11:35 a.m., Administrator #2 stated the facility charges billed to the resident's account during the resident's skilled stay from 02/19/24 to 04/03/24 were incorrect and the corporate person responsible for entering the transactions no longer worked for the corporation. The business office manager identified 38 residents in the facility trust. 1. Resident #8, #44, #55, #174 had monies deposited in the facility's Resident Trust account. On 04/24/24, a charge of $3.25 was applied to each of their accounts for the purchase of checks. On 07/19/24 at 11:25 a.m., the BOM stated $3.25 was charged to each persons' account in the Trust to purchase new checks drawn on the Residents' Trust account. The BOM stated when the Trust needed more checks, they divided up the cost of ordering the checks by the number of residents with monies in the Trust so the cost was shared among all. The BOM stated the checks were used to pay the facility's fees for room and board, insurance costs (such as vision, hearing, and dental), and resident purchases (such as Walmart).

Based on observation, record review, and interview, the facility failed to ensure skin assessments were conducted for two (#42 and #3) and failed to ensure orders for intravenous care were obtained upon return from the hospital for one (#8) of three sampled residents who were reviewed for quality of care. The DON identified 73 residents who resided in the facility and one resident with intravenous access. Findings: The undated Procedure for Care of the Central Venous Catheter policy, read in parts, .Specific flush orders are obtained from the physician .DRESSING CHANGE Frequency .24 post insertion or on admission, at least weekly . 1. Resident #42 had diagnoses which included hypertension. The Order Recap Report, dated 07/03/24 through 07/31/24, read in part, .Skin assessment to be completed within 24 hours of admission and then at least every 7 days thereafter .Order Date 07/03/24 . The Admit/Readmit Screener, dated 07/03/24, documented the resident had right antecubital bruising. The Care Plan, dated 07/03/24, documented Resident #42 required weekly skin inspections. The admission assessment, dated 07/10/24, documented the resident was cognitively intact for daily decision making. On 07/15/24 at 9:53 a.m., Resident #42 stated the facility was supposed to obtain a cream for under their breast but they had not been applying any treatment. On 07/18/24 at 10:58 a.m., skin assessments for Resident #42 were requested from the DON. The Skin Observation Tool, dated 07/18/24 at 1:22 p.m., documented the resident had redness with a foul odor noted under their left breast and new orders were received. A Physician's Order, dated 07/18/24, documented Resident #42 was ordered Nystatin powder under the left breast twice daily for ten days. On 07/19/24 at 12:44 p.m., the DON stated the charge nurses were to complete skin assessments weekly and document them in the electronic health record. They stated they did not know why Resident #42 had not had skin assessments conducted between 07/03/24 and 07/18/24. 2. Resident #3 had diagnoses which included a history of erysipelas (an infection of the outer layers of skin) and cellulitis. The Care Plan, revised 04/29/24, documented the resident required weekly skin inspections and to report to the charge nurse if the resident has any open areas, redness, bruises, scratches, or cuts. The Skin Observation Tool, dated 07/03/24, documented Resident #3 had scabbed areas to the bilateral lower legs, to encourage the resident to not pick at the scabbed areas, and the resident's nails were trimmed. On 07/15/24 at 11:02 a.m., Resident #3 was observed to have superficial open areas to the bilateral lower legs. No dressings or bandages were observed. Resident #3 stated the staff used to place dressing on their legs but have not done so recently. On 07/16/24 at 11:45 a.m., Resident #3 was observed in their room with superficial open areas to both lower legs. No bandages or dressings were observed. The Skin Observation Tool, dated 07/20/24, documented Resident #3 had nervously scratched sores to the bilateral lower legs, they were cleaned, and a treatment had been ordered. A physician order, dated 07/21/24, documented to apply genetian violet 1% to the bilateral lower leg scabbed areas daily. On 07/22/24 at 12:33 p.m., the DON stated they did not know why Resident #3 had not had a skin assessment between 07/03/24 and 07/20/24. They stated skin assessments were to be completed weekly by the charge nurses. They stated the areas the resident had scratched/picked at on the bilateral lower legs should have been addressed before 07/20/24. 3. Resident #8 had diagnoses which included atrial fibrillation. The Admit/Readmit Screener, dated 07/09/24, documented the resident had returned from a hospital stay and had a midline placed in the left arm. The Care Plan updated 07/11/24, documented the resident had returned from the hospital with an order for an intravenous antibiotic. On 07/16/24 at 1:20 p.m., Resident #8 was observed to have a PICC line to their left upper arm. Review of the July medication and treatment administration records did not reveal orders for PICC line care. On 07/19/24 at 11:35 a.m., LPN #2 stated the facility had one resident with intravenous access. They stated the protocol was for the nurse assigned to treatments to flush the access every shift, change the dressing every three days, and to document on the treatment administration record. They stated LPN #1 was assigned to treatments. On 07/19/24 at 11:37 a.m., LPN #1 stated Resident #8 was not ordered any treatments related to the PICC line. They stated the charge nurse was going to speak to the physician about discontinuing the PICC line. On 07/19/24 at 11:39 a.m., LPN #1 observed the PICC line in Resident #8's left upper arm. They stated the dressing was dated 07/08 and had not been changed since the resident was readmitted from the hospital on 07/09/24. On 07/19/24 at 11:41 a.m., the DON stated the treatment nurse was to complete the dressing changes and flushes for the PICC line for Resident #8. The DON reviewed the electronic health record and stated they did not know why but they had not obtained orders from the physician for flushes or dressing changes for the PICC line for Resident #8 when they were readmitted from the hospital.

On 06/10/22 at 5:11 p.m., an Immediate Jeopardy (IJ) was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to assess and monitor the residents' skin condition facility wide and failed to assess, monitor, or intervene on residents' with pressure ulcers resulting in infected wounds requiring hospitalization and surgical intervention for resident #1 and #2; four previously unidentified wounds for resident #2; and three previously unidentified pressure injuries for resident #3. At 5:20 p.m., the facility's administrator and DON was made aware of the IJ situation related to the facility's failure to assess, monitor, and intervene on residents' with pressure ulcers. On 06/13/22 at 1:02 p.m., the administrator provided an acceptable plan of removal. The plan of removal, dated 06/10/22, documented, 6/10/2022 Plan of removal for alleged Immediate Jeopardy called at 5:11pm on 6/10/22 All facility residents received a complete head to toe skin assessment on 6/9/2022 All facility residents will receive a complete skin assessment at least every 7 days Newly admitted residents will receive a full skin assessment on day one of admission and then at least every 7 days thereafter. All newly admitted residents with wounds will have a wound assessment completed on day one and then at least every 7 days thereafter. All residents with newly identified wounds will have a completed wound assessment on day one of discovery and then at least every 7 days thereafter. All residents that have existing wounds will have appropriate treatment orders in place. All newly admitted residents with wounds and any resident with newly discovered wounds will have appropriate treatments in place on day one of admission or discovery. If regular nurse assigned to complete wound assessments is unavailable for whatever reason and unable to complete assessments within the 7 day period another licensed nurse will complete assessment All LPN and RNs will receive inservice training by Saturday 6/11/2022 at 12:00pm, [any individual that is unable to attend inservice training in person will be provided inservice training over the phone with in person inservice provided at the beginning of their next scheduled shift]. Inservice will cover appropriate wound care based on current standards of practice related to cross contamination/infection control including: o Proper method to clean wound to prevent cross contamination o Proper hand washing and hygiene related to wound care to prevent cross contamination o Importance of treating each identified area as an individual wound requiring separate cleansing with separate materials o Completing wound assessments/evaluations as stated above. All LPN and RNS will receive inservice training by Saturday 6/11/2022 at 12:00pm regarding completion of weekly skin assessments as stated above. [any individual that is unable to attend inservice training in person will be provided inservice training over the phone with in person inservice provided at the beginning of their next scheduled shift]. All nursing staff [RN, LPN, CMA, CNA] will receive inservice training by Saturday 6/11/2022 at 12:00pm regarding completion of weekly skin assessments as stated above. [any individual that is unable to attend inservice training in person will be provided inservice training over the phone with in person inservice provided at the beginning of their next scheduled shift]. Inservice will cover observing and reporting of development of wounds and other skin conditions. o CNA should be observing skin on all residents daily during routine care such as dressing, undressing, bathing, incontinent care, and toileting o Any newly observed change in skin should be reported immediately by completing a STOP/WATCH form which should be turned in to charge nurse .within 30 minutes of observation or as soon as possible after providing care and ensuring residents safety but not to exceed 1 hour after observation .copy is to be provided to DON and Administrator .If DON and/or administrator not on site call is to be placed to administrator or DON within the 1 hour timeframe of observation o Any newly observed change in skin should be documented through POC charting which will flag observation to nurse for further evaluation/assessment o Nurses will check and address flagged notifications at least 3 times during the course of their shift .Any individual that is unable to attend inservice training in person will be provided inservice training over the phone with in person inservice provided at the beginning of their next scheduled shift .DON/ADON/or appointed designee will monitor for compliance by o Monitoring for completion of assessments as stated above at least daily x 2 weeks then 3X weekly X 4 weeks then weekly x 4 weeks then randomly but at least monthly o Monitoring charts on all new admissions within 24 hours of admit to ensure completion of assessments will be per admission X 60 days then will re-evaluate o Monitoring wound assessments weekly to ensure compliance with assessment being completed at least every 7 days X 2 monthly QAPI meetings then will re-evaluate o Reviewing skin assessment forms at least daily x 2 weeks then 3X weekly X 4 weeks then weekly x 4 weeks then randomly but at least monthly to ensure forms are being fully and appropriately completed o Random observations at least 3x weekly of CNAs providing care such as dressing/undressing, bathing, toileting and incontinent care to monitor method of skin observation and subsequent reporting of findings o Random observations of LPN/RN providing wound care to ensure proper infection control practices are being observed at least 3x weekly X 2 monthly QAPI meetings then will re-evaluate o Random observations of LPN/RN completing wound assessments/evaluations at least weekly X 2 monthly QAPI meetings then will re-evaluate. On 06/14/22, interviews were conducted with a total of fifteen employees who worked different shifts in the nursing department. The employees verified they had been in-serviced regarding the components documented in the plan of removal and that they understood the information provided. On 06/14/22 at 5:00 p.m., the administrator and DON were informed the IJ had been removed as of 06/10/22 at 11:00 p.m. when all components of the plan of removal had been completed. The deficient practice remained at a level of harm at a pattern. Based on record review, observation, and interview, the facility failed to assess and monitor residents' skin condition facility wide and failed to assess, monitor, or intervene on residents' with wounds/pressure ulcers for three (#1, 2, and #3) of three sampled residents who were reviewed for pressure ulcers. The facility's failure resulted in infected wounds requiring hospitalization and surgical intervention for resident #1 and resident #2. The facility's failure resulted in resident #2 having four previously unidentified wounds and resident #3 having three previously unidentified pressure ulcers. The DON identified three residents with pressure ulcers and 17 residents who were at risk for pressure ulcer development. Findings: 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan, dated 03/12/22, documented the resident had the potential/actual impairment to skin integrity r/t fragile skin. The goal was to maintain or develop clean and intact skin by the review date of 06/10/22. The care plan documented interventions to monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Skin Observation Tool, dated 03/18/22, documented the resident had no open areas to the skin. The skin observation tool was signed as completed on 04/10/22. Review of the clinical record revealed the skin observation tool was the first documented observation of the resident's skin. The admission assessment, dated 03/21/22, documented the resident was at risk for developing pressure ulcers but had no wounds, rashes, or other skin problems. The admission assessment documented the resident required extensive two person assistance with bed mobility and required extensive two person assistance to total dependence on all other activities of daily living. The Skin Observation Tools, dated 03/25/22, 04/01/22, and 04/08/22, documented the resident had redness noted to their buttocks/perineal areas and had a treatment in place. The skin observation tools were all three signed as completed on 04/10/22. The skin assessment tool, dated 04/08/22, was the last complete skin assessment documented in the residents clinical record. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order date on the order summary report for the [MEDICATION(S)] was 04/18/22. The Wound Weekly Observation Tool, dated 04/20/22, documented it was the first observation of a stage II pressure ulcer acquired on the coccyx. The wound measured 1.4cm x 1.7cm with no documented depth. The wound was described as having granulation tissue; was moist with a small amount of serosanguinous drainage; and had no odor. The peri-wound (the area surrounding the wound) was described as reddened with a well-defined wound edge and shape. There was no documentation of signs or symptoms of wound infection. The wound observation tool documented the treatment was to apply a [MEDICATION(S)] dressing every three days and as needed. The Wound Weekly Observation Tool, dated 04/26/22, documented the resident had a stage II pressure ulcer on the coccyx. The wound measured 1.0cm x 0.7cm with no documented depth. The wound was described as improving with epithelial tissue present; had a scant amount of serous drainage; and had no odor. There was no change in the description of the peri-wound, signs or symptoms of infection, or ordered treatment. The Wound Weekly Observation Tool, dated 05/07/22 (which was performed 11 days after the previous weekly wound observation tool), documented the resident had a stage II pressure ulcer on the coccyx. The wound observation tool documented the wound increased in size and measured 1.9cm x 0.6cm with no documented depth. The wound was described as improving with epithelial tissue present; had a scant amount of serous drainage; and had no odor. There was no change in the description of the peri-wound, signs or symptoms of infection, or ordered treatment. The Wound Weekly Observation Tool, dated 05/11/22 (which was performed four days after the previous weekly wound observation tool), documented the resident had a stage II pressure ulcer on the coccyx. The wound measured 1.5cm x 0.6cm with no documented depth. The wound was described as improving with epithelial tissue present, had no drainage, and had no odor. There was no change in the description of the peri-wound, signs or symptoms of infection, or ordered treatment. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Weekly Observation Tool, dated 05/21/22 (which was performed 10 days after the previous weekly wound observation tool), documented the resident had a stage II pressure ulcer on the coccyx. The skin observation tool documented the wound had increased in size and measured 1.5cm x 1.9cm with no documented depth. The wound was described as worsening with 25% slough tissue (yellow, tan, white, stringy tissue); was moist with a small amount of serous drainage; and had no odor. The peri-wound was described as reddened, macerated, tissue with an irregular wound edge and shape. There was no documentation of signs or symptoms of wound infection. The wound observation tool documented the treatment was to apply zinc around the wound edges and cover with [MEDICATION(S)] dressing daily and as needed. The Wound Weekly Observation Tool, dated 05/28/22, documented the resident had a stage II pressure ulcer on the coccyx. The assessment documented the wound increased in size and measured 2.0cm x 2.6cm with no documented depth. The wound was described as unchanged with 25% slough tissue present; was moist with a small amount of serosanguinous drainage; and had no odor. There was no change in the description of the peri-wound, signs or symptoms of infection, or ordered treatment. The assessment documented the resident was repositioned from side to side every two hours and as needed. The Wound Weekly Observation Tool, dated 06/05/22, documented the resident had a stage II pressure ulcer on the coccyx. The assessment documented the wound increased in size and measured 2.0cm x 1.3cm with no documented depth. The wound was described as unchanged with 25% slough tissue present; was moist with a small amount of serosanguinous drainage; and had no odor. There was no change in the description of the peri-wound, signs or symptoms of infection, or ordered treatment. The assessment documented the resident was repositioned side to side every two hours and as needed. On 06/07/22 at 1:50 p.m., LPN #1 was observed to perform a dressing change on resident #3 with the assistance of CNA #1. The over-bed table held a cup labeled normal saline, a small soufflé cup labeled zinc and another labeled [NAME] (an antifungal cream), loose 4x4 gauze, and a [MEDICATION(S)] dressing. The LPN and CNA positioned the resident onto their left side. Without sanitizing or washing their hands, the LPN donned gloves and removed the old dressing from the resident's coccyx. There was small dried brown and black flakes observed on the loose folds of the resident's buttocks with larger streaks of dried brown and black present on the lower half of the buttocks. The resident's right calf was observed to have a red area approximately the size of a nickel. The LPN was asked what the brown and black flakes and streaks were on the resident's buttocks. The LPN stated they did not know but it did not come off of the resident. With the same gloved hands, the LPN obtained saline soaked 4x4 gauze, dabbed at the wound bed, then dabbed onto the area of intact skin with the brown and black flakes, and then dabbed onto the wound bed again. The LPN discarded the used 4x4 gauze and retrieved another saline soaked gauze from the cup. The LPN again dabbed at the wound bed, swept the saline soaked gauze across a streak of dried brown substance, across a reddened area located on the left buttocks, and back into the wound bed. The LPN discarded the used wet 4x4 gauze. With the same gloved hands, the LPN pat dried the area with dry 4x4 gauze. The LPN entered the wound bed with the dry 4x4 gauze, then pat dried the areas of the buttocks wet with saline, pat dried the brown and black flakes and streaks, the reddened area of the left buttock, and then went back onto the wound bed with the same gauze. The LPN discarded the dry gauze and repeated the action with another dry 4x4 gauze, dabbing across the brown streaks and back into the wound. Without changing her gloves, the LPN applied zinc paste to the macerated peri-wound area using a cotton tipped applicator. The [MEDICATION(S)] dressing was applied over the coccyx wound with a portion of the adhesive border atop the zinc paste and macerated skin. The LPN removed their gloves and donned another pair from their pocket without sanitizing or washing their hands. CNA #1 was observed to wipe the resident's buttocks with an incontinence wipe and remove the brown and black substance from the resident's buttocks. LPN #1 was observed to apply an antifungal cream to the resident's buttocks with her gloved hand. The resident was repositioned on their back. LPN #1 was asked what the brown and black substance was which was observed on the resident's buttocks. They stated it was dried feces. The LPN was asked how they assessed the wound. They stated they did not assess wounds but was the treatment nurse who performed dressing changes. They stated LPN #2 assessed the wounds. On 06/09/22 at 6:42 p.m., LPN #2 and CNA #2 were observed to provide catheter care and incontinent care. The resident's abdominal folds were observed to be red and moist. The resident's labia was observed to be angry red, raised, and swollen. The coccyx dressing was observed to be dated 06/08/22 and initialed by LPN #1. The reddened area to the right calf was observed with LPN #2. The LPN stated they had not noticed the area on the resident's right calf. After observing the area, the LPN stated it was a deep tissue injury and they needed to inform the DON and exited the room. On 06/09/22 at 7:10 p.m., LPN #2 was observed to exit the room of resident #3. The LPN stated the wound to the resident's right calf was a deep tissue injury measuring 1.1cm x 1.0cm. The LPN was asked if there were other skin issues with resident #3. They stated they did not know. The LPN returned to the resident's room and assisted the resident onto their left side. A partial edge of pale blue bruise was observed on the resident's left calf. The LPN observed the resident's back, buttocks, and legs and stated there were no other skin issues observed. The LPN was asked about the resident's left leg. The LPN lifted the resident's left leg and a large, black area, surrounded by blue and red colored skin, was observed on the back of the resident's left calf. The LPN was asked about the area on the left calf. They stated it was a large deep tissue injury but did not know how the resident obtained the injury. The LPN repositioned the resident onto their right side. A reddened area, with two open areas, was observed on the resident's left hip/buttock. The LPN was asked about the open areas on the left hip/buttock. They stated it was two stage II pressure ulcers. The LPN was asked if they were aware of the two deep tissue injuries on the resident's lower legs or the two stage II pressure ulcers on the resident's left hip/buttock prior this observation. They stated no. On 06/09/22 at 7:55 p.m., the DON stated they had ordered a low air loss mattress for resident #3 and had scheduled a doctor's appointment for 06/10/22 with their physician. The DON was asked what other interventions were in place to ensure resident skin issues were addressed. They stated they instructed nursing staff to perform skin assessments weekly and planned to schedule a day of the week to perform them. The DON stated the resident wounds would also be assessed at least weekly and if the wound nurse was not available, another licensed nurse would perform the wound assessment. The DON was asked how they would ensure other residents in the facility did not have unidentified wounds or other skin issues. The DON stated the facility nurses were to perform a skin sweep and assess the skin of all residents. A hand written skin observation tool, dated 06/09/22, documented resident #3 had a stage II pressure ulcer on the coccyx which measured 2.0cm x 1.3cm, a stage II pressure ulcer on the left hip which measured 1.0cm x 0.3cm, a stage II pressure ulcer on the left hip which measured 0.2cm x 0.3cm with a reddened area measuring 4.0cm x 3.3cm surrounding both left hip wounds, a right lower leg suspected deep tissue injury which measured 1.1cm x 1.0cm, and a lower left leg suspected deep tissue injury measuring 5.7cm x 5.2cm with a reddened area measuring 21cm long and surrounding the suspected deep tissue injury. 2. Resident #2 was admitted on [DATE] with multiple pressure ulcers. The Wound Weekly Observation Tool, dated 05/11/22, documented the resident had a left great toe wound which measured 2.0cm x 1.5cm, a left second toe wound which measured 1.5cm x 1.0 cm, a right great toe wound which measured 1.0cm x 1.0cm, a right second toe wound which measured 1.3cm x 0.7cm, and a right foot fifth digit wound which measured 0.4cm x 0.5cm. All of the above listed wounds were documented to have necrotic tissue present, no drainage, no odor, and a scab-like irregularly shaped peri-wound. The wound weekly observation tool documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Weekly Observation Tool, dated 05/11/22, documented the resident had a left shin wound which measured 4.0cm x 1.5cm, a right knee wound which measured 2.2cm x 1.7cm,and a left knee wound which measured 1.5cm x 1.2cm. The above listed wounds were documented to have necrotic tissue present, no drainage, no odor, and a scab-like irregularly shaped peri-wound. Another left knee wound was documented to measure 1.0cm x 0.3cm and was described as scabbed over. The wound weekly observation tool documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Weekly Observation Tool, dated 05/11/22 documented the resident had four wounds to the buttocks. One measured 2.3cm x 1.4cm, one measured 0.5cm x 0.5cm, one measured 0.7cm x 1.0cm, and one measured 1.5cm x 0.3cm. All four wounds to the buttocks were documented as having slough tissue present, no drainage, no odor, with an irregularly shaped peri-wound. The wound observation tool also documented a suspected deep tissue injury on the upper buttocks which measured 3.5cm x 1.2cm with 100% slough tissue to wound bed, no drainage, no odor, with an irregularly shaped peri-wound, and a discolored area measuring 14.0cm x 8.0cm. The wound weekly observation tool documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Weekly Observation Tool, dated 05/11/22, was documented six days after the resident's admission. Review of the clinical record revealed no prior documented descriptions of the resident's wounds. The admission assessment, dated 05/12/22, documented the resident was cognitively intact for daily decision making, required moderate assist with activities of daily living, had four stage II pressure ulcers, one deep tissue injury, and diabetic foot ulcers. The Skin Observation Tool, dated 05/12/22 (which is seven days after admission), read in part, .See wound assessment. Treatment in place . The skin observation tool was signed as completed on 05/16/22. On 05/17/22, resident #2 was admitted to the hospital. The hospital records documented the resident had severe [CONDITION(S)] secondary to an extended spectrum beta-lactamase producing bacteria, a urinary tract infection from Escherichia coli, an abscess on their back, gangrene of the toe, and an infected unstageable sacral decubitus ulcer with [CONDITION(S)]. The Skin Observation Tool, effective date 05/19/22, documented the resident was in the hospital. There were no further skin observation tool assessments documented for resident #2 in the clinical record. Resident #2 was readmitted to the facility on [DATE]. The wound clinic note, dated 06/02/22, documented the resident had an unstageable pressure ulcer to the sacral region, a stage III pressure ulcer to the right buttock, a stage III pressure ulcer to an unspecified site, and an abrasion on the left lower leg. The clinic note documented to cleanse the sacral wound with normal saline, pack the wound with Dakins moistened fluffed gauze, cover with dry gauze and an ABD pad, and secure with [MEDICATION(S)] tape. The wound clinic note did not document measurements of the wounds, any further description of the wounds, or further treatment orders. The wound clinic note, dated 06/06/22, documented the resident had an unstageable pressure ulcer to the sacral region, a stage III pressure ulcer to the right buttock, a stage III pressure ulcer to an unspecified site, an abrasion on the left lower leg, a non-pressure chronic ulcer with the fat layer exposed on the right foot, and a non-pressure chronic ulcer on the left foot with bone involvement without evidence of necrosis. The clinic note documented to cleanse the open wounds on the legs and feet with normal saline, apply [MEDICATION(S)] ointment to open wounds, cover with dry gauze and an ABD pad, wrap with gauze, and secure with tape (wounds included: right second toe, right fourth toe, right lateral foot, left lower leg, left second toe, left great toe, and the right great toe). The clinic note documented to cleanse the sacral wound and left ischial wound with normal saline, pack the wounds with Dakins moistened fluffed gauze, cover with dry gauze and an ABD pad, and secure with [MEDICATION(S)] tape. The wound clinic note documented the right lateral malleolus wound was to be cleansed with normal saline, [MEDICATION(S)]-iodine applied to the wound, cover with an ABD pad, and wrap with gauze. On 06/07/22 at 12:40 p.m., LPN #1 was observed to provide wound care to resident #2 with the assistance of CNA #1. The resident was positioned on their left side with their back and buttocks exposed. A dressing was observed to be dated 06/07/22. The bedside table contained gloves, a box of loose 4x4 gauze, one cup of wet 4x4 gauze labeled normal saline, one cup of wet 4x4 gauze labeled Dakins, and an ABD pad. The LPN washed their hands and donned gloves. The LPN removed the old dressing and wound packing. The wound was observed to be butterfly shaped with extended wings. Yellow escar was observed along the left side of the wound and other areas of the wound bed was observed to be yellow in color with what appeared to be a bone deep sacral center to the wound. Without sanitizing their hands or changing gloves, LPN #1 was observed to dab random areas of the wound bed, intact skin, and open areas of the buttocks with the same saline soaked wet gauze. The LPN repeated the random cleaning pattern with the second and third saline soaked wet gauze pad. The random dabbing pattern used to clean the wound potentially cross contaminated the wounds with bacteria from other wounds or from the intact skin. Without sanitizing hands or changing gloves, LPN #1 was observed to dab the wet areas of the wound bed, intact skin, and open areas of the buttocks with a dry 4x4 gauze pad. The LPN repeated the drying process with a second dry 4x4 gauze pad. The LPN removed their gloves, pulled another pair of gloves from their pocket and donned them without sanitizing their hands. The LPN packed the wound bed with wet 4x4 gauze from the cup labeled Dakins, covered the wound with an ABD pad, and secured three quarters of the ABD pad's border, leaving the upper left corner of the ABD pad unsecured. The ABD pad was observed to cover open wounds to the mid buttocks bilaterally. The resident's bilateral leg wounds feet and toes were observed without the ordered dressings. The bilateral legs were observed to be covered in [MEDICATION(S)] and left open to air and bilateral feet and toes were observed open to air. The LPN stated the resident was seen at the wound clinic on 06/06/22 and the wound clinic ordered the legs, feet, and toes to be open to air. A hand written skin observation tool, dated 06/09/22, documented resident #2 had multiple open wounds including the outer left foot; great toe and second toe of the left foot; the great toe and second toe of the right foot had sores and the outer right foot had a scab; three sores to right ankle; open areas to the bilateral shins; open areas to the bilateral knees; open area to the right elbow; a bruise to an unspecified upper arm; an open sore to the left elbow; a bruise to the back of an unspecified arm; and a dressing covering an open area on the left buttocks. There was no description or measurements documented or provided for the wounds listed above. 3. Resident #1 was admitted to the facility with a stage IV pressure ulcer to the sacrum. The admission assessment, dated 12/13/21, documented the resident was cognitively intact for daily decision making, required extensive one to two person assistance with all activities of daily living, was incontinent of bowel, had a urinary catheter, moisture associated skin damage, and a stage IV pressure ulcer. The Wound-Weekly Observation Tool, dated 12/20/21 (17 days after admission), documented the resident had a stage IV sacral pressure ulcer with scant serosanguinous drainage, no odor, measuring 6.4cm x 4.0cm x 1.4cm with no tunneling or undermining, and the peri-wound was healthy and intact. The current treatment plan section of the tool documented to cleanse the wound with normal saline, pat dry, apply [MEDICATION(S)] AG to base of wound, fill dead space with dry fluffed 4x4 gauze, cover with ABD pad and secure with minimal [MEDICATION(S)] tape daily and as needed for soilage. The Wound-Weekly Observation Tool, dated 12/27/21, documented the resident had a stage I to the left heel which measured 7.0cm x 6.0cm and the blistered area was white from moisture. The current treatment plan section of the tool documented to wrap with a dry dressing daily for protection. The tool documented the stage IV sacral pressure ulcer improved, had a small amount of serosanguinous drainage, no odor, measured 7.0cm x 6.0cm x 1.5cm with no tunneling or undermining and the peri-wound was healthy and intact. The ordered wound treatment did not change. The Wound-Weekly Observation Tool, dated 01/03/22, documented the resident had a stage II pressure ulcer to the left heel which measured 5.7cm x 4.8cm x 0.1cm, had a scant amount of serosanguinous drainage, and had improved. The current treatment plan section of the tool documented to cleanse the area with normal saline, pat dry, apply calcium alginate, cover with [MEDICATION(S)] and tape every day and as needed. The tool documented the stage IV sacral pressure ulcer improved, had a scant amount of serosanguinous drainage, no odor, measured 6.7cm x 3.8cm x 2.0cm with no tunneling or undermining and the peri-wound was healthy and intact. The ordered wound treatment did not change. The Wound-Weekly Observation Tool, dated 01/10/22, documented the resident had a stage II pressure ulcer to the left heel which measured 3.2cm x 4.0cm x 0.1cm, had a scant amount of serosanguinous drainage, and had improved. The ordered wound treatment did not change. The tool documented the stage IV sacral pressure ulcer improved, had a scant amount of serosanguinous drainage, no odor, measured 6.0cm x 5.0cm x 2.0cm with 2.8cm of tunneling and/or undermining at five o'clock, and the peri-wound was healthy and intact. The ordered wound treatment did not change. The Wound-Weekly Observation Tool, dated 01/17/22, documented the resident had a stage II pressure ulcer to the left heel which measured 6.0cm x 5.0cm x 0.1cm with a scant amount of serosanguinous drainage and had improved. The ordered wound treatment did not change. The tool documented the stage IV sacral pressure ulcer improved, had a small amount of serosanguinous drainage, no odor, measured 6.5cm x 3.0cm x 1.3cm with 2.0cm of tunneling and/or undermining at five o'clock, and the peri-wound was healthy and intact. The current treatment plan section of the tool documented to cleanse the wound with normal saline, pat dry, apply calcium alginate, cover with [MEDICATION(S)] and tape daily and as needed. A review of the clinical record did not find a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Wound-Weekly Observation Tool, dated 01/24/22, documented the resident had a pressure ulcer to the left heel which measured 2.8cm x 3.4cm with a scant amount of bloody drainage and had improved. The ordered wound treatment did not change. The tool documented the stage IV sacral pressure ulcer improved, had a small amount of serosanguinous drainage, no odor, measured 6.0cm x 3.0cm x 1.0cm with [TRUNCATED]

Based on record review, observation, and interview, the facility failed to ensure residents with indwelling urinary catheters received treatment and services to prevent infection for three (#3, #2, and #1) of three sampled residents who were reviewed for urinary catheter care. This deficient practice resulted in actual harm for resident #2 and resident #3 when they were both hospitalized for [CONDITION(S)] related to urinary tract infections. The Resident Census and Condition of Residents form identified three residents with indwelling urinary catheters. Findings: 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan, dated 03/12/22, documented the resident had an indwelling urinary catheter. The interventions on the care plan included positioning the catheter bag and tubing below the bladder, monitor/record/report signs of [CONDITION(S)], and to provide catheter care every shift. An admission assessment, dated 03/21/22, documented the resident was moderately impaired in cognition for daily decision making, required extensive assistance with most ADLs, and had an indwelling urinary catheter. A progress note, dated 05/22/22 at 3:46 p.m., documented the nurse was called to the resident's room by the CNAs for [CONDITION(S)] like activity. The progress note documented the resident was shaking as if they were cold, had a foaming substance coming from their mouth, and was sent to the emergency room via ambulance. A hospital Admission History and Physical, dated 05/22/22, documented the resident presented to the emergency room with fever and [CONDITION(S)]. The history and physical documented the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital urinalysis culture, dated 05/25/22, documented the hospital had obtained urine from the resident's indwelling urinary catheter upon admission to the emergency room . The urine culture revealed the resident had Escherichia coli ESBL bacteria in the urine. A hospital blood culture, dated 05/26/22, documented Staphylococcus spp was detected in the resident's blood. The facility Order Summary Report, dated 05/28/22, documented the resident had been ordered [MEDICATION(S)] (an antibiotic) one gram intravenously every eight hours for 12 days for [CONDITION(S)]/[CONDITION(S)] upon return to the facility. On 06/09/22 at 1:40 p.m., resident #3 was observed in bed, laying on their left side. The urinary catheter was observed to not be anchored to the leg to reduce the risk of trauma. The catheter bag, in a dignity bag, was observed to be in contact with the floor. On 06/09/22 at 4:30 p.m., the urinary catheter tubing was observed to be unanchored and the catheter bag was observed to be in contact with the floor. On 06/09/22 at 5:50 p.m., CNA #3 was asked what their responsibilities were for a resident with a urinary catheter. They stated they made sure the area was clean. They stated if the catheter was soiled they would clean the catheter with a wipe. They stated they cleaned the catheter by securing the end closest to the resident and cleaned the tubing by wiping away from the resident. They stated they were to place the tubing above the leg, utilized dignity bags, and were to keep the tubing and catheter bag off the floor. The CNA was asked why they were to keep urinary catheter tubing and bags off the floor. They stated the floor was dirty and it could cause an infection. On 06/09/22 at 6:30 p.m., CNA #4 was asked what their responsibilities were for a resident with a urinary catheter. The CNA stated they were to make sure the catheter stayed clean and did not come in contact with the floor. They were asked if they provided catheter care to residents. The CNA stated yes. The CNA stated if they were performing incontinent care and the catheter was dirty, they would secure the tubing close to the resident's body and wipe the tubing clean, moving away from the resident. The CNA was asked why they were to keep the catheter tubing and bag from making contact with the floor. The CNA stated it was an infection control concern because the floor was dirty. On 06/09/22 at 6:42 p.m., CNA #2 and CNA#4 were observed to provide incontinent care to resident #3. The catheter bag was observed to be in contact with the floor. CNA #4 was asked if the urinary catheter bag was properly positioned. The CNA stated no. The CNA stated the bag was in contact with the floor and could cause an infection. On 06/09/22 at 6:45 p.m., LPN #2 entered the resident's room and stated urinary catheter care was on the treatment sheets for the nurses to provide. The LPN was observed to wipe feces from the resident's perineal area with incontinent wipe three times with downward strokes, removing feces from the perineal area each time. The LPN was observed to fold a feces soiled incontinent wipe, secure the catheter, and pull the soiled wipe up over half of the urinary catheter tubing. The LPN indicated the catheter care was complete. The LPN was asked if they were finished catheter care. They stated yes. The LPN was asked what the dried, brown substance was remaining on the upper area of the urinary catheter tubing. LPN #2 observed the tubing and stated the substance was feces and they had not noticed it during catheter care. The LPN was asked if the resident had been incontinent. They stated yes. The LPN was asked if they were going to provide the resident with incontinent care. They stated yes and incontinent care was initiated by CNA #2 with assistance from CNA #4. CNA #2 was observed to remove feces from between the resident's legs, from the vaginal area, perineum, anus, and buttocks. After incontinent care was provided, catheter care was not performed. On 06/09/22 at 8:00 p.m., the DON was informed of the observations of catheter bags in contact with the floor and of the catheter care observed for resident #3. The DON stated the nursing staff knew catheter bags were not to be in contact with the floor due to the increased risk in infection. The DON stated the nursing staff should have provided incontinent care and fully cleaned resident #3 prior to the catheter care. The DON stated the catheter should have been secured and cleaned from the point it was secured to the very end of the catheter. 2. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan, dated 05/08/22, documented the resident had an indwelling urinary catheter. The documented interventions included change catheter monthly, position catheter bag and tubing below the level of the bladder, and monitor for signs/symptoms of [CONDITION(S)]. An admission assessment, dated 05/12/22, documented the resident was cognitively intact for daily decision making, required extensive assistance with ADLs, and had an indwelling urinary catheter. A hospital Discharge Summary, dated 05/26/22, documented the resident was admitted to the hospital on 05/17/22 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . coli [CONDITION(S)]. A facility Order Summary Report, dated 06/02/22, documented the resident was ordered [MEDICATION(S)] [an antibiotic] one gram intravenously every eight hours for a urinary tract infection. On 06/07/22 at 12:40 p.m., resident #2 was observed in bed. The urinary catheter was observed to not be anchored to the leg to reduce the risk of trauma. The urinary catheter bag was observed in a dignity bag, hanging from the side of the bed and in contact with the floor. On 06/09/22 at 1:40 p.m., resident #2 was observed in bed. The urinary catheter tubing was observed to not be anchored. The urinary catheter bag was observed to be hung from the side of the bed without a dignity bag and was in contact with the floor. On 06/09/22 at 8:00 p.m., the DON was informed of the observations of catheter bags in contact with the floor. 3. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment, dated 12/13/21, documented the resident was cognitively intact for daily decision making, required extensive one to two person assistance with all activities of daily living, was incontinent of bowel, and had a urinary catheter. The resident was discharged to the hospital on 04/15/22 after they had attended an appointment with their. A hospital laboratory report, dated 04/16/22, documented the urine culture revealed greater than 100,000 Klebsellia pneumonia bacteria. On 06/06/22 at 10:38 a.m., resident #1 was asked if he had concerns related to his care at the facility. Resident #1 stated they had concerns related to catheter care. The resident stated the catheter care was not good and there were times when the catheter was blocked and they were unable to void. The resident stated it was hours before a nurse responded and fixed the catheter to allow for urine to flow. On 06/09/22 at 8:00 p.m., the DON was asked if she was aware resident #1 complained of a lack of catheter care and at times, an inability to void through his catheter. She stated she was unaware of the complaints.

Based on observation, interview and record review, it was determined the facility failed to ensure a resident did not incur injuries from falls for one (#1) of three residents reviewed for falls. The facility identified 14 residents who were a high risk for falls and resided at the facility. Findings: An undated accident prevention policy documented, .Each resident will receive adequate supervision and assistive devices to prevent accidents . Resident #1 had diagnoses which included displaced intertrochanteric fracture of the left femur and dementia. A fall risk evaluation, dated 12/03/20 at 10:50 a.m., documented the resident was a low risk for falls and had no history of falls in the previous three months. A care plan focus, dated 12/03/20, documented the resident had limited physical mobility related to weakness. The care plan identified three interventions also dated 12/03/21. Those were to ambulate, to attend activities to promote physical mobility and exercise, and for the staff to monitor and report various medical conditions which included fall related injury. A care plan focus, dated 12/03/20, documented the resident was a low risk for falls related to dementia. The focus had seven assigned interventions, each dated 12/03/20. These included for staff to anticipate and meet the resident's needs and to follow the facility's fall protocol. An admission assessment, dated 12/16/20, documented the resident had been admitted to the facility on [DATE]. The assessment further documented the resident had moderate impairment of cognition, had continuous inattention and disorganized thinking, required supervision with walking and locomotion, and had no impairment related to the range of motion in both upper and lower extremities. The assessment documented the resident had no history of falls in the six months prior to admission nor any diagnoses related to fractures. A progress note, dated 02/23/21 at 3:30 a.m., documented the resident was found lying on the floor in front of a recliner and the resident complained of hip and elbow pain. The note further documented the resident was observed to have had a hematoma on the back of her head. A progress note, dated 02/23/21 at 6:43 a.m., documented the resident had returned to the facility from an emergency room with a cervical collar and documentation that indicated a fracture of the seventh cervical vertebrae. A fall risk assessment, dated 02/23/21 at 3:30 a.m., documented the resident was a low risk for falls and had no history of falls in the previous three months. Discharge instructions from a community hospital, dated 02/23/21, documented the resident was sent to a hospital to be evaluated following a fall. The discharge instructions documented the diagnoses of closed C7 fracture without spinal cord injury initial encounter, closed head injury and low back pain. A care plan focus, dated 02/23/21, documented the resident had an actual fall with minor injury. The care plan identified five assigned interventions, each dated 02/23/21. These included that staff continue interventions on the at-risk plan. A quarterly assessment, dated 03/15/21, documented the resident had moderate impairment of cognition, had continuous inattention and disorganized thinking, required supervision with walking and locomotion, and had no impairment related to the range of motion in both upper and lower extremities. The assessment documented the resident had experienced one fall with injury since admission and had no diagnoses related to fractures. The assessment documented the resident had received no occupational therapy, physical therapy, nor restorative nursing programs including training and skill practice in transferring and walking. A fall risk assessment, dated 03/16/21 at 12:10 p.m., documented the resident was a low risk for falls and had one-to-two falls in the previous three months. A progress note, dated 03/16/21 at 1:21 p.m., documented the resident had been found on a hallway floor at 12:10 p.m. It further documented the resident's head had made contact with the floor and the resident had complained of throbbing pain from the back of her head. A care plan focus, dated 03/16/21, documented the resident had an actual fall with a minor injury. A review of the resident's care plan found no new interventions related to falls. A fall risk assessment, dated 04/20/21 at 12:15 p.m., documented the resident was a high risk for falls and had one-to-two falls in the previous three months. A progress note, dated 04/20/21 at 1:00 p.m., documented the resident had been found on the floor of a doorway and blood had been observed on the resident's head and on the floor. It further documented the resident had a laceration on the right side of her forehead and that steri strips had been applied. A care plan focus, dated 04/20/21, documented the resident had an actual fall with a minor injury. A review of the resident's care plan found one new intervention related to falls. The intervention, dated 04/20/21, documented neuro checks were to be conducted per facility protocol. Discharge instructions from a community hospital, dated 04/21/21, documented the reason for the resident's visit on 04/21/21 was due to a fall, head injury, and facial swelling. The discharge instructions further documented the diagnoses of chronic subdural hematoma, traumatic contusion of right preorbital region, compression fracture of the second [MEDICATION(S)] vertebra, compression fracture of the third [MEDICATION(S)] vertebrae, and contusion of the left knee. A progress note, dated 05/08/21 at 5:44 p.m., documented staff had witnessed the resident fall to the ground of the dining room after missing a chair in an attempt to sit. The note further documented the resident had landed on her right side, did not strike the floor with her head, and made no report of pain. A fall risk assessment, dated 05/08/21 at 7:00 p.m., documented the resident was a high risk for falls and had two-to-three or more falls in the previous three months. A care plan focus, dated 05/08/21, documented the resident had an actual fall with no injuries. A review of the resident's care plan found no new interventions related to falls. A progress note, dated 05/17/21 at 7:40 p.m., documented the resident had been found on the floor of her room lying on her left side. The note further documented a moderate amount of blood was observed on the floor and the resident had a laceration to her left eye brow. The note documented the resident had been unable to to straighten her left leg and outward rotation had been noted, the resident had grabbed her left thigh area and stated the leg hurt, and EMS was called and the resident was sent to an emergency room . A fall risk assessment, dated 05/17/21 at 7:45 p.m., documented the resident was a high risk for falls and had one-to-two falls in the previous three months. A progress note, dated 05/17/21 at 9:25 p.m., documented the facility staff had received a call from the emergency room and informed them the resident had a fractured left hip. A care plan focus, dated 05/17/21, documented the resident had an actual fall with both minor and major injuries. A review of the resident's care plan found one new intervention related to falls. The intervention, dated 05/17/21, documented the resident had been transferred to an emergency room for evaluation and treatment. The care plan further documented the resident had been admitted to a hospital with a left hip fracture. A progress note, dated 05/23/21 at 9:50 a.m., documented a member of the facility's housekeeping staff had found the resident on the floor in front of a recliner lying on her right side. The note further documented a raised area was observed on the right side of the resident's forehead. A fall risk assessment, dated 05/23/21 at 9:50 a.m., documented the resident was a high risk for falls and had two-to-three or more falls in the previous three months. A care plan focus, dated 05/23/21, documented the resident had an actual fall with a minor injury. A review of the resident's care plan found one new intervention related to falls. The intervention, dated 05/23/21, documented ice packs could be applied to the rights side of the head for a raised area. A significant change assessment, dated 05/27/21, documented the resident had moderate impairment of cognition, had continuous inattention and disorganized thinking, the resident required extensive assistance and a one person physical assist with walking and locomotion, and had physical impairment in the lower extremity of one side. The assessment further documented the resident could not steady herself during walking or transferring except when stabilized with staff assistance and had a diagnosis of hip fracture. The assessment documented the resident had experienced a fall with a fracture in the past six months. The assessment further documented the resident had received 123 minutes of occupational therapy and 120 minutes of physical therapy during the seven day look back period and that the therapy had started on 05/21/21. A care plan focus, originally dated 12/03/21 was revised on 05/27/21, with the phrase, .Low risk for falls . change to, .High risk for falls . A review of the resident's care plan found no new intervention related to the revised focus. On 07/08/21 at 10:26 a.m., the DON was asked if she recalled the resident. She was asked what had the facility staff done to decrease the number of falls the resident had experienced. She stated the resident was moved to a room closer to the nurses station because she was confused about many things. We made sure the staff checked on her more often after the falls started. She was asked if new interventions had been attempted after each fall. She stated they would try to figure out if there was a pattern and if we tried an intervention and it did not work we would try something new. She stated that sometimes a person can do all that can be done and a person would continue to fall. She was asked if the resident's care plan documented new interventions after each fall. She stated she believed one of their problems as a group was that they did not document what they have done. She stated they should have come up with new interventions. She was asked where do their staff refer to for the interventions to provide personalized care to each resident. She stated they could look at the residents' care plans and there was also a book at the nurses station with the care plan information. She was asked to refer to an entry in the resident's care plan for the intervention to follow the fall protocol. She was asked if she would present a copy of the protocol. She stated their was no fall protocol and she believed that was a standard intervention that was included in the EMR's software. She was asked if she felt the facility staff could have done anything more to prevent the falls and injuries that the resident had experienced. She stated she felt like they had discussed the situation but had not documented them. She stated she did not feel they could have done anything different. At 11:06 a.m., RN #1 was asked how long she had been a nurse. She stated twenty plus years. She was asked if she was responsible for the development of care plans at the facility. She stated that she was. She was asked how she determined what interventions to use for someone with falls or other issues. She stated she tried to assess the resident, look at their diagnoses, speak with the nursing staff and then write interventions that would meet the residents' needs. She was asked in reference to the resident and her multiple falls, how often did she add new interventions. She stated she would add new interventions but not after each fall. She was asked if a set of interventions were put in place to correct a problem but the problem continued what should have been done. She stated there should have been new interventions. She was asked to provide a copy of the fall protocol that was included in the care plan on 12/03/21. She stated there was no written fall protocol and that the intervention was provided as a choice in the EMR's software. She was asked to provide the at-risk plan that was used as an intervention on 02/23/21. She stated the at-risk plan was the initial fall focus and the accompanying interventions that were entered into the care plan on 12/03/20. She was asked where the staff would have been getting information to care for the resident related to her falls. She stated the care plan. She was asked what interventions would they have used over the course of the resident's stay at the facility. She stated they would have used the same ones as they did not change. She was asked if the facility staff had done everything they could to help the resident not fall. She stated she thought so and that falls were going to happen but they did the best they could. At 11:30 a.m., RN #2 She was asked if she recalled the resident. She stated yes. She was asked if she was aware of the resident's falls. She stated the resident was confused and required constant reminders and redirection. She was asked what interventions she and other staff had used to assist the resident not fall. She stated they would they would give her reminders such as where her room was and give her things to keep her busy. She was asked if she referred to the resident's care plan for interventions. She state no. She was asked if she ever looked at a resident care plan to find out what interventions had been put in place. She stated no. At 11:40 a.m., LPN #1 was asked if she recalled the resident. She stated yes. She was asked to describe the resident's care. She stated the resident had been confused. She was asked if she knew about the resident's falls. She stated that she had never seen one occur. She was asked what interventions had been in place to prevent the resident from falling. She stated she would remind the resident where her room was and ask how she was doing. She was asked if she ever referred to resident care plans for care information. She stated she did not as she was too busy. At 12:00 p.m., CNA #2 was asked to describe the resident's care. She stated the resident had very bad dementia and fell often although she did very good when she had first arrived. She stated she recalled one time that the resident had fallen coming out of a bathroom. She had not pulled up her pants, tripped and hit her head. She was asked when that had occurred. She stated she did not recall. She stated the resident had fallen a lot. She was asked what interventions had been in place to assist the resident not to fall. She stated the staff was suppose to check on her often to see if she needed to go to the bathroom so she would not fall. She was asked if she had ever referred to a care plan. She stated she had when she needed to find out things such as the number of staff required for a certain task. She was asked if she had ever been told about new interventions to try after the resident's falls. She stated no and that they were told to just keep watching the resident. At 12:15 p.m., CNA #1 was asked to describe the resident's care. She stated the resident had dementia and would repeat herself a lot. She stated the resident had broken her hip and believed it was from another fall. She was asked how she knew what care to give to a resident. She stated the care plan. She was asked if she ever read the residents' care plans. She stated that she did all the time. She was asked if she recalled what interventions had been in place to assist the resident from falling. She stated they were to remind her where things were and checked on her needs such as going to the bathroom.

Based on observation, interview, and record review, it was determined the facility failed to ensure: ~ a resident did not receive unnecessary [MEDICAL CONDITION] medications without indications for use; without adequate monitoring, and without adverse consequences for one (#59) of five sampled residents reveiwed for unnecessary medications. The resident became over sedated and had a decline in activities of daily living; and ~ PRN orders for [MEDICAL CONDITION] medications were limited to 14 days for one (#5) of five sampled residents reviewed for [MEDICAL CONDITION] drug use. The resident census and condition report identified 50 residents received psychoactive medicaitons. Findings: 1. Resident #59 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Nurse's notes, dated 04/01/18 through 07/24/18, were reviewed. There were no behaviors documented. A quarterly assessment, dated 05/14/18, documented the resident was severely impaired cognitively; had no behaviors; was independent with bed mobility; required supervision only with locomotion on and off the unit, and eating; and had received an antianxiety and an antidepressant medication seven days out of the seven day look back period. An update to the care plan for [MEDICAL CONDITION] Medication, dated 07/11/18, documented, Received order for [MEDICATION NAME] 0.5mg 1 PO TID prn for agitation. There was no documentation of what behaviors the resident was having related to agitation. A nurse's note, dated 07/24/18 at 3:00 p.m., documented the resident's physician was called regarding the resident's behaviors and the physician had ordered a geri-psych evaluation. There was no documentation of what behaviors the resident was having in the clinical record. The previous nurse's note was dated 07/04/18, and did not mention any behaviors. There were no behavior monitoring sheets found for (MONTH) (YEAR). A nurse's note, dated 07/25/18 at 11:15 a.m., documented the resident was out of the facility to geri-psych on an evaluation with a staff member. A nurse's note, dated 07/25/18 at 2:30 p.m., documented the resident was admitted to geri-psych. The resident returned to the facility on [DATE]. A physician's orders [REDACTED]. A care plan, dated 09/19/18, documented: Problem [MEDICAL CONDITION] medication: [MEDICATION NAME], Klonopin, [MEDICATION NAME], and [MEDICATION NAME]. Goal Will have no increase in [MEDICAL CONDITION] medication times 90 days. Approach Observe for side effects of [MEDICAL CONDITION] medicaitons. AIMS testing as needed. Behavior monitoring on every shift. Explain procedures, use calm approach. If the resident is resistive to care, do not continue and notify the charge nurse. Determine if the resident is in pain. Reposition the resident for comfort. Encourage the resident to participate in forefront telemed sessions and talk therapy sessions. An admission assessment, dated 09/26/18, documented the resident was severely impaired cognitively; had no behaviors; required supervision only with eating; required limited assistance with bed mobility and locomotion off of the unit; and had received an antipsychotic, antianxiety, and an antidepressant medication seven days out of the seven day look back period. There was no behavior monitoring sheet found for (MONTH) (YEAR). A monthly physician's orders [REDACTED]. [MEDICATION NAME] 20 mg every day. Klonopin disintegrating tablet .25 mg two times a day. Klonopin 0.5 mg every day. [MEDICATION NAME] 3 mg BID (Start date 09/19/18) A behavior monitoring sheet, dated (MONTH) (YEAR), documented the resident had no behaviors. On 10/16/18 at 10:15 a.m., the resident was observed in the hallway. The resident was having difficulty self ambulating in his wheelchair. The resident was leaning to the right in his wheelchair with his arm hanging over the arm rest. The resident's head was down and he did not respond to the surveyor. At 11:02 a.m., the resident was observed sitting in his wheelchair in the hallway on the opposite side of the hall. The resident was leaning to the right with his arm hanging over the arm rest. The resident was stuck on the housekeeping cart and was unable to move without staff assistance. The resident's head was down. At 12:48 p.m., the resident was observed in his wheelchair sitting at the assisted dining table. The resident was observed to feed himself a couple of bites and was then assisted by staff to eat the rest of his meal. The resident was leaning to the right in his chair with his arm hanging over the arm rest. At 2:55 p.m., the resident was observed leaning forward in his wheelchair trying to stand up. The resident's wheelchair was not locked and was moving backward. The surveyor intervened to prevent the resident from falling. At 3:21 p.m., the resident was observed in his wheelchair in front of the nurses' desk. The resident was leaning forward and to the right. The resident's head was down. On 10/17/18 at 3:52 p.m., the DON was asked for the resident's behavior monitoring sheet for (MONTH) (YEAR). The DON stated there were no behavior monitoring sheets for (MONTH) (YEAR) after the resident had returned from the geri-psych facility. At 4:21 p.m., the ADON was asked for documentation regarding resident behaviors. She stated there was no documentation regarding the resident's behavior prior to being sent to Geri psych. On 10/18/18 at 8:09 a.m., the resident was observed sitting in his wheelchair at the assisted dining table. The resident was leaning forward and to the right. The resident's right arm was hanging off of the wheelchair. The resident's head was down. The resident did not respond to the surveyor. At 8:41 a.m., CNA #2 was asked about the resident's behaviors. She stated his behaviors had changed completely since he had gone to geri psych. She stated the resident did not interact with staff anymore and did not ask for anything. She stated he did not want to go outside to smoke. She stated the resident was able to feed himself before he went to geri-psych but now he had to be fed by staff. She stated the resident leaned forward in his chair. She stated she was concerned the resident was going to fall out of his wheelchair. She stated they tried to reposition him in his wheel chair but he just continued to lean to the side. The CNA was asked what behaviors the resident had prior to him being sent to geri-psych. She stated basically the resident wanted coffee all of the time and wanted to go outside to smoke. She stated that was how he had always been. She stated he had never been physical towards staff or other residents. She stated the resident's behaviors had not changed prior to him being sent out. At 10:59 a.m., LPN #1 was asked about documentation regarding the resident's behavior prior to his transfer to geri-psych. She stated there was no documentation about behaviors prior to him being sent to geri psych. She stated the resident had a habit of wanting to go out the front door. She stated he was usually redirected easily so something must have happened that day. The LPN was asked how the resident was different since coming back from geri-psych. She stated he did not wheel around as much and he went to bed more frequently. She stated when he started leaning forward they would lay him down. She stated the resident required assistance to eat. She stated the resident had not had any behaviors since he had returned from geri psych. On 10/18/18 at 11:52 a.m., LPN #3 was asked what behaviors the resident had prior to being sent out to geri-psych. She stated he was pounding on the door wanting to go outside and could not be re-directed. The LPN was asked what the process was for the decision to send a resident to geri-psych. She stated the administrator had told her to call the doctor about sending the resident to geri-psych. The LPN was asked what behaviors had been documented. She stated there had been no behaviors documented. At 12:51 p.m., the DON was asked about the resident's behaviors. She stated the resident had always had some behaviors like trying to go out the front door. She stated the day he was sent out he had been banging on the front door and banging into the walls with his wheelchair. The DON stated there had been no documentation about his behaviors and there should have been. The DON was asked if they had looked at any reasons for the resident's behavior change. She stated they had not. She stated they should have possibly checked labs on the resident and they had not. The DON was asked how the resident had been since returning to the facility. She stated when he first came back he was very sedated. She stated he had improved since he was admitted but he was still sedated. She stated when he first came back they tried to put in him a different chair because he could not sit up in his wheelchair. She stated they had decided to keep him in his wheelchair. She stated at times he could feed himself with assistance. On 10/22/18 at 1:54 p.m., CNA #4 was asked what the resident was like before he was sent out to the hospital. She stated he wheeled himself in his wheelchair around the facility and wanted a lot of coffee. She stated he had no behaviors. The CNA was asked what the resident was like when he came back from geri-psych. She stated he leaned to one side and did not talk as much. She stated he had to be fed by staff now. She stated before he sat at a regular table and fed himself. On 10/23/18 at 10:18 a.m., the resident was observed in the hallway leaning to the right. The resident did not respond to the surveyor. At 11:42 a.m., the DON was asked when she would have expected a gradual dose reduction to have occurred for this resident. She stated she thought the facility had called the doctor about his sedation and getting a reduction in the resident's [MEDICATION NAME] but she had discovered it had not been done. At 12:28 p.m., the administrator was asked what the facility did if a resident had a behavior. She stated they tried to redirect them. She stated sometimes the facility would do lab work, assess the resident for pain, and check the resident for hunger and thirst. The administrator was asked if that had happened before this resident was sent out. She stated apparently they had not because it had not been documented. 2. Resident #5 had [DIAGNOSES REDACTED]. A nurse's note, dated 08/13/18 at 1:00 p.m., documented .Resident kicking, hitting, not wanting to stay in chair. Dr. (name withheld) notified. Order received to give [MEDICATION NAME] 1 mg IM every 6 hrs prn .may send to (hopital name deleted) for eval and treat . A Medication Administration Record, [REDACTED]. A monthly physician order, dated (MONTH) (YEAR), documented the resident had an order for [REDACTED]. A licensed nurse flow sheet, dated (MONTH) (YEAR), documented the resident had received [MEDICATION NAME] 1 mg IM prn on 09/10/18, 09/22/18, and 09/29/18. The monthly (MONTH) (YEAR) physician's orders [REDACTED]. The order was received on 08/13/18. On 10/16/18 at 9:15 a.m., the resident was observed sitting in a scoop chair against the wall in the hallway across from the nurse's desk. On 10/18/18 at 11:23 a.m., a charge nurse was asked what behaviors would necessitate the prn administration of [MEDICATION NAME]? She stated hitting and kicking. She was asked about resident #5 and the last time she had given him a prn dose of [MEDICATION NAME]. A monthly physician's orders [REDACTED]. On 10/23/18 at 11:00 a.m., the director of nursing was asked how long a prn [MEDICAL CONDITION] medication order was valid. She stated 14 days. She stated she had become aware the resident's prn [MEDICATION NAME] order had not been renewed every 14 days as required. She stated the resident's physician had been contacted the evening before and stated he did not wish to discontinue the medication. The director of nursing stated the physician renewed the order for 14 days for prn use. She stated she and the ADON would be developing a method to monitor the prn use/ordering of the medication.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents maintained their highest level of well-being for 3 (#3, #6, and #10) of 13 sampled residents whose records were reviewed for resident well being. The facility failed to: a. Assess, monitor, and intervene for resident #6 who had experienced a urinary tract infection [MEDICAL CONDITION], which resulted in pain/discomfort. The facility failed to obtain the resident's medication for over three weeks. The facility failed to notify the resident's physician of the resident's abnormal lab results which indicated resident #6 had a UTI. The director of nursing (DON) identified 17 residents who had experienced a urinary tract infection in the last 90 days. b. Identify, thoroughly assess, and thoroughly monitor for the development and worsening of open skin areas for residents #3, #6, and resident #10. c. Notify the physcian of changes in the resident's skin condition for resident #6. The facility census and condition report documented 72 residents lived at the facility. Findings: 1. Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. a. A nurse's note, dated 06-23-14 at 4:00 p.m., documented a urine sample was obtained and sent to the lab. The note stated the resident's urine was dark red in color. A urinalysis (UA) lab document, with a collection date of 06-23-14 and a fax date of 07-02-14, documented the culture grew out greater than 100,000 Escherichia coli (E. coli). A nurse's note, dated 06-24-14, documented resident #6's lab results were faxed to the resident's physician. A urine culture report, dated 07-03-14, documented a hand written order for [MEDICATION NAME] 100 milligrams to be given twice a day for 10 days. The hand written order date was 07-29-14. A nurse's note, dated 07-29-14, documented the resident complained of nausea and vomiting and was febrile. The nurse's note documented a new order was received for [MEDICATION NAME] 100 milligrams two times a day for ten days due to a positive UA and a culture and sensitivity which reported E. coli. The nurse's note documented the resident refused to be transported to the hospital on multiple occasions. A nurse's note, dated 08-01-14 at 12:00 a.m., documented, "...c/o (complained of) pain to shoulders bilat (bilateral) Kidney area explained had UTI (urinary tract infection) it contributes to his Kidney pain..." A telephone order, dated 08-01-14, documented, "...Admit to (facility name deleted) DX: (diagnosis)[MEDICAL CONDITION] & (and) [MEDICAL CONDITION]" A nurse's note, dated 08-01-14, documented the resident was admitted to the hospital with [REDACTED]. A care plan, dated 08-18-14, documented the resident had a urinary tract infection. The care plan goal documented the infection would be resolved. The care plan approaches included antibiotics would be administered as ordered; labs would be obtained as ordered by the physician; the physician would be notified if the resident's condition changed or worsened; and the resident's urine would be monitored for odor, cloudiness, sediment, or blood and changes would be reported. An admission assessment, dated 08-25-14, documented the resident was cognitively intact, required total assistance from staff with transfers, bed mobility, dressing, bathing, and toileting. The assessment documented the resident was frequently incontinent of bowel and had an indwelling urinary catheter. The assessment documented the resident had experienced a urinary tract infection in the last 30 days. On 10-06-14 at 11:37 a.m., resident #6 was observed lying in bed on his back. There was an indwelling urinary catheter hanging on the lower bed rail draining cloudy yellow urine. On 10-09-14 at 8:20 a.m., the assistant director of nursing (ADON) was asked about resident #6's UA. The ADON stated it was the charge nurse's ultimate responsibility to ensure labs were followed up on but she did have the tracking book. The ADON stated the lab was collected on 06-23-14 and the antibiotic was not started until 07-29-14. The ADON stated she did not know what happened to this one. On 10-09-14 at 9:00 a.m., the director of nursing (DON) was asked what the facility's procedure was for following up on resident labs. The DON stated when the facility received a lab result by fax a copy was given to the DON and assistant director of nursing (ADON) and a copy was given to the nurses. The DON stated she was in charge of infection control and the ADON was in charge of keeping the lab book. The DON was asked about resident #6's UA. The DON stated she could not imagine what happened. The DON stated the nurses had been told to fax the physician and then call the physician if they did not receive a response. On 10-09-14 at 11:30 a.m., the DON stated she had contacted the lab and the only UA that had been obtained for resident #6 was on 06-23-14. The DON stated they were just late in getting the culture from the lab and faxing it to the physician. On 10-09-14 at 1:25 p.m., resident #6 was asked if he had experienced pain with his urinary tract infection prior to going to the hospital. He said, "Boy was I." The resident stated he had experienced pain and burning with urination On 10-09-14 at 2:00 p.m., licensed practical nurse (LPN) #2 was asked what the process was for following up with the physician after lab results were sent to him/her. LPN #2 stated when they received the lab results the physician was faxed. LPN #2 stated if she did not hear from the physician before she was ready to leave for the day she would call the physician's office and/or would have him paged. LPN #2 stated she was the one who had faxed the physician with resident #6's lab result. LPN #2 stated she must have just told the next shift instead of calling the physician. b. A care plan, dated 08-18-14 and updated on 09-04-14, documented the resident was at risk for skin integrity impairment. The care plan goal documented the resident would have intact skin. The care plan had approaches which included the resident would have a pressure relieving device for his bed/chair, any red or open areas would be reported, caution would be exercised during transfers and handling of the resident, skin checks would be done weekly and if skin was not intact a progress note would be written, the resident would be turned and repositioned every 2 hours, and a pillow would be placed between the resident's legs and behind his back when the resident was lying on his side. The care plan was updated on 09-04-14 and documented an order had been received for [MEDICATION NAME] to be applied to resident #6's buttocks every shift and as needed. An admission assessment, dated 08-25-14, documented the resident was cognitively intact, required total assistance from staff with transfers, bed mobility, dressing, bathing, and toileting. The assessment documented the resident was frequently incontinent of bowel and had an indwelling urinary catheter. The assessment documented the resident did not have a pressure ulcer. A telephone order, dated 09-04-14, documented [MEDICATION NAME] was to be applied to resident #6's bottom every shift and as needed. A facility treatment administration record, dated September 2014, documented, "[MEDICATION NAME] to bottom q (every) shift et (and) prn (as needed) Sheared reddned (sic) area 9-4-14..." The treatment record documented the resident received a treatment every shift from 09-04-14 through 09-30-14. A facility treatment administration record, dated October 2014, documented, "[MEDICATION NAME] Apply topically to buttocks, scaral (sic) and periarea Q shift and prn..." The treatment sheet documented the resident received a treatment every shift from 10-01-14 through 10-07-14. On 10-06-14 at 11:37 a.m., resident #6 was observed lying on his back in bed on a standard mattress. There was an indwelling urinary catheter hanging on the lower bed rail draining cloudy yellow urine. On 10-06-14 at 1:30 p.m., resident #6 was observed lying in bed on his back. Certified nurse assistant #2 (CNA) brought the resident's lunch tray and placed it on the overbed table. The CNA explained to the resident that he would need to put the head of his bed up to eat. The resident said no at first but then did allow the CNA to raise the head of the bed. The CNA offered to help the resident cut up the chicken. The resident stated no, do not touch it. On 10-07-14 at 2:55 p.m., certified nurse assistant (CNA) #1 and CNA #2 were observed providing incontinent care for resident #6. The resident was observed to be incontinent of bowel. During the incontinent care the surveyor observed 2 open areas on the resident's left buttock and at least 8 open areas on the resident's right buttock. The resident stated his bottom was stinging during the incontinent care. On 10-07-14 at 3:23 p.m., CNA #2 was asked if she had been aware the resident had wounds on his bottom. CNA #2 stated yes the resident had had open areas on his bottom for approximately 3 or 4 weeks. CNA #2 was asked if she had reported the resident's wounds. CNA #2 stated yes, she had informed the nurse. On 10-07-14 at 3:35 p.m., CNA #1 was asked if she was aware resident #6 had wounds on his bottom. CNA #1 stated yes, she had noticed the breakdown a couple of months ago. CNA #1 stated she had informed the charge nurse. On 10-07-14 at 4:15 p.m., register nurse (RN) #1 was asked when she had last observed resident #6's buttocks. RN #1 stated she had applied a treatment to resident #6's bottom last Saturday, October 4th. RN #1 stated she had observed an open area at that time. RN #1 stated she had not documented her observation of the open area. RN #1 was asked when the physician should be notified. RN #1 stated the physician should be notified with any changes. RN #1 was asked if she had notified the physician. RN #1 stated no. A nurse's note, dated 10-07-14 untimed, documented resident #6's buttock wounds were assessed. The note documented there were two separate open areas on the resident's left buttock draining small amounts of serous fluid. The note documented there were 13 separate areas on the resident's right buttock. The note documented there were also open areas found in the resident's abdominal fold. The note documented the resident would be placed on a specialty low air loss mattress and the physician would be called for treatment orders. A nurse's note, dated 10-07-14 at 7:00 p.m., documented, "...Resident has been placed on Specialty mattress..." There were no other notes found documenting any buttock wounds in the resident's record. On 10-08-14 at 8:10 a.m., licensed practical nurse (LPN) #4 was asked about resident #6's buttock wounds. LPN #4 stated she was the wound nurse who documented wound size and condition one time each week. She stated she had observed resident #6's bottom on 10-02-14 and at that time the resident's bottom was just excoriated. LPN #4 stated she would not have documented excoriation just open areas. LPN #4 was asked if she had seen the resident's buttock wounds since they had been brought to the facility's attention. LPN #4 stated she would be checking the resident's skin on 10-09-14. LPN #4 stated the treatment nurse did the resident's treatments and should be documenting any wound changes. LPN #4 was asked where the treatment nurse would document the wound changes. LPN #4 stated they did not usually document in the chart. She stated they usually just leave me a note. LPN #4 stated any nurse should assess the resident, document what they had observed, and should call the physician. On 10-08-14 at 9:26 a.m., resident #6 was observed lying on a specialty low air loss mattress with the head of his bed up. On 10-08-14 at 9:28 a.m., CNA #2 was asked when the resident had received the specialty air mattress. CNA #2 stated the air bed came last night. CNA #2 was asked how often the resident was turned and repositioned. CNA #2 stated they used a wedge under the resident to try to keep him off his bottom. CNA #2 was asked how often the resident was repositioned. CNA #2 stated they tried to do it every 2 hours but sometimes it might be several hours. On 10-08-14 at 9:43 a.m., the director of nursing (DON) was asked about resident #6's wound. The DON stated she was not aware resident #6 had a wound on his bottom until last night. The DON stated licensed practical nurse (LPN) #3 was asked to assess the wound last night and call the physician. The DON was asked what the nursing staff should do if a wound was identified. The DON stated if a nurse noticed a change like a wound she should start a wound sheet, document in the nurses' notes, and call the physician. The DON was asked why interventions like a pressure relieving mattress had not been obtained for this resident previously. The DON stated she had not thought about it. She stated the resident had not previously had breakdown on his bottom. The DON stated she should have thought about it because the resident had experienced a decline. On 10-08-14 at 9:55 a.m., RN #1 was asked why she had not documented resident #6's wounds. RN #1 stated she was not the wound nurse, she was a treatment nurse and she had not documented any changes because they had been doing a treatment on the resident's bottom. RN #1 stated the resident had open areas they had been treating for a while. RN #1 stated she thought the wound nurse was aware of the resident's buttock wounds and had been measuring them. RN #1 stated she did not think anyone was aware the wounds were not being documented. On 10-08-14 at 10:00 a.m., LPN #5 was asked if she was aware of resident #6's buttocks wounds. LPN #5 stated the last time she had observed resident #6's bottom was on 10-03-14. She stated at that time his bottom was red and there had been an open area. LPN #5 was asked if the resident's open area was new. LPN #5 stated no it was not new but was not sure how long it had been going on. LPN #5 was asked what should be done if a wound was observed. LPN #5 stated the wound should be measured and it should be documented in the nurses' notes. LPN #5 stated the wound nurse should be informed. LPN #5 stated she thought the wound nurse was aware of resident #6's buttocks wounds. LPN #5 was asked what she would do if a CNA reported a wound. LPN #5 stated if a CNA reported a change like an open area she would go check it and call the physician for an order. On 10-08-14 at 11:00 a.m. resident #6 was observed lying in bed. Resident #6 was asked if staff helped him reposition. Resident #6 stated they put a wedge under him. The resident was asked if staff were applying medication to his bottom. The resident stated yes they were and "it stings." 2. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A care plan, dated 05-10-14, documented the resident had a pressure ulcer. The care plan documented the goal was for the resident's wound to heal. The care plan documented the following approaches; the resident would be turned and repositioned every 2 hours, the resident's skin would be kept clean and dry, the resident's wound would be monitored for signs of infection, and the resident's wound perimeters would be assessed at least weekly and would be documented. Resident #3 was missing wound assessment/parameter documentation for the following dates; 05-22-14, 05-29-14, 06-16-14, and 08-28-14. A quarterly assessment, dated 08-01-14, documented the resident was severely impaired cognitively, required extensive assistance with transfers and bed mobility, was incontinent of bowel and bladder, and had no pressure ulcer. A monthly physician's orders [REDACTED]. A nurse's note, dated 10-02-14, documented, "...Res (resident) has an area to her R (right) buttocks that started as a shere (sic). This area measures 0.5 x 0.75...nice pink granulated tissue noted in wound bed..." A facility wound flow sheet, dated 10-02-14, documented the resident had a stage II wound on her right buttock. The wound measured 0.5 centimeters (cm) by 0.75 cm and was pink in color. On 10-06-14 at 11:40 a.m., resident #3 was observed lying on her left side on an air mattress. The resident was observed to be clean and dry. The resident's eyes were closed and there was a bolster on both sides of the resident. On 10-07-14 at 3:35 p.m., wound care was observed for resident #3. Wound care was observed to be done according to the physician's orders [REDACTED]. On 10-08-14 at 8:20 a.m., resident #3 was observed lying on her back with her eyes closed. On 10-09-14 at 2:30 p.m., the DON was asked how often pressure ulcer measurements and treatments were done. The DON stated the pressure ulcer measurements were to be done weekly on the same day of the week if possible and treatments were to be done per the physician's orders [REDACTED]. The DON was asked if a new pressure ulcer was found what should they do. The DON stated if a new wound was found it should be measured right then and treated as soon as there was a physician's orders [REDACTED]. 3. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 02-07-14, documented, "...Problem...SKIN INTEGRITY, IMPAIRED ACTUAL R/T (related to) BUTTOCKS AND ABDOMINAL FOLD/GROIN...Approach...Report any red or open areas..." An admission assessment, dated 02-20-14, documented resident #10 was cognitively intact, was independent with eating and hygiene, required extensive assistance with transfers, dressing and bathing, had 2 Stage II pressure ulcers, was continent of bowel, and was occasionally incontinent of bladder. A Braden Scale form, dated 04-08-14, documented resident #10 had a score of 17. A quarterly assessment, dated 08-22-14, documented resident #10 was cognitively intact, required extensive assistance with most activities of daily living, had no pressure ulcers, and was frequently incontinent of bowel and bladder. A nurse's note, dated 09-18-14, documented resident #10 was found to have an open area to the right buttocks. The nurse's note documented the resident had 2 shearing areas to the right buttocks. The nurse's note documented one open area measured 1.5 cm and the second open area measured 2.5 cm. The nurse's note documented the resident's physician was notified and an order was obtained for [MEDICATION NAME] B to be applied every shift and as needed. A wound flow sheet, documented 09-18-14, documented resident #10 had a shearing wound located on the right buttock. The wound flow sheet documented the wound color was pink, with no odor or drainage noted. The wound flow sheet documented the resident would be repositioned every 2 hours, [MEDICATION NAME] would be applied, and care foam padding would be placed over the wound. A care plan, dated 09-18-14, documented the resident had developed a wound. The care plan documented 2 areas located to resident #10's right buttocks. One open area measured 1.5 cm and the second open area measured 2.5 cm. The care plan documented interventions which included assessing the wound perimeters at least weekly, documenting findings, and applying [MEDICATION NAME] B every shift and as needed. A nurse's note, dated 09-24-14, documented resident #10 had 2 open areas to the right buttock. The nurse's note documented one area, located on the right buttock, measured 2.5 cm. The nurse's note documented a second area, located close to the right gluteal fold, measured 1.5 cm. The nurse's note documented [MEDICATION NAME] was to be applied every shift and as needed. The nurse's note documented the wounds were pink in color with granulation on the wound bed and surrounding tissue. A wound flow sheet, documented 09-24-14, documented resident #10 had a shearing wound located to the right buttock. The wound flow sheet documented the wound was pink, with no odor or drainage noted. The wound flow sheet documented the resident would be repositioned every 2 hours, [MEDICATION NAME] would be applied, and care foam padding would be placed over the wound. A nurse's note, dated 10-02-14, documented resident #10 had 2 open areas to the right buttock. The nurse's note documented one open area, located in the right gluteal fold, measured 1.0 by 2 cm and the second open area, located at the bottom of the right cheek, measured 1.0 by 2 cm. The nurse's note documented both areas had pink granulated tissue in the wound bed with no drainage and no odor. On 10-08-14 at 9:20 a.m., resident #10 was observed lying in bed, he was alert, talkative and a resident interview was conducted. On 10-08-14 at 9:45 a.m., licensed practical nurse (LPN) #5 was observed performing wound care for resident #10. During the wound care, it was observed by this surveyor, the resident's buttocks were red and there were a total of 5 pressure wound areas. Four of the areas were opened and one area appeared to be dark red. LPN #5 was asked how the nursing staff was made aware of any new wounds or skin breakdown. The LPN stated the certified nurse aides (CNAs) would report new areas of breakdown to the charge nurses. The LPN stated during shift report new wounds were reported. The LPN stated when she found new areas of skin breakdown she would measure the area, notify the resident's attending physician, and begin treatment of [REDACTED]. The LPN stated LPN #4 was responsible for the measuring and documenting all resident wounds. A review of resident #10's clinical record did not show documentation of the 3 new identified open areas on the resident's buttocks. On 10-08-14 at 11:15 a.m., CNA #10 was asked if she provided personal care for resident #10. The CNA stated yes. The CNA was asked if she was aware of any new open areas on resident #10's buttocks. The CNA stated she thought the resident had 3. On 10-08-14 at 11:20 a.m., CNA #11 was asked if she provided personal care for resident #10. The CNA stated no. The CNA was asked if she discovered a resident she was caring for had a new open area on their skin what would she do. The CNA stated she would report the open area to her charge nurse. On 10-08-14 at 11:35 a.m., LPN #4 was asked how many open areas resident #10 currently had on his buttocks. The LPN stated since her last assessment a week ago, the resident only had 2 wounds. LPN #4 was asked if she was aware that resident #10 had 3 more areas of skin breakdown on his buttocks. The LPN stated no she was not aware.