Every finding on record at Newport News Nursing & Rehab

Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain a clean, comfortable, and homelike environment for one Resident (Resident #104) in a survey sample of 22 Residents. The findings included:From initial tour on 4-27-26 through the course of survey concluding on 4-30-26, the physical plant was observed and inspected. Those observations continue below.Initial tour of the facility revealed Resident #104's room on the Meadowdale unit to be crowded (hoarded) with boxes, and plastic storage containers in front of, and on top of his wheelchair, over bed table and air conditioning unit. There were articles of clothing scattered around, open containers of butter, food sauces, and food spices all spilled and on surfaces. Also noted were partially eaten different food items, 2 drinking glasses partially filled with dark liquid and dripped down the sides of the glasses. Nothing was refrigerated, and the room had a sour spoiled food smell. The Resident was sitting on a soiled bed encrusted with spilled food. The Resident's yellow shirt was encrusted in a 6-inch by 6-inch stain on the front with dried, spilled foods and liquids, as the resident stated when asked I just spilled something on it. Resident #104's roommate was not in the room.It was noted that during the rest of the survey Resident #104's roommate stayed out of the room most of the time and was found in the dining room, facility entry hallway, and at the nursing station most of the time during daytime hours. Resident #104's roommate was asked why he stayed out of his room, and he did not reply, and he continued walking down the hallway ending the conversation.On 4-29-26 at 12:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that Resident #104 was very resistant to cleaning in the room and would become very belligerent if things in the room were moved or trash was thrown away. She went on to state that the Resident refused to even speak to her now as she had been going in and cleaning the room. On 4/29/2026 at 4:00 p.m., the Administrator, and DON were notified at the end of day debriefing of the continuing concerns of hoarding and unclean areas. They stated that cleaning would be again completed in those areas mentioned and they had no further information to provide.

Based on observations, staff interviews, and facility documentation review, the facility staff failed to ensure that medication(s), hazardous materials, and biologicals were properly secured to prevent unauthorized staff or resident access on three of three units. This deficient practice had the potential of placing all 93 residents residing in the facility, staff, visitors, and volunteers at risk of harm and resulted in the identification of immediate jeopardy and substandard quality of care. Following the removal of the immediacy, the scope and severity was lowered to a level two, pattern. The findings included:On 3/4/2026 at approximately 12:15 PM, on a facility tour of the Pinebrook unit, a medication storage room door was found to be unlocked and unsecured. It was easily accessed by pushing the door open. There was no staff monitoring the door and inspection of the door revealed the latch of the door was taped open to give access to the medication room without the use of a key. Observations of the area within the room revealed a toolbox with zip ties on the top drawer and the lower drawers not secured or locked. The contents included: Antibiotic medications of Ceftriaxone, Vancomycin hydrochloride, Piperacillin, Imipenem, Ceftazidime, Cefepime, Meropenem, Ertapenem. The bottom shelf system held approximately 10 sodium chloride solution bags. Per the container log, it appeared the following items were missing: one vial of Ampicillin sodium 2gm, one vial of Cefepime 1gm, and one vial of Sterile water missing 10ml. There was also a two-drawer filing cabinet that was unlocked and contained a shaving kit bag belonging to Resident #13. The bag contained medications that included, Famotidine 20 MG tablets, Pravastatin 40 MG tablets, Furosemide 20 MG tablets, Metoprolol Tartrate 50 MG tablets, Hydralazine 50 MH tablets, Ezetimibe 10 MG tablets. On 3/4/2026 at approximately 1:00 PM, a staff interview was conducted with a (Registered Nurse/the Pinebrook Unit Manager). RN #2 was asked about the medication room door and if it was to be locked. RN #2 stated, the door is to be locked but because of a key being broken off in the door and the staff needing access to the room, the door was taped open to allow staff access to the medication storage room. Maintenance was told to tape the door open to allow staff access to the medication room. There are no narcotics in the medication storage room and that the medication storage box should be locked. RN #2 stated they were not aware of resident medications being in medication room. On 3/4/2026 at approximately 1:15 PM, a staff interview was conducted with Licensed Practical Nurse (LPN #1) regarding resident medications and where they are stored. LPN #1 stated resident medications are stored in locked medication carts and locked medication rooms. LPN #1 stated she did not know about resident medications being stored in medication storage room on the Pinebrook unit. LPN #1 stated that the resident in question had resided on Pinebrook unit but now resided on Meadowlands unit and has been on the Meadowlands unit for about six months. On 3/4/2026 at approximately 1:25 PM a staff interview with LPN #2 (the Meadowland unit manager) and Director of Nursing (DON) was conducted regarding resident medications and an unlocked medication storage room on Pinebrook Unit. LPN #2 and the DON stated that medications are stored under lock and key in medication carts and in medication storage rooms. The DON stated, they were aware the medication storage room door on Pinebrook was broken and a key had broken off in the lock. LPN #2 and DON stated, they did not know about Resident #13 medications being stored in the Pinebrook medication storage room. DON said, the resident had transferred from Pinebrook unit to the hospital and then returned to the facility to the Meadowland unit. The medications were turned over to the DON for proper disposal. On 3/4/2026 at approximately 2:47 PM, a staff interview was conducted with the Director of Maintenance about the medication storage room door on the Pinebrook unit. The Director of Maintenance stated the following, they were aware that the door of the medication room on unit #4 had a key broken in the lock. The medication room door had been broken for about a month. The door had to be pried open to gain access: and that staff (nurses) needed immediate access to the room. The Director of Maintenance stated tape was applied to the latch to keep the door from locking to allow staff ease of access to the room without a key. On 3/4/2026 at approximately 3:45 PM, at the end of the day meeting, the Vice-President of Operations (VPO) stated the medication door on unit #4 was fixed and was secured and locked. On 3/5/2026 at approximately 8:38 AM, a facility tour with the DON was conducted of the Pinebrook unit. The medication room door was found to be secured and locked with a new locking mechanism installed. On 3/9/2026 at 9:43 AM, a staff interview with Registered Nurse (RN #2) was conducted and the question was asked, did you know the Pinebrook medication room door was broken? RN #2 stated, I know the door had been broken before I started here on 1/15/2026. On 3/9/2026 at 9:46 AM, a staff interview with RN #1 was conducted about the Pinebrook medication storage door. RN #1 stated initially not knowing the door was broken. Then RN #1recanted her statement and stated I did know the door was broken but it was locked. I do not go into the medication storage room that often. On 3/9/2036 at approximately 9:30 AM, a facility tour of all units was conducted by a surveyor with the Director of Maintenance the following issues were noted: Meadowland Unit: An electrical room door was found unlocked and unmonitored with live (hot) wires. A Clean utility room, containing portable metal cylinders labeled oxygen, was found unlocked and unmonitored. Pinebrook Unit: Storage room beside the nursing office, contained cleaning supplies (multi surface disinfectant cleaner, max dual action floor cleaner was dripping onto floor, and bio-enzymatic odor eliminator) was unlocked and unmonitored. Rosewood Unit: Biohazard room containing two large sharps (needles and syringes) containers (approximately eighteen (18) inches tall) that were open and accessible. The needles and syringes were noted to have a red substance appearing to be blood on them. Two large full boxes (approximately twenty-four (24) inches tall by twenty-four (24) inches wide) lined with red bags were opened and accessible and appeared to contain biohazardous materials. Clean utility room, containing portable metal cylinder labeled oxygen, was found unlocked and unmonitored. Beauty salon was found unlocked and unmonitored had water leaking into a large trash can that was overflowing water onto the floor. The water was noted traveling under a rotting cabinet to a wall with light outlets on it. The above-mentioned rooms that were unsecured and unmonitored could have been accessed by residents, visitors, and staff. On 3/9/2026 at 12:58 PM, the facility was notified that immediate jeopardy had been identified, related to securing medications and hazardous materials to prevent resident and unauthorized staff access. The immediate jeopardy began on 1/15/26 as confirmed by an interview with RN #2. The maintenance director confirmed it has been over a month since he had tapped the door where it could be opened without a key. On 3/9/2026 at 4:30 PM, the facility submitted an immediate removal plan that was accepted. The plan read as: The facility took the following actions: *Secured Hazardous Areas Immediately *All doors were audited for functionality by the ED, and regional [NAME] president and Maintenance Director *All medication rooms, supply rooms, biohazard rooms, and chemical storage areas were immediately secured. Locks were replaced and the tape was removed on the Medication room on Pinebrook unit. The housekeeping storage on the Pinebrook unit, had the door adjusted so that it would latch and lock as intended on March 9th. *The beauty shop, the biohazard storage and clean utility room on Rosewood had the locks replaced immediately by the maintenance director, then tested for functionality. *The facility had already identified the leak in the beauty shop and the regional maintenance will address today. *The electrical room door lock on Meadowland, is currently being replaced by the maintenance director. *The facility placed a staff member to sit at the door of the identified soiled utility room on meadowland, until the maintenance director can fix that final lock this afternoon. *For doors that are unsecure, a staff member was assigned to monitor the door till it could be fixed to function as intended. Completed 3/9/2026 Provide immediate education to 100% of all facility staff regarding Medication Room Security Importance of rooms containing hazards such as oxygen, hazardous materials, sharps, and cleaning chemicals, being closed and locked at all times Reporting issues through the work order system. Education was initiated on 3/9/26 and all current staff will be educated prior to their next shift on medication storage and policy, hazardous material storage by Administrator or designee. All aspects of the plan will be completed by 3/9/26 by 11:59pm. On 03/09/26 at approximately 5:23 PM at the end of the day meeting with facility: attended: VPO (Vice President of Operations), Regional MDS (Minimum Data Set), Administrator, AIT (administrator in training), and DON, and the above findings were discussed. The staff had no additional information to add. On 3/10/2026 beginning at approximately 8:30 AM, the surveyors conducted staff interviews on all units throughout the facility to verify staff education on medication(s) and hazardous materials storage was provided per IJ removal plan. A facility tour was conducted to verify storage doors were secured and locking mechanisms were in working order to limit access. Following the removal of IJ (Immediate Jeopardy) on 3/10/2026 at 9:30 AM, the scope/severity was reduced to level 2 widespread.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an available call bell system for multiple Residents which was identified initially for one Resident (Resident #117), and secondarily as the sample was expanded, for three other residents (#118, #119, and #120) in a sample of 22 residents resulting in a finding of immediate jeopardy (IJ). Following the removal of IJ, the scope and severity was lowered to a level two pattern. The findings included.For Resident #117 and others, the call bell system was inoperable and no alternative means to call for assistance was in place for them in the facility. Resident #117 was most recently readmitted to the facility on [DATE]. The Resident's diagnoses included Cerebral palsy, left sided hemiplegia, Aphasia, stroke, malnutrition, dysphagia, contractures of upper extremities, lack of coordination, and dementia.The most recent MDS (Minimum Data Set federal assessment) was most recently completed as an annual assessment with an Assessment Reference Date (ARD) of 3-13-26. The assessment described the Resident with a Brief Interview for Mental Status (BIMS) score of unable to complete, indicating severe cognitive impairment. The Resident required extensive to fully dependent assistance from staff with all activities of daily living except eating, however, staff feeding was necessary at times. The Resident was dependent on staff for self-care and hygiene and had contractures of both hands.On 4-28-26 at 11:30 AM, Resident #117 was observed lying in bed with her call bell clipped above the Resident's head to the head of the bed and outside of the residents reach. An untouched breakfast tray remained on the overbed table in front of Resident. When asked whether the meal was cold, the Resident nodded affirmatively. When asked whether she still wanted to eat, the Resident again nodded affirmatively. She was asked if she could eat by herself or needed help, she held up both hands which were contracted and attempted to pick up the biscuit and put it in her mouth, then started coughing as she was in a reclined position and could not adequately expectorate the bread. A staff LPN [licensed Practical Nurse] entered the room to assist the Resident. The Resident's hands were both contracted in such a way that using the traditional corded spherical call button was impossible for the Resident even if she could have reached it. The call bell was depressed by the surveyor, and the call light did not light at the doorway, nor provide any auditory or visual signal to a centralized location.Resident #117's roommate's call bell was engaged and was again found to not be functioning. Registered Nurse #1 was interviewed and stated, we have to watch for the lights over the doors because the audible bell doesn't work. She was aware of an issue with the audible ring of the call bells on the unit but was not aware that Resident #117 nor her roommate's light over the door for the call bells had stopped functioning as well.Upon further immediate interview of the Maintenance Director, it was reported by him that a contractor came out in March 2026 regarding the call bell system not functioning properly, and the company sent a report with its recommendations. Unfortunately, the problem was never fixed or ok'd to be fixed so I called in a second company on 4-1-26. They came out on 4-7-26 and identified a facility wide issue with the call bell system and recommended it be fixed. I just called them after you asked me about it and they are sending a projected cost to us this week.Documents from the contractors were supplied to the surveyors and revealed the following excerpt from the documents. it is necessary to update your ring bell system. The summary is that they really need an update to their entire call bell system of the rooms. Their system is very old, and you can see the wear.Upon discovering the call system inoperability Surveyor #2 notified Surveyor #1 of the findings. Surveyor #1 then proceeded to other units, and Resident rooms, and found 3 other Residents rooms [Residents #118, #119, and #120] with call bells not functioning.The facility staff, despite knowledge of call-bell system failures, did not ensure residents have a means to call for assistance from the beside and bathroom. The facility needed to take immediate action to ensure ALL residents can call for assistance with basic needs, or in the event of an emergency such as choking. The inability to call for assistance is likely to result in serious injury, serious harm, serious impairment, or death due to a delay in treatment.On 4-28-26 at 2:30 PM Immediate jeopardy was levied by the survey team and state agency. The facility Administrator and Director of Nursing [DON] were notified and asked to provide an immediacy removal plan with a date and time for its implementation completion.On 4-28-26 at 3:45 PM after 2 iterations, a third immediacy removal plan was submitted by the facility and accepted by the survey team and the state agency. A time and date were chosen by the facility for completion of the plan, and for it to be fully implemented and successfully tested to be in place. That date and time was 4-28-26 at 6:00 PM. On 4-28-26 At 6:30 PM the plan was tested by surveyors and found to be fully implemented by the survey team onsite, thus immediacy was removed.The facility immediacy removal plan follows below.April 28, 2026This Plan of Immediacy Removal serves as [name of facility] response to the Immediate Jeopardy that occurred on April 28, 2026. The facility has taken actions to remove immediacy at the center including the actions listed in this Plan.The facility took immediate action to respond to the Immediate Jeopardy that occurred when the facility failed to ensure residents had a means to call for assistance from the bedside due to inoperable call bell.Facility Administrator held an ad-hoc meeting, to include notification to facility medical director, on 4/28/2026 at 2:45pm to discuss details of Immediate Jeopardy and creation of this plan. Ad-hoc QAPI meeting attendees included Administrator, DON, corporate and regional support team.Immediately placed manual call bell for affected residents. For residents who may be unable to use a manual call bell, they will be relocated to a room with a functioning corded call bell, alternate pancake style call bell may be used in place or standard corded call bell based on resident need. Completed 4/28/206 at 6:00 pm. Education on use of manual bell provided to affected residents. Completed 4/28/2026 at 6:00 pm. All resident rooms and resident bathrooms were inspected immediately for functioning call bells. Manual bells were provided to those rooms that were found to not have functioning corded call bells. For residents who may be unable to use a manual call bell, they will be relocated to a room with a functioning corded call bell, alternate pancake style call bell may be used in place or standard corded call bell based on resident need. Completed 4/28/206 at 6:00. All communal shower rooms were inspected immediately for functioning call bells. All call bells in those areas were found to be in proper working order. Completed 4/28/2026 at 3:37. Provide immediate education to all staff on expectations for:Immediately reporting of broken call bells to facility maintenance director, Administrator and DON,Immediate placement of alternative call bell, example manual bell, when corded call bell broken,Completed 4/28/206 at 6:00 pm.Staff members not present at time of immediate education will be educated prior to their next worked shift.On 4-28-26 at 5:30 PM, the survey team began conducting interviews with various facility staff from all departments to test the immediacy removal plan for successful implementation. The staff were able to answer questions about training regarding the call bell function checks and how to proceed should a call bell be found that is inoperable. Staff were expected to know where to access devices for the Residents according to each resident's assessed need such as manual [cow] bells, corded pancake style bells for those with contractures and dementia, and standard corded spherical button bells. Staff were expected to be able to describe how to use those devices, and in what situations a particular device would be used, and how to train residents should the need arise. Interviews were conducted with the residents of the facility, and they were able to identify how to use manual devices, and corded call bell devices including pancake corded devices. Residents with inoperable corded call bells were moved to other rooms with call bells which were operable. Call bells in current resident rooms were randomly checked by surveyors and found to be working on 4-28-26 from 6:00 PM to 6:30 PM and then continued 4-29-26 at 10:30 AM to cover a new shift entrance of staff.Staff education records with signatures were supplied to surveyors documenting staff completion.The facility policy on Call lights accessibility and timely response. was reviewed and revealed the following policy statement. The purpose of the policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.After removing the immediacy the deficiency was levied at a scope severity of level 2 pattern.On 4-29-26 at 5:30 PM that facility Administrator and DON were made aware of findings. They stated they had nothing further to provide.

Based on observation, staff interviews, and review of facility documentation, the facility staff failed to implement their abuse policy regarding the screening of employees and permitted a certified nursing assistant to work over 15 months, providing direct care to residents within the entire facility while having been convicted of a barrier crime, which barred employment within a nursing facility. This non-compliance placed all 93 residents residing in the facility at a significant and on-going risk for harm by allowing unrestricted access to a staff member convicted of a crime of moral turpitude. This resulted in the identification of Immediate Jeopardy and substandard quality of care on 3/6/26 at 8:10 PM. Following the removal of IJ on 3/9/26 at 12:30 PM, the scope and severity was lowered to a level two, pattern. The findings included: The facility staff failed to implement their abuse policy regarding the screening of employees by permitting Certified Nursing Assistant (CNA #3) to provide direct care to residents with unrestricted and unsupervised access despite the employee had a conviction for a barrier crime, which prohibits employment in a long-term care facility under regulatory requirements.The facility's Abuse, Neglect, Exploitation & Misappropriation policy with a revision date of 11/28/17 read in part: .1. Screening: Persons applying for employment with the center will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. This includes but not limited to: employment history, criminal background check, abuse check with appropriate licensing board and registries prior to hire, sworn disclosure statement prior to hire, Licensure or Registration verification prior to hire, Documentation of status of any disciplinary actions from licensing or registration boards and other registries, information from former employees. The center will ensure that all prospective consultants, contractors, volunteers, caregivers, and students are pre-screened as required by law . On 3/6/26 at 11:55 AM, while completing a review of employee records, it was noted that CNA #3's Commonwealth of Virginia Department of State Police criminal history and sex offender record read: 08/28/2023 Guilty - Felony 18.2 - 474.1 Jail: Delivery of Drugs to Prisoner.On 3/6/26 at 11:56 AM, an interview was conducted with the Administrator in Training (AIT) and the Human Resource Coordinator (HRC). The findings of CNA #3's criminal history and sex offender record was brought to the AIT's attention. The AIT said, Can we please take a break? and exited the room. The HRC then said, You do not understand what is going to happen to me.On 3/6/26 at 12:30 PM an interview was conducted with the Administrator. The Administrator stated that CNA #3 should not be working at the center due to the results of the employee's background check. A review of the facilities payroll documentation revealed that CNA #3 worked from 11:22 PM on 3/5/26 until 7:35 AM on 3/6/26. On 3/6/26 at 8:10 PM the facility's Administrator in Training, Director of Nursing, and an Administrator from another facility within the company were informed of the non-compliance which constituted Immediate Jeopardy and substandard quality of care. The IJ was determined to have began on 11/26/24, when CNA #3 was hired. On 3/6/26 at 10:45 PM an interview was conducted with the Administrator in Training. The Administrator in Training stated that CNA #3 was a full time employee on the 11pm - 7 am shift and full-time employment means 35 hours a week. The Administrator in Training also stated that CNA #3 was hired on 11/26/24 and worked throughout the entire facility and was not assigned to a dedicated unit/hall/or set of residents. The Administrator in Training further confirmed that CNA #3 had worked the prior night 3/5/26 on the 11pm -7am shift. The facility's staff presented several unaccepted Removal Plans on 3/6/26 which required revisions. The removal plans failed to detail how the facility would prevent an employee with a barrier crime conviction to work in the facility and provide direct care to residents. The Facility's Final/Accepted Removal Plan dated 3/6/26 at 11:17 PM, read: This immediacy removal plan serves as [Name of the Provider redacted] response to the Immediate Jeopardy that occurred on March 6, 2026.The facility took the following actions: Immediately contacted the employee at 14:00 notifying her of the barrier crime and being removed from the schedule. At 17:45 employee was contacted by Administrator and was informed she could not return to work and employee resigned. Completed 3/6/2026. Complete skin assessments on 100% of non-interviewable residents under the employee's care to evaluate any unexplained injuries, bruises, or skin concerns. To be completed by 3/9/2026, 08:00. Interview alert and oriented residents regarding any concerns related to care, treatment, or interactions with any employee. Will contact responsible parties of non interviewable residents regarding any concerns related to care, treatment, or interactions with any employee. To be completed by 3/9/2026, 08:00. Conduct a 100% audit of current employee personnel files to confirm background checks were completed and properly reviewed prior to their next scheduled worked shift, and that no employee with a barrier crime was employed. Provide immediate education to 100% of all staff and contractors regarding the facility's abuse policy and procedure prior to employees returning to work Provide immediate education to the Administrator, DON and HR Staff on:- State barrier crime regulations- Required background screening procedures- Documentation requirements prior to employment clearance.- Abuse and neglect policy.- Completed 3/6/2026. HR manager was provided with 1:1 education to reinforce policy that no employee may begin work until background checks are fully reviewed and documented as cleared. Completed 3/6/2026. All aspects of the plan will be completed by 3/9/26 at 08:00 AM On 3/9/26, the survey team validated the facility's implementation of the IJ removal plan. The survey team verified skin assessments were conducted on 100% of non-interviewable residents under the CNA #3's care during the employee's employment to evaluate any unexplained injuries, bruises, or skin concerns. A reviewed was conducted of the interviews of alert and oriented residents and responsible parties regarding any concerns related to care, treatment, or interactions with any employee. The 100% audit of current employee files to confirm background checks were completed and properly reviewed prior to their next scheduled worked shift, and that no employee with a barrier crime was employed, was reviewed. The survey team verified immediate education of 100% of all staff and contractors regarding the facility's abuse policy and procedure prior to employee's returning to work. The team verified immediate education to the Administrator, DON, and HR staff on: State barrier crime regulations, required background screening procedures, documentation requirements prior to employment clearance, and abuse and neglect policy. Evidence was reviewed that the HR manager was provided 1:1 education to reinforce policy that no employee may begin work until background checks are fully reviewed and documented as cleared. A review of the Facility Reportable Incidents (FRI) between the dates of 11/26/24 to present to verify CNA #3 with the barrier crime was not subject to any abuse allegations. Interviewed the social worker, DON, and Administrator regarding any complaints from residents about CNA #3.Following the removal of IJ on 3/9/26 at 12:30 PM, the scope and severity was lowered to a level two, pattern.No additional information was provided prior to the conclusion of the survey.

Based on staff interviews, resident interviews, facility document review and clinical record review, the facility staff failed to protect a resident's right to be free from physical abuse by a staff member for one Resident (Resident #114), in a survey sample of 46 Residents. The witnessed incident of physical and verbal abuse resulted in Resident #114 suffering psychosocial harm as evidenced by emotional distress and a decline in cooperation of care, which was harm for the resident. The facility self-identified the non-compliance and implemented a plan of correction that achieved past-noncompliance. The findings include:A certified nurse's aide (CNA #5) hit Resident #114 and used derogatory language when incontinence care was attempted after the resident refused/resisted the care. Resident #114 (R114) was admitted to the facility with diagnoses that included severe chronic kidney disease, diabetes, hypertension, deep vein thrombosis, myocardial infarction, history of pulmonary embolism, diabetic retinopathy, delirium, dementia with agitation, pulmonary edema and spondylosis. The minimum data set (MDS) dated [DATE] assessed R114 with severely impaired cognitive skills. R114's admission assessment dated [DATE] documented the resident had clear speech, was able to make herself understood, was sometimes able to understand instructions, had pleasant mood, no observed behaviors, was always incontinent of bowel/bladder, had no skin impairments and that the resident was ambulatory with use of a walker. Nursing documented daily skilled notes on 5/9/25, 5/10/25 and 5/11/25 listing the resident no voiced complaints, with no resistance to care or refusals noted. A change of condition form dated 5/12/25 at 9:30 a.m. documented the primary nurse caring for R114 witnessed a certified nurse's aide (CNA) hit the resident during incontinence care and the resident reacted with paranoid/aggressive behaviors following the incident. This change in condition form documented, The resident was in her bed being changed by the assigned aide and the resident became aggressive and swinging at the aide, broke her necklace. The aide had the nurse come in the room. The assigned nurse witnessed the aide punch the resident x 2 in her lower back both fist. (sic) This change of condition form documented the CNA was removed from the room, escorted to the administrator's office and immediately suspended. The facility documented R114 demonstrated aggression, refused to be assisted/changed, refused physical assessment and ran into the hallway with no pants following the incident. The form documented the resident would not allow anyone to touch her and sat in a chair in the hall with a sheet placed over her legs and that the administrator, resident's family member and the nurse practitioner (NP) were notified. The NP assessed R114 immediately following the incident. The NP note dated 5/12/25 documented, .Patient was seen today upon request of DON [director of nursing] and nurse. Staff report patient has become increasingly confused, agitated, and combative for staff .seen outside in the hallway sitting in a chair. She is currently soiled wearing a disposable brief, however she will not allow staff to change her. Patient is unaware of her self, surrounding, or location. She reports she is trying to get a hold of her father which is why she was attempting to leave the room . The NP documented that she was unable to complete a thorough review of systems or physical exam due to the resident's mental status and listed the resident as agitated, combative with staff, refusing care and disoriented to person, place and time. The NP assessed the resident with dementia with agitation and delirium. The NP listed the resident was on the medication Seroquel nightly for agitation/delirium prior to admission, entered a new order for the anti-anxiety medication Ativan 0.5 mg (milligrams) every 24 hours if needed for acute agitation during next five days, ordered a urinalysis and culture to rule out infection, non-drug behavioral management strategies and psychiatry consultation. Nursing notes documented that the resident's family member came to the facility on 5/12/25 at 10:55 a.m. in response to the incident. Nursing documented R114 calmed after talking with the family member, returned to the room and then allowed staff to clean/change the resident with assistance of family. R114's vital signs were assessed, skin assessment completed with no impairments, pain or signs of injury or pain noted. Social services documented an attempt to talk to R114 on 5/12/25 at 1:36 p.m. following the incident. This note documented the resident stated she did not want to talk to any social worker. Nursing documented the resident calmed after the family arrived 5/12/25, resumed taking medicines and allowed staff members to provide care and services. A nursing note dated 5/13/25 documented the resident attended out of room activities, including exercises with other residents and listed, her mood was calm and happy. Daily skilled nursing notes on 5/13/25 and 5/14/25 documented the resident as oriented to person/place, with no aggressive behaviors, as conversive with staff, with calm/pleasant mood, ambulating in halls and with no pain. A nursing note dated 5/15/25 documented, .the resident has been calm and cooperative these last two days but there is confusion. She has no c/o [complaints of] pain. 5/13/25 and 5/14/25 I assessed he [the] skin and no new bruising noted .family are supportive and coming to visit her . Psychiatry assessed R114 on 5/16/25 regarding the altercation with a CNA on 5/12/25. The psychiatry progress note dated 5/16/25 documented, Patient states the CNA came from behind, grabbed, and started hitting her. She states she had to defend herself and staff intervened . Psychiatry documented the resident was recently started of Seroquel during hospitalization (prior to admission to the facility) due to delirium. Psychiatry documented under review of systems, .Denies feeling depressed, anxious or agitated, Denies any insomnia, Reports appetite to be good, No reported hallucinations or delusions, No reported suicide ideation, intent plan, No reported restlessness or irritability, No reported intrusive thoughts, No reported fatigue, No reported loss of interest in activities, Reported memory loss, No reported phobias or fears, racing thoughts . The psychiatry NP documented R114 as stable with orders to continue monitoring and current plan of care with no changes in treatment ordered. R114's medication administration record (MAR) documented no administration of the as needed Ativan prescribed for acute agitation during the five days following the incident. The urinalysis with culture ordered on 5/12/25 was negative for an infection. R114's clinical record documented ongoing assessment with the combative behaviors and resistance to care noted after diagnosis/treatment of a urinary tract infection on 5/19/25. The resident's plan of care was updated on 5/12/25 to include problems, goals and interventions related to maintaining psychosocial well-being due to physical abuse. The facility's investigation of R114's abuse incident of 5/12/25 was reviewed and documented that CNA #5, who was witnessed hitting the resident, was immediately removed from the room, taken to the administrator's office and suspended. The abuse incident was reported to the responsible party, medical provider, state survey agency, adult protective services, ombudsman, state department of health professions and law enforcement on 5/12/25 as required. The investigation documented skin assessments on all residents with BIMS (brief interview of mental status) score of 8 or below and interviews with all other residents that were cared for by CNA #5. Investigation findings were reported to the state agency and documented that CNA #5 voiced that she became upset that her necklace was broken while performing personal care for R114. The investigation documented CNA #5 was aware that R114 did not want to be changed and that care was attempted because the resident was scheduled for therapy and needed to be cleaned. The investigation documented CNA #5's actions agitated R114, that RN #3 witnessed CNA #5 hit R114 with abuse substantiated and CNA #5 terminated. The facility's investigation documented the following written statements from registered nurse (RN#3) that witnessed the incident and CNA #5 that was witnessed hitting and using derogatory language in front of the resident. RN #3's written statement dated 5/12/25 documented, .I was called in the [R114's] room by the Aide [CNA #5] on assignment stating 'Can you come help me. She's [R114] try to fight me.' I entered into the room and saw the aide trying to remove the patients brief. The .paint [patient] expressed that she wanted the Aide to stop and to leave her alone. I asked the Aide to step out but she refused stating 'she broke my grandma chain and its somewhere in the bed or her breif [brief].' The aide then pushed the patient on her side stating 'She's shitty and I need my chain.' the patient tried to roll back over then the Aide punched the patient in her thigh/back twice and said 'I just don't care anymore' . (sic) A written statement from CNA #5 dated 5/12/25 documented, I went into [R114's room] after I picked up the breakfast trays to get her cleaned up for therapy. I explained to her what I was doing + she started getting combative with me. I tried to explain to her that she cant hit me + that I was trying to help her get cleaned up for the day. She continued to hit me. She grabbed my necklace + broke it + my nametag too. I then went + got the nurse to help me. She still was fighting + I was trying to grab her arms + explain that she cant hit me + that I was trying to help her. She kept refusing for me to clean her up even after the nurse tried to explain as well that she was dirty. (sic) On 3/5/26 at 9:05 a.m. the administrator, administrator in training (AIT) and the director of nursing (DON) were interviewed about R114's abuse and actions taken in response. The current administrator was not employed at the facility at the time of the incident. The DON stated that RN #3 immediately reported on 5/12/25 that she witnessed CNA #5 hit R114 when CNA #5 attempted to perform incontinence care after the resident stated she did not want to be changed. The DON stated R114 grabbed CNA #5's shirt during the incident and broke the CNA's necklace. The DON stated CNA #5 then pushed the resident and punched the resident in the back/thigh twice with her fist as witnessed by RN #3. The DON stated RN #3 told CNA #5 to get out of the room and she was escorted to the administrator's office. The DON stated she went to the unit and R114 was standing in the hall and would not return to her room. The DON stated she and staff members stayed with the resident and finally got the resident to sit. The DON stated R114 was agitated, confused, would not allow staff to assess or change her and that staff stayed with the resident in the hall. The DON stated she went to the office and interviewed CNA #5 about what happened with the administrator at that time and AIT present. The DON stated she asked CNA #5 if she hit R114 and that CNA #5 responded, Yes. The DON stated CNA #5 was upset that the resident broke her grandmother's necklace. The DON stated she informed CNA #5 that hitting the resident was abuse, that she was suspended and CNA #5 was then escorted out of the building. The DON stated she returned to check on R114 and after the resident's family arrived, the resident returned to her room and allowed staff members to clean, change and assess her. The DON stated the family came within an hour of the incident and were instrumental in getting the resident cleaned/changed as the resident did not want staff to clean her. The DON stated she assessed the resident with no pain, and a skin assessment revealed no signs of physical injury. The DON stated the police were notified and came the same day. The DON stated the NP assessed R114 following the incident and the resident was later assessed by psychiatry. The DON stated the family member reported the resident had been combative and resistive to care at times prior to admission to the facility. The DON stated psychiatry assessed the resident with baseline cognitive status and that the resident was aware that she had been hit by a staff member. The DON stated the resident required no additional medication in response to the incident and did not display fear of staff in the days following the incident. The DON stated the resident ambulated with a walker, was out of the room and attended a group activity with other residents the next day. The DON stated interviews were immediately conducted with alert/oriented residents in addition to skin assessments for all other residents with no abuse findings. The DON stated education was initiated on 5/12/25 for all staff in response to the incident. The DON and AIT stated there had been no history of any concerns with CNA #5's performance prior to this incident and resident interviews revealed she was well-liked by residents. The AIT stated that CNA #5 was terminated as a result of this incident. The AIT presented a copy of a state and national criminal background for CNA #5 with no findings and signed acknowledgment of code of ethics and employee handbook that included abuse prevention policies completed in June 2024. The administrator at the time of this incident and RN #3 that witnessed the abuse were not available for interview as they no longer worked at the facility. The facility's policy titled Abuse, Neglect, Exploitation & Misappropriation (revised 11/16/22) documented, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property.Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse.No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident.Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.Physical Abuse includes.hitting.slapping.punching.Verbal Abuse may be considered a form of mental abuse. Verbal abuse incudes the use of oral, written, or gestured communication, or sounds, to resident within hearing distance.Mental and Verbal Abuse include.Harassing a resident.mocking, insulting, ridiculing.Yelling or hovering over a resident, with the intent to intimidate.Acts of abuse directed against residents are absolutely prohibited. The facility presented the following plan of correction for abuse initiated on 5/12/25 in response to this incident 1. Corrective Action for Affected Resident - Immediately upon receiving the allegation on 5/12/25, the resident was protected from further potential harm. A licensed nurse completed a full skin-to-skin head-to-toe skin assessment to identify any injuries or changes in condition. No injuries were identified at the time of assessment. The DON reviewed the clinical findings and supervised continued monitoring of the resident following the incident to ensure safety. CNA #5 named in the allegation was immediately removed from resident care duties, suspended pending the facility's investigation in accordance with the facility's abuse prevention policy. 2. Identification of Other Residents Who May Have Been Affected - Review of all staff assignments was completed on 5/12/25. Interviews were conducted with residents assigned to the alleged staff member. Review was conducted of all clinical documentation for residents receiving care during the shift. Additional skin-to-skin head-to-toe nursing assessments were completed for all residents who received care from CNA #5. All assessments were conducted by licensed nursing staff with oversight by the DON. 3. Systemic Changes Implemented - Immediate re-education of 100% of facility staff regarding abuse prevention and mandatory reporting requirements. Education included review of the facility's zero-tolerance abuse policy, reinforcement of professional conduct expectations during resident care, increased supervisory rounds by nursing leadership during resident care activities and review of reporting expectations with all department heads. 4. Monitoring Plan with Specific Dates – The DON or designee will monitor compliance through observational audits and skin-to-skin head-to-toe assessments according to the following schedule: Week 1 monitoring audit 5/19/25; week 2 monitoring 5/26/25; week 3 monitoring 6/2/25; week 4 monitoring 6/9/25. June 16, 2025 – Final review of the 4-week monitoring period. These audits include direct observation of CNA-resident care interactions and random skin-to-skin head-to-toe nursing assessments. Results will be reviewed by the DON. Following completion of the 4-week monitoring period ending 6/16/25, the results will be reviewed during the facility's Quality Assurance and Performance Improvement (QAPI) meeting to determine if additional monitoring is required. 5. Correction date was 6/13/25. The surveyor verified that R114's abuse incident was reported to the state survey agency, department of health professions, adult protective services, law enforcement in addition to the medical provider and family representative. There was evidence that the abuse prevention policies for reporting and investigating the incident were followed. Documentation was provided of resident interviews and skin assessments as listed in step 1 of the correction plan with no further abuse identified. Documentation was provided of staff education that started on 5/12/25 on abuse/neglect policies, professional conduct during care and abuse reporting. Skin assessments of residents care for by CNA #5 were documented in addition to weekly monitoring CNA-resident care and ongoing skin audits. The QAPI meeting agenda for August 2025 included review of the substantiated staff to resident abuse incident of 5/12/25, with staff member termination noted. On 3/5/26 starting at 11:48 a.m., multiple staff members on each nursing unit were interviewed and voiced education had been provided regarding abuse prevention, reporting and professional conduct during care with staff aware of abuse protocols for prevention, reporting and expectations for conduct during care. The survey team deemed the plan of correction was implemented as listed. During the current survey, resident interviews, family interviews, a resident group/council interview, staff interviews and record reviews conducted with no reports of resident abuse and no deficiencies cited for resident abuse since 6/13/25. This deficiency was cited as past non-compliance.

Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to provide treatment and services to prevent and heal pressure sores for two Residents (Residents # 113 and #9 ) in a survey sample of 46 Residents, resulting in harm for Resident # 113.The findings included:For Resident # 113, the facility staff failed to address the potential for developing a pressure ulcer, failed to identify the risks, failed to develop a plan of care and failed to implement interventions to prevent pressure ulcer development, resulting in Harm. Resident #113 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pathological fracture of right femur, a history of malnutrition, B 12 deficiency, adult failure to thrive, need for assistance with personal care, difficulty in walking, lack of coordination and unsteadiness on feet. The most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Review Date of 5/20/2023. The MDS coded the BIMS (Brief Interview for Mental Status as 7 out of 15, indicating severe cognitive impairment. Resident # 113 required assistance with ADLs (Activities of Daily Living.) The MDS Section M-Skin Conditions-M 150-Risk of Pressure Ulcers/Injuries was coded as a 1 indicating Resident # 113 was at risk of developing pressure ulcers/injuries. Section M0210 coded a 0 indicating there were no unhealed pressure injuries on admission. Review of the closed clinical paper record was conducted 3/5/2026 to 3/10/2026. Review of inpatient hospital records prior to admission to the facility revealed an inpatient Wound Care services consult dated 5/10/2023 for wounds to left second and third toes. The Plan was: Primary RN (Registered Nurse) to order and utilize wedges and heel medix boots from central supply if not already present in room. The note also stated ''Aggressive repositioning-reposition patient at least every 2 hours utilizing wedges and pillows to offload pressure from bony prominences. Float heels-offload pressure from heels via pillows or heel medix boots any time patient is in bed. Resident # 113 was admitted to the facility on [DATE]. The admission assessment dated [DATE] at 4 p.m. described skin issues on the upper mid vertebrae, right elbow, groin and right thigh (rear) with bruises and 12 staples. There were no concerns noted on the feet. There was no documentation of orders carried over from the hospital regarding prevention of pressure wounds to include use of wedges, pillows, floating heels, repositioning or use of Medix boots. Resident #113's care plan did not address the presence of wounds, risk for pressure ulcer development, or implementation of interventions to prevent the development of a pressure wound. On 5/16/2023, the admission assessment documented no open areas. Weekly skin assessments were conducted and revealed the following: 5/25/2023- no open areas. 5/28/2023- Right Heel -red area. 5/31/2023-right heel open, redness, bleeding. 6/1/2023 @ 1728 (5:28 p.m.)-right heel-stage 3 pressure injury-5x3.2x.02 measurement Treatment-Collagen and santyl daily off load and reposition. Physicians Progress Notes were reviewed. The Physicians Progress notes on 5/17/2023 and 5/23/2023 revealed no skin issues. On 5/30/2023-Physicians Progress Notes stated has wounds to bilateral heels. The right is open and the left is DTI (Deep Tissue Injury.) skin right heel wound-left heel DTI-plan: left heel: paint with skin prep every shift. right heel: iodosorb every other day. Float heels with prevalon boots while in bed Review of Physicians orders from the Order Summary Report 5/16/2023-7/10/2023 totaling 8 pages revealed orders for the following listed under other orders 5/16/2023-verbal-Weekly skin checks 5/30/2023-prescriber written-Prevalon boots while in bed to bilateral heels 5/30/2023-prescriber written-right heel wound: clean with wound cleaner, apply iodosorb to wound, cover with bordered gauze every other day. 6/1/2023-verbal-right heel-clean with wound cleaner, apply santyl and collagen to wound bed, cover with gauze, and wrap with kerlex. Every day shift for wound care Under Pharmacy Orders was written:6/1/2023- Santyl External Ointment 250 unit/gm(gram) (Collengenase)- verbal -Apply to right heel wound bed topically every day shift for wound care 6/8/2023-verbal-right heel-clean with wound cleaner, apply santyl to wound bed, cover with moistened Dakins gauze; wrap with kerlex every day shift for wound care The wound care physician notes dated 6/15/2023 revealed documentation of pressure wound on the right heel as a Stage 4. The note stated: 6/15/2023-Consultant Wound Care Report-Wound Evaluation and Management Summary-stated referred by provider-chief complaint was about a wound on the right heel. Focused Wound exam-Site 2-Pressure, Stage 4, duration >14 days, Wound size (L x W x D) 4.5x 2.0 x Not measurable cm (centimeters)-Thick adherent black necrotic tissue (eschar)-30%, Thick adherent devitalized necrotic tissue-20% Granulation tissue-50%. Dressing treatment plan- Primary dressings -Santyl apply once daily for 16 days, sodium hypochlonite solution (dakins) apply once daily for 19 days. 1/4 strength dakens moistened gauze to be applied with santyl to the wound bed. Cover with kerlex daily. Secondary dressing-Gauze roll (kerlix) 4.5 apply once daily for 16 days. Periwound Treatment-skin prep, apply once daily for 19 days. Plan of care reviewed and addressed Recommendations: Off-Load Wound, Reposition per facility protocol. During the consultant wound care physician's visit, the wound on the right heel was debrided of necrotic tissue to establish the margins of viable tissue. The thick adherent eschar and devitalized tissue were removed. After the Consultant Wound Care Specialists visit, Weekly Pressure Ulcer Wound Reports were conducted and revealed the following: 6/15/23- Pressure Ulcer Wound rounds -pressure-right heel-4.5 x 2 x nm- Stage 4 6/22/23- Pressure Ulcer Wound rounds -pressure-right heel-5 x2 x nm-Stage 4 6/29/23- Pressure Ulcer Wound rounds -pressure-right heel -5 x2 x nm-Stage 4 7/6/23 - Pressure Ulcer Wound rounds -pressure-right heel-4.5 x 2 x nm- Stage 4 Resident # 113 resided in the facility for 12 days prior to the discovery of a reddened area on the right heel on 5/28/2023. No descriptions or measurements were documented. Two days later on 5/30/2023, the first physicians' orders were documented. Three days after the first discovery of a reddened area (on 5/31/2023), the area was described as right heel open, redness and bleeding. There was no documentation of the description to include staging or sizing. On 6/1/2023, the staging and documentation of measurements were documented as Stage 3 and measuring 5x3.2x.02. There was no order for interventions for the prevention of pressure wounds in Resident #113, who was a resident with known risks for the development of pressure ulcers. There was a physicians order for weekly skin checks on the day of admission but no further documentation of interventions for the prevention of the development of pressure ulcers/wounds. The order for Prevalon boots on bilateral heels and a treatment order were written on 5/302023, two weeks after admission. On 3/4/2026 at 11:10 a.m., an interview was conducted with Certified Nursing Assistant # who stated residents should be turned and repositioned at least every two hours. Certified Nursing Assistant # stated the staff check the skin of the residents during ADL care and any skin issues should be reported to the nurse. On 3/5/2026 at 2:20 p.m., an interview was conducted with Licensed Practical Nurse # who stated residents at risk of pressure ulcer development should be turned and repositioned every two hours or more if needed. She stated that the Certified Nursing Assistants were expected to inform the nurse of any noted skin issues. Licensed Practical Nurse # stated that interventions should be used for residents at risk for developing pressure ulcers. She stated if a pressure wound developed, the physician and the family would be notified. The facility's policy titled Pressure Injury Prevention and Management (revised 11/7/25) documented, .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .Assessments of pressure injuries will be performed by a licensed nurse, and documented accordingly. The staging of pressure injuries will be clearly identified .Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present .The attending physician will be notified of .presence of a new pressure injury upon identification . On 3/9/2026, the Director of Nursing was informed that there was no noted documentation of staging of the wound prior to a stage 3 on 6/1/2023.There were no noted interventions to prevent the development of pressure ulcers prior to the identification of a reddened right heel on 5/28/2023. The Director of Nursing stated she would check the documentation in the clinical record and any Quality Assurance Performance Improvement documentation. She stated that wounds should be identified prior to advance stages and interventions should be implemented for residents at risk of pressure ulcer development. During the end of day debriefing on 3/10/2026, the Director of Nursing, Administrator and [NAME] President of Operations were informed of the findings resulting in harm for resident # 113. The Director of Nursing stated she did not find any further documentation. No further information was provided. 2. Topical treatment and dressing changes were not implemented for Resident #9's pressure ulcer until 15 days after admission when the resident was assessed by the consultant wound physician. Initial assessments by nursing of the pressure ulcer included no wound measurements or description of the wound's appearance and/or status. Resident #9 (R9) was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), sacral pressure ulcer, bipolar disorder, benign prostatic hyperplasia, orthostatic hypotension, schizotypal disorder, chronic kidney disease, ichthyosis, anemia, dementia, hip fracture, psychotic disturbance, mood disorder and protein-calorie malnutrition. The minimum data set (MDS) dated [DATE] assessed R9 with severely impaired cognitive skills. R9's clinical record documented the resident was admitted from the hospital on 4/30/25 following treatment for hypotension and anemia. Hospital records documented that the resident was assessed and treated for an unstageable pressure ulcer on the sacrum during the hospitalization. A hospital wound assessment dated [DATE] documented R9's sacrum pressure injury measured 7.5 cm x 5.5 cm (length by width in centimeters) with eschar, purple/burgundy, non-blanchable erythema with eschar covering over 55% of the wound surface. The hospital Discharge summary dated [DATE] listed instructions for care of the pressure ulcer to include daily treatment with wound cleanser, application of hydrophilic dressing with silicone foam dressing to cover. R9's admission assessment dated [DATE] documented the resident was assessed upon admission with a sacral wound. The admission assessment documented no wound measurements and listed no description of the wound's appearance including size, wound/skin color, peri-wound color, pain presence or presence of drainage. A skin assessment dated [DATE] documented unstageable necrosis to sacrum but included no measurements or description of the wound's status/appearance. A skin assessment dated [DATE] documented the resident had an unstageable sacrum pressure ulcer and that the consultant wound physician would assess the wound. The consultant wound physician documented assessment of R9's sacrum pressure ulcer on 5/16/25. The wound note dated 5/16/25 documented the resident with an unstageable pressure injury on the sacrum measuring 5.5 cm x 3.0 cm with depth undetermined due to presence of necrotic tissue. The wound description listed 60% coverage with eschar and light serous drainage with no signs of infection. The wound physician ordered treatment with Santyl, and application of gauze saturated with 1/4 strength Dakin's solution covered with superabsorbent gel fiber with silicone border dressing daily and as needed. Skin prep was ordered once daily for application to skin surrounding the wound. Treatment orders for R9's pressure ulcer were entered and implemented starting on 5/16/25. The wound physician documented ongoing assessment of the pressure ulcer with changes in treatments implemented based upon assessments. Interventions in addition to topical treatments and dressing changes included turning and repositioning, weekly skin checks, low air loss mattress, off-loading of pressure areas, liquid protein supplement and a daily multivitamin. Wound assessments documented the wound improved without complications and was listed as resolved on 12/1/25. On 3/3/26 at 4:27 p.m., R9 was observed in bed with feet/heels elevated on a cushion and pressure relief mattress in use. R9's clinical record documented a foam dressing was applied three times per week to the sacrum for prevention of skin breakdown with no current pressure injuries. On 3/4/26 at 12:00 p.m., the director of nursing (DON) was interviewed about the delayed treatment and lack of assessment for R9's sacrum pressure ulcer. The DON stated she reviewed the clinical record and did not see treatment orders entered upon admission on [DATE]. The DON stated if a resident was admitted with a pressure injury, the admitting nurse should have assessed the wound, measured it, described it and obtained orders for care. The DON stated there should have been a thorough assessment of the pressure ulcer when noted on the weekly skin check sheets. The DON stated the admitting nurse noted there was a wound and the nurse should have obtained orders for care. The DON stated there was a delay in care. The DON stated the wound physician provided ongoing assessment with care/treatments implemented as ordered after 5/16/25. The DON stated R9's sacrum ulcer healed without complication and that the resident currently had no pressure injuries. On 3/5/26 at 8:26 a.m., the licensed practical nurse unit manager (LPN #8) caring for R9 was interviewed about the delay in treatment and lack of assessment for the pressure ulcer. The unit manager stated that if a pressure ulcer was identified, the nurse should document a full assessment with measurements. The unit manager stated the admission nurse should have obtained treatment orders upon admission. The facility's policy titled Pressure Injury Prevention and Management (revised 11/7/25) documented, .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .Assessments of pressure injuries will be performed by a licensed nurse, and documented accordingly. The staging of pressure injuries will be clearly identified .Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present .The attending physician will be notified of .presence of a new pressure injury upon identification . The National Pressure Injury Advisory Panel (NPIAP) defines a pressure ulcer/injury as localized damage to the skin and underlying soft tissue usually over a bony prominence .The injury occurs as a result of intense pressure, prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue . The NPIAP defines an unstageable pressure injury as, .Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, as Stage 3 or Stage 4 pressure injury will be revealed . (1) This finding was reviewed with the administrator, director of nursing and regional MDS coordinator during a meeting on 3/4/26 at 12:00 p.m. with no further information presented prior to the end of the survey. (1) Pressure Injury and Stages. National Pressure Injury Advisory Panel. 3/12/26. www.npiap.com/

Based on staff interview and clinical record review, the facility staff failed to develop a comprehensive plan of care for four of forty-six residents in the survey sample (Residents #2, #3, #113 and #115).The findings include:1. Resident #2 had no care plan developed regarding PTSD (post-traumatic stress disorder). Resident #2 (R2) was admitted to the facility with diagnoses that included vascular dementia, schizophrenia, diabetes, PTSD, major depressive disorder, chronic kidney disease, cerebrovascular disease, atrial fibrillation, deep vein thrombosis, anxiety and peripheral vascular disease. The minimum data set (MDS) dated [DATE] assessed R2 as cognitively intact. R2's clinical record documented ongoing monitoring by a licensed clinical social worker (LCSW) for mental health conditions that included PTSD. The most recent LCSW note dated 2/3/26 listed the resident had agreed to psychotherapy up to twice per month to address depression/anxiety symptoms related to PTSD, vascular dementia and schizophrenia. The psychiatry note documented the resident's PTSD was related to a serious accident as a teenager that affected his life. Interventions included trauma-informed care approaches during psychotherapy sessions and continued provision of supportive counseling focused on coping strategies and therapeutic engagement. Barriers to progress included medical comorbidities with interventions listed that included psychotherapy sessions twice per month. R2's plan of care (revised 10/8/25) included no problems, goals and/or interventions regarding PTSD. The plan of care listed the resident took psychotropic medications for management of PTSD but did not include the resident's identified trauma (serious accident), triggers related to the trauma or interventions that included monthly psychotherapy sessions with the LSCW. On 3/5/26 at 11:00 a.m., the licensed practical nurse (LPN #6) responsible for MDS and care plan development, was interviewed about R2. LPN #6 stated the care plan mentioned medicines but there was nothing else in the plan about the PTSD. LPN #6 stated the care plan should include problems, goals and interventions regarding PTSD. This finding was reviewed with administrator, director of nursing and the regional MDS coordinator on 3/9/26 at 5:00 p.m. with no further information presented prior to the end of the survey. 2. Resident #3 (R3) did not have a comprehensive care plan developed to address the need for dialysis. R3 diagnoses include end stage renal disease with dialysis, diabetes, major depression, and kidney failure. The most recent MDS (minimum data set) was a quarterly 2/16/26 and indicated R3 was cognitively intact. Review of R3's physician orders indicated R3 went to dialysis three days per week. R3's care plan was also reviewed and did not have evidence that a dialysis care plan had been developed. On 3/05/2026 at 9:47 a.m. the MDS coordinator reviewed R3's care plan and agreed that there was no dialysis care plan on the current comprehensive care plan and stated she would get one completed. On 3/5/2026 at 4:00 p.m. the above information was presented to the administrator and director of nursing. No other information was presented prior to exit summary on 3/10/26. 3 For Resident # 113, the facility staff failed to develop a care plan for the risk of development of pressure ulcers/wounds and did not develop a care plan when a wound was discovered on the right heel. Resident #113 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pathological fracture of right femur, a history of malnutrition, B 12 deficiency, adult failure to thrive, need for assistance with personal care, difficulty in walking, lack of coordination and unsteadiness on feet. The most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Review Date of 5/20/2023. The MDS coded the BIMS (Brief Interview for Mental Status as 7 out of 15, indicating severe cognitive impairment. Resident #113 required assistance with ADLs (Activities of Daily Living.) Resident #113's admission MDS was coded as at risk for the development of pressure ulcers/injuries. Review of inpatient hospital records prior to admission to the facility revealed an inpatient Wound Care services consult dated 5/10/2023 for wounds to left second and third toes. The Plan was: Primary RN (Registered Nurse) to order and utilize wedges and heel medix boots from central supply if not already present in room. The note also stated ''Aggressive repositioning-reposition patient at least every 2 hours utilizing wedges and pillows to offload pressure from bony prominences. Float heels-offload pressure from heels via pillows or heel medix boots any time patient is in bed. On 5/28/2023, twelve days after admission, a reddened area was identified on Resident # 113's right heel. No measurements were documented. On 6/1/2023, the pressure ulcer on the right heel was identified as a Stage 3 wound and measuring 5x3.2x.02. The care plan was reviewed and revealed no documentation that a care plan had been developed to prevent or reduce the risk of the development of pressure ulcers. There was no focus area, goals or interventions listed regarding the risk of pressure ulcer development. Treatment orders were written two days after the discovery of a reddened area on the right heel. There was no order for interventions for the prevention of pressure wounds in a resident with known risks for the development of pressure ulcers. The care plan was not updated when Resident #113 developed a pressure ulcer on the right heel. On 3/06/2026 at 10:27 a.m., the Director of Nursing reviewed Resident #113's care plan and agreed that there was no documentation of a care plan for risk for development of pressure ulcers/wounds on the comprehensive care plan. The Director of Nursing stated the care plan should reflect the problems related to the resident. On 3/6/2026 during the end of day debriefing, the Administrator, Administrator in Training and Director of Nursing were informed of the findings. No further information was provided. 4. For Resident # 115, the facility staff failed to develop a care plan that was tailored to the specific needs of the resident. The care plan was not specific. Resident #115 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: multiple myeloma, Diabetes with Diabetic chronic kidney disease, chronic obstructive pulmonary disease, atrial fibrillation, acute cystitis with hematuria, acute posthemorrhagic anemia, and hemorrhage of the anus and rectum. The most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Review Date of 4/10/2023. The MDS coded the BIMS (Brief Interview for Mental Status as 15 out of 15, indicating no cognitive impairment. Resident # 115 required assistance with ADLs (Activities of Daily Living.) Review of the care plan revealed the care plan was not tailored for Resident # 115. There were concerns that were written that did not have specific information. The care plan was a template with the word specify included, the goal was not measurable and some problems/concerns were not included in the plan. A Focus area read- The resident has an ADL self-care performance deficit related to activity intolerance Goal: The resident will improve current level of function in (SPECIFY ADLs) through the review date. The goal was not specific and did not identify which activities of daily living. Another excerpt from Resident #115's care plan read: Focus- Has the potential for pressure injury development related to immobility. No Goal was written in the care plan. The Goal section was blank. The care plan did not address that Resident # 115 was known to be allergic to four (4) medications and prescribed two of them for pain relief. Tramadol was ordered as needed and Tylenol extra strength was scheduled for administration three times per day. There was no documentation of nursing staff assessing and monitoring for signs and symptoms of allergic reactions to those medications. On 3/06/2026 at 10:37 a.m., the Director of Nursing reviewed Resident # 115's care plan and stated that the care plan was not specific and tailored. She stated the comprehensive care plan should reflect the problems/concerns related to the resident. No further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain a clean, comfortable, and homelike environment on 2 of 3 nursing units, shower rooms, storage rooms, and for four Resident's room (Resident #8, Resident #23, Resident #37, and Resident #72) within the greater facility. The findings included: From initial tour on 3/3/2026 through the course of survey concluding on 3/10/2026, the physical plant was observed and inspected. Those observations continue below. Initial tour of the facility revealed Resident #8's room on the Meadowdale unit to be crowded (hoarded) with boxes, and plastic storage containers in front of, and on top of the air conditioning unit restricting air flow. There were articles of clothing scattered around, opened large (16 to 18 ounce) containers of food sauces, and food spices all spilled and on surfaces. Also noted were partially eaten different food items mixed together and unidentifiable, 4 drinking glasses partially filled with dark liquid and dripped down the sides of the glasses. Nothing was refrigerated, and the room had a sour spoiled food smell. The Resident was sitting on a soiled bed encrusted with spilled food. The Resident's black sweatshirt was encrusted in a 6-inch by 6-inch stain on the front with dried, spilled foods and liquids, as the resident stated when asked I just spilled something on it. Resident #8's roommate was lying in his bed with a curtain drawn between them. There were several rooms with hoarding habitation noted during tour, and an interview with the Administrator in Training (AIT) revealed that a new program was being launched to address these issues. It was noted that during the rest of the survey Resident #8's roommate stayed out of the room most of the time and was found in the dining room, facility entry hallway, and at the nursing station most of the time during daytime hours. Resident #8's roommate was asked why he stayed out of his room, and he replied, I want to. Then he continued down the hallway ending the conversation. On 3/4/2026 beginning at 8:35 A.M., in the Meadowdale women's shower room observations by 2 surveyors revealed a black substance along corners and caulking area, and broken tiles in the showers. In the men's shower room, used soap and hair in the drain cover was sticking out. Handrail portions and end plugs/caps were broken in places and on the floor. A shower stretcher was found with used soap on it. Base boards were observed to be knocked down in places where they had become un-adhered. Used shampoo and soap was lying on the floors, and feces was found in the toilets within the shower rooms. The inspection continued on the Rosewood unit to reveal what appeared to be a shampoo bottle lying in the floor of the shower. Also found was calking that was pulled away from tiles which were lying on the floor and still attached to broken tiles. This revealed open holes in the wall approximately 6 inches in circumference. The shower chair was also observed with no anti slip grip on the seat and arm rest. The second shower area revealed that lights were out and this was where wheelchairs were being stored. On 3/4/2026 at 12:00 P.M., an interview was conducted with a housekeeping staff member cleaning the hallway on the Meadowdale unit. She was asked what her workload was like daily, and she replied we do 22 rooms each, and public areas as needed every day. This statement was confirmed by the maintenance director and the Housekeeping Director. Schedules of cleaning assignments were requested and supplied. Resident rooms were devoid of personal items, photographs, or artwork, and were not comfortable and homelike. Divider bed curtains were stained and not clean. Few rooms contained clocks or personal items. The sink area and steam table in the main dining room were encrusted with a black substance on the top and in the bowl of the sink, and on the countertop. The stainless steel or aluminum steam table was dirty and unkempt. On 3/4/2026 at 12:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that the hallway would be cleaned immediately, and his expectation was that staff should clean the shower rooms and bathrooms if they were dirty. On 3/9/2026 at 10:00 AM on a facility tour with the Maintenance Director, The Rosewood unit beauty shop was found to be open and had a continuous water leak covering about 30% of the back wall, the wall appeared to be rotten, and a kitchen trash can was in the middle of the floor overflowing with water dripping onto the floor and into the wall. On 3/9/2026 at 4:00 p.m., the Administrator, DON and Regional [NAME] President of Operations were notified at the end of day debriefing of the concerns of hoarding and unclean areas. They stated that cleaning had been completed in those areas mentioned and they had no further information to provide. 2. For R23 and R37 the resident's rooms were in disrepair and were not homelike. On 3/3/26 at 2:56 p.m. Resident #23 (R23) was interviewed. When asked about conditions of the room (room [ROOM NUMBER]), R23 verbalized there is unsanded and unpainted spackling on the wall, the bathroom door is scrapped up and unpainted, and the molding around the base of the wall is pulling away from the wall. R23 verbalized that the concerns had been reported but nothing is done about it. The concerns were observed at the time of the interview. On 3/4/26 at 9:20 a.m. Resident #37's (R37) family member (responsible party, RP) requested to speak to the surveyor. During the interview the RP verbalized that R37's closet door wass no longer attached to the closet and R37 does not have a dresser for clothes and other items like other residents have. The RP verbalized buying a small plastic three draw storage bin but feels that it doesn't accommodate all items and can be easily fixed by getting a dresser from a room that is not being occupied. The RP verbalized these items have been requested to be fixed or replaced for a while. On 3/4/26 at 9:28 a.m., observations were conducted of R37's room.The closet door was detached and leaning against the side of the closet and there was not a facility owned dresser beside the R 37's bed like had been oberved for R37's roommate and other rooms. On 3/05/26 at 1:30 p.m. the maintenance director was interviewed and confirmed the observations/concerns in each room noted above. The maintenance director verbalized the closet door of R37's room could not be fixed and would have to be replaced and the corporate would have to be contacted to get a replacement closet. Regarding the missing dresser, the maintenance director verbalized he would try to get another one from an empty room. The maintenance director then observed R23's room and agreed that the above concerns need to be fixed. The maintenance director verbalized that there are two maintenance employees (including himself) and the other person was newly hired and at this time both the maintenance employees are currently working on priority issues and plan to come up with a maintenance schedule. On 3/5/2026 at 4:00 p.m. the above information was presented to the administrator, director of nursing, and administrator in training (AIT). The AIT verbalized that corporate is no longer replacing closets with another closet and will be replaced with a dresser. No other information was presented prior to exiting on 3/10/26. 3. For Resident #72, the facility staff failed to maintain a homelike enviornment, by failure to replace a broken receptical cover. A comprehensive record review of R72's medical record revealed that R72 has a most recent BIMS (Brief Interview for Mental Status) score of 6 indicating significant mental impairment on his most recent (Quarterly) MDS (Minimum Data Set) Assessment. The same MDS assessment demonstrated that R72 is dependent on staff for transfers and utilizes a wheelchair. Review of the medical record showed that R72 has poor impulse control, frequent falls out of bed, and behaviors. On 3/3/26 R72 was observed sitting in bed in their room. While standing at the foot of the bed, an electrical outlet was noted on the wall behind the right side of the bed. This electrical outlet had a plate that was broken with the left side of the plate no longer present and a subsequent hole in the wall exposing the elements of the outlet plug. This electrical outlet was within arm's reach of the floor mats placed on both sides of R72's bed. An interview with the Maintenance Director was conducted on 03/06/2026 10:50 A.M. States when a repair is needed the process is to place a work order in with maintenance. States that a broken electrical outlet would be considered an emergency and the expectation would be for it to be fixed immediately upon discovery. Maintenance Director stated that this electrical outlet had been repaired since this issue was brought to their attention after surveyor discovery on 3/3/26 and produced a photograph of the repaired outlet. No further information was provided prior to exit.

Based on Staff interview, clinical record review, and facility document review, the facility failed to provide medications as ordered by a physician for one Resident (Resident #113) in a survey sample of 46 residents.The findings included:For Resident # 113, the facility staff failed to ensure medications were available for administration.Resident #113 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pathological fracture of right femur, a history of malnutrition, B 12 deficiency, adult failure to thrive, need for assistance with personal care, difficulty in walking, lack of coordination and unsteadiness on feet. The most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Review Date of 5/20/2023. The MDS coded the BIMS (Brief Interview for Mental Status as 7 out of 15, indicating severe cognitive impairment. Resident # 113 required assistance with ADLs (Activities of Daily Living.) A review of Resident #113's electronic clinical record was conducted 3/6/2026-3/10/2026. This review revealed the following, but not limited to, excerpts from the progress notes:7/7/2023-20:52 (8:52 p.m.-Enoxaparin Sodium inject 0.3 ml (milliliters) subcutaneously two times a day for prevent blood clots until 6/20/2023- awaiting for medication7/7/2023- 08:41- a.m.-Enoxaparin Sodium inject 0.3 ml (milliliters) subcutaneously two times a day for prevent blood clots until 6/20/2023- waiting for pharmacy to send7/6/2023-9:57 a.m.- Enoxaparin Sodium inject 0.3 ml (milliliters) subcutaneously two times a day for prevent blood clots until 6/20/2023- calling pharm no more left6/16/2023-Enoxaparin Sodium inject 0.3 milliliters subcutaneously two times a day for prevent blood clots until 6/20/2023- called pharm for refill6/8/2023- 12:08 p.m.- Gabapentin 100 milligram oral capsule give one capsule by mouth three times a day for nerve pain -med not administered called pharm will come today.6/5/2023- 20:02 (8:02 p.m.) Enoxaparin Sodium inject 0.3 ml (milliliters) subcutaneously two times a day for prevent blood clots until 6/20/2023- called pharm will send meds6/5/2023-Enoxaparin Sodium inject 0.3 ml (milliliters) subcutaneously two times a day for prevent blood clots until 6/20/2023- ran outta med sent refill request to pharm 6/3/235/17/2023 0803- Gabapentin 100 milligram oral capsule give one capsule by mouth three times a day for nerve pain -med ordered waiting for pharm to send it5/17/2023 12:04 p.m.- Gabapentin 100 milligram oral capsule give one capsule by mouth three times a day for nerve pain -waiting on pharm to deliver medEnoxaparin Sodium inject 0.3 ml (milliliters) subcutaneously two times a day for prevent blood clots until 6/20/2023- ran outta med sent refill request to pharm 6/3/23During medication pass and pour observation on 3/4/2026, an interview was conducted with the Licensed Practical Nurse # 2 who administered medications. She stated that medications should be given as ordered by the physician. On 3/6/2026 at 1:30 p.m., an interview was conducted with the Director of Nursing who stated medications should be available for administration as ordered by the physician. She stated the nurses should call the Pharmacy to inform them that the medication was not available in the medication cart, order the medication, check the Omnicell and notify the physician if the medication was not available to be administered. She stated the Pharmacy delivers twice a day at the facility. She also stated the expectation was for the Pharmacy to send medications on the next delivery after notification that a medication was not available as ordered. A copy of the Omicell Inventory list was requested.On 3/9/2026 at 9:45 a.m., an interview was conducted with the Director of Nursing who stated medications should be available for administration as ordered by the physician. The Director of Nursing stated the Pharmacy should have ensured the medication was available for administration. She also stated the nurses should have checked the Omnicell (in house Stat box) for an available supply of the medication. The Director of Nursing presented a copy of the Omnicell inventory list. Review of the Omnicell Inventory list revealed that the medication, Gabapentin 100 milligrams capsules, was available in the Omnicell. The nurses should have notified the pharmacy to gain access to the medication.During the end of day debriefing on 3/9/2026, the Facility Administrator, Administrator in Training and Director of Nursing were informed of the findings. They stated medications should be available for administration as ordered by the physician. Enoxaparin was not available for administration. No further information was provided.

Based on observation and staff interviews, the facility failed to appropriately store medications and medical supplies for 2 out of 3 total medication rooms, the Meadowland Unit medication room and the Rosewood Unit medication room.The findings include:An inspection of a medication room on the Meadowland unit took place on 3/5/26 at 12:15 P.M. The following expired items were discovered:An opened box of 2-piece urostomy pouches with a listed expiration date of 12/2024.An opened box of drainable ostomy pouches with a listed expiration date of 12/2024.An opened box of ostomy barrier rings with a listed expiration date of 9/2025.An opened box of no sting barrier film with a listed expiration date of 11/9/2025.Four saline enema sets all with listed expiration dates of 2/2026.Eleven urethral self-catheterization kits with listed expiration dates of 10/31/2024.A rigid tipped urinary catheter with a listed expiration date of 8/2/25A female luer lock cap with a listed expiration date of 7/28/25.On 3/5/26 at 12:42 P.M. an inspection was conducted of a medication room located in the Rosewood unit. The following expired items were discovered:A package of 2 needles with an expiration date of 2/20/26An opened box of 2-piece ostomy pouches with an expiration date of 2/1/26An additional opened box of 2-piece ostomy pouches with an expiration date of 12/1/25An opened box of closed ostomy pouches with an expiration date of 2/1/26.An interview was conducted with LPN (Licensed Practical Nurse) #3 on 3/5/26 at 12:42 P.M. LPN #3 stated these items are expired and the expectation is that expired medications and supplies are discarded upon discovery.An interview was conducted with LPN #1 on 3/5/26 at 2:07 P.M. LPN #1 stated these items are expired and when expired medical supplies and expired medications are discovered, the expectation is that they are discarded. According to the undated facility policy titled, Medication Storage, it read in part, . 8. Unused medications: Th pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, and detiorated medications with worn, illegible, or missing lables. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. The Administrator and the Director of Nursing were made aware of the above findings at 4:35 P.M. on 3/5/26.No further information was presented prior to exit.

Based on observation, staff interview, and facility documentation review, the facility staff failed to store food in accordance with professional standards for food safety in the main kitchen and in two of three nourishment room refrigerators (Rosewood Unit refrigerator and Meadowland Unit refrigerator) inspected. The findings include:On 3/3/2026 at 1:45 PM an initial tour of the kitchen was conducted with the Dietary Manager (DM). The DM explained that food products are dated when they are delivered and a use-by-date is labeled on individual items when they are opened. An observation of the dry storage room revealed half of a loaf of bread opened with no date. A hot dog bun package was found opened and not dated. A large container of apple cider vinegar was noted to be open without a date. The walk-in refrigerator revealed an opened package of shredded cheese that was not dated. The DM confirmed that opened and undated food items should not have been in the dry goods area or walk-in refrigerator and they were discarded. On 3/5/2026 at 10:56 AM the DM explained that outside food that is brought in by visitors for residents should be labeled with the residents' name, room number and date it was brought in prior to it being placed in the nourishment refrigerators. The Rosewood Unit refrigerator was then observed with DM and contained an opened container of soup that expired on 2/14/2026 and an opened bottle of salad dressing ([NAME] Creamy Italian) that was not dated. The DM stated that those items should have been labeled and should not have been put in the refrigerator. An observation of the Meadowland Unit nourishment refrigerator was conducted with the DM. Several items in the refrigerator were not labeled or dated, including small bags of packaged apple slices that were spoiled and past the expiration date of 1/31/2026. A small carton of whole milk that expired on 2/16/2026, the DM discarded the milk. On 3/5/2026 at 11:03 AM an interview with the Nursing Supervisor of the Meadowland Unit, Licensed Practical Nurse (LPN#1), was conducted. LPN #1 described the process of storing foods that were brought in for residents by family members or visitors. LPN #1 stated that all staff were aware that residents' food should be labeled with the residents' name, room number and the date it was brought in. It was verbalized that on Friday's the nursing staff were supposed to inspect the resident nourishment refrigerators and discard any out of date or spoiled food items. LPN #1 noticed the spoiled bags of apple slices with the expiration date of 1/31/2026 and stated that they should not have been in the refrigerator. On 3/5/2026 at 11:21 AM an interview with the Nursing Supervisor of the Rosewood Unit, (LPN #2), was performed. LPN #2 explained that nursing staff were supposed to label all food with the residents' name, room number and the date. LPN #2 confirmed that the opened and expired soup container and opened and undated salad dressing should not have been in the refrigerator. LPN #2 advised that resident families have been asked not to bring in any more outside food due to refrigerators being overcrowded with so much food. The Administrator presented a policy regarding food safety requirements and food storage and retention. The policy included practices to maintain safe refrigerated storage which included labeling, dating and monitoring refrigerated foods. A facility policy was presented titled Use and Storage of Food Brought in by Family or Visitors read in part, All foods items that are already prepared by the family or visitor brought in must be labeled with content and dated. On 3/9/2026 at 4:30 PM the Administrator, [NAME] President of Operations and Regional Minimum Data Set (MDS) Coordinator were notified of the above finding. No other information was provided prior to the exit conference at 12:30 PM on 3/10/2026.

Based on interviews, clinical record reviews and facility document reviews, the facility staff failed to ensure that 4 of 5 sampled residents were offered and/or provided the Pneumococcal/Influenza vaccine in accordance with facility policy in a survey sample of 46 residents. (Residents #18, 10, 48, and 9).Findings include:a. Resident #18 was originally admitted on [DATE] and readmitted on [DATE] after a brief hospitalization for treatment of acute on chronic hypoxic respiratory failure and fluid overload secondary to congestive heart failure. Her diagnoses included but are not limited to chronic obstructive pulmonary disease with acute exacerbation, hypertensive heart disease with heart failure, obstructive sleep apnea, morbid obesity with alveolar hypoventilation, type 2 diabetes mellitus, cocaine abuse, and chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission. Resident #18's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) 1/26/26 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15 indicating no cognitive impairment. A review of Resident #18's immunization record showed no information of offering or administering the influenza or pneumococcal vaccines. A review of Resident #18's physician orders revealed orders for Flu vaccine annually and Pneumovax if needed. A review of the clinical record showed no known allergies. An interview was conducted with Resident #18, and according to her no one at the facility had asked her about what vaccinations she had received or offered any vaccines. b. Resident #10 was admitted on [DATE] with diagnoses to include but not limited to spina bifida with hydrocephalus, type 2 diabetes mellitus, hypertension, history of colon cancer, anxiety, depression and sacral pressure injuries. Resident #10's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) 2/10/26 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15 indicating no cognitive impairment. A review of Resident #10's immunization record showed no information of offering or administering the influenza or pneumococcal vaccines. A review of Resident #10's physician orders revealed orders for Flu vaccine annually and Pneumovax if needed. A review of the clinical record revealed allergies to ciprofloxacin, clonidine, nitrofurantoin, nystatin, trospium, cat dander, Latex, and hydrofera blue 4x4 wound dressing (according to the National Institute of Health, these medications, environmental factors or materials do not generally prevent a person from receiving the flu or pneumococcal vaccines). An interview was conducted with Resident #10, and according to him he does not recall anyone at the facility asking him about vaccinations or if he wanted any vaccines. c. Resident #48 was admitted [DATE] with diagnoses to include but not limited to cerebral infarction due to occlusion or stenosis of small artery, and type 2 diabetes mellitus, mild intellectual disabilities, epilepsy, chronic combined systolic and diastolic congestive heart failure, major depressive disorder, schizoaffective disorder, bipolar type, violent behaviors, acute respiratory failure with hypoxia, and hypertension. Resident #48's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) 2/10/26 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 09 out of a possible 15 indicating moderate cognitive impairment (meaning noticeable, moderate problems with memory and thinking). A review of Resident #48's immunization record showed no information on offering or administering the influenza or pneumococcal vaccines. A review of Resident #48's physician orders revealed orders for Flu vaccine annually and Pneumovax if needed. A review of the clinical record noted allergies to ibuprofen, Dilantin, and penicillin (according to the Centers for Disease Control and Prevention allergies to Dilantin, ibuprofen and penicillin generally do not prevent a person from getting the flu or pneumococcal vaccine). An interview was conducted with Resident #48, and according to her she cannot remember anyone asking her about vaccinations). d. Resident #9 was admitted on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease, bipolar disorder, altered mental disorder, paralytic ileus, dementia without behavioral disturbance, major depressive disorder, pressure ulcer sacral region, and diabetes mellitus type 2. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) 1/24/26 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 02 out of a possible 15 indicating severe cognitive impairment (having significant difficulties with memory, orientation and ability to process information). A review of Resident #9's immunization record showed no information of offering or administering the Pneumovax vaccine. A review of Resident #9's physician orders revealed orders for Flu vaccine annually and Pneumovax if needed. A review of the clinical record showed no known allergies. Resident #9 was non-interview able for information regarding whether he was educated or offered the pneumovax vaccination. On 3/4/26 an interview was conducted with the facility's IP (Infection Preventionist). According to the Infection Preventionist she had only been employed for a few months and was trying to catch up on the vaccination status of all residents. A review of Residents #18, #10, #48, and #9 was completed with the IP and she stated she was aware that some residents were missing vaccine information and she was working to obtain consents for the vaccinations and had just recently gained access to (VIIS) the State's Immunization Information System portal in order to access residents vaccination history. A review of the facility's Influenza and Pneumococcal Vaccines policies was completed which read in part: Policy entitled Influenza Vaccination dated 6/1/2025, reviewed/revised 11/13/25: Policy Explanation and Compliance Guidelines: . 2. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this period or refuses to receive the vaccine . 9. The resident's medical record will include documentation that the resident and/or the resident's representative were provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal . Policy entitled Pneumococcal Vaccine dated 6/1/2025, reviewed/revised on 10/22/25, Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. 2. Each resident shall be offered the pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. 3. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization with the education documented in the clinical record . On 3/9/26 during the end of day meeting with the Executive Director, Regional Director of Operations, Administrator-in-Training and Director of Nursing, the above information was shared with them. An opportunity was offered to the facility staff to present additional information. On 3/10/26, the IP (Infection Preventionist) presented copies of vaccine information for Residents #48, #10, #18 and #9 she had printed from the State's VIIS on 3/10/26 but not yet entered into the residents' electronic clinical record. They had no further comments regarding the above information.

Based on interviews, clinical record review and facility document review, the facility staff failed to ensure 4 of 5 residents were educated, offered and/or provided the COVID-19 vaccine in a survey sample of 46 residents (Residents #18, 10, 48, and 9).Findings included:For Resident #18, 10, 48, and 9, the facility staff failed to provide education and offer the COVID-19 vaccine. a. Resident #18 was originally admitted to the facility on [DATE] and readmitted on [DATE] after a brief hospitalization for treatment of acute on chronic hypoxic respiratory failure and fluid overload secondary to congestive heart failure. Her diagnoses included but are not limited to chronic obstructive pulmonary disease with acute exacerbation, hypertensive heart disease with heart failure, obstructive sleep apnea, morbid obesity with alveolar hypoventilation, type 2 diabetes mellitus, cocaine abuse, and chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission. Resident #18's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) 1/26/26 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15 indicating no cognitive impairment. A review of Resident #18's immunization record showed no information that the resident was educated, offered or had been given the COVID-19 vaccine. A review of the clinical record showed no known allergies. An interview was conducted with Resident #18, and according to her no one at the facility had asked her about whether she had been given the COVID-19 vaccine, provided her with education on the vaccine or offered her the vaccine. b. Resident #10 was admitted to the facility on [DATE] with diagnoses to included but not limited to spina bifida with hydrocephalus, type 2 diabetes mellitus, hypertension, history of colon cancer, anxiety, depression and sacral pressure injuries. Resident #10's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) 2/10/26 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15 indicating no cognitive impairment. A review of Resident #10's immunization record showed no information of education, offering or administration of the COVID-19 vaccine. A review of the clinical record revealed allergies to ciprofloxacin, clonidine, nitrofurantoin, nystatin, trospium, cat dander, Latex, and hydrofera blue 4x4 wound dressing (according to the National Institute of Health, these medications, environmental factors or materials do not generally prevent a person from receiving the COVID vaccine). An interview was conducted with Resident #10, and according to him he does not recall anyone at the facility asking him about the COVID-19 vaccine or any vaccine. c. Resident #48 was admitted to the facility on [DATE] with diagnoses to included but not limited to cerebral infarction due to occlusion or stenosis of the small artery, type 2 diabetes mellitus, mild intellectual disabilities, epilepsy, congestive heart failure, major depressive disorder, schizoaffective disorder, bipolar type, violent behaviors, acute respiratory failure with hypoxia, and hypertension. Resident #48's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) 2/10/26 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 09 out of a possible 15 indicating moderate cognitive impairment (meaning noticeable, moderate problems with memory and thinking). A review of Resident #48's immunization record showed no information on education, offering or the administration of the COVID-19 vaccine. A review of the clinical record noted allergies to ibuprofen, Dilantin, and penicillin (according to the Centers for Disease Control and Prevention allergies to Dilantin, ibuprofen and penicillin generally do not prevent a person from getting the COVID vaccines). An interview was conducted with Resident #48, and according to her she cannot remember anyone asking her whether she had any vaccinations. d. Resident #9 was admitted on [DATE] with diagnoses to included but not limited to chronic obstructive pulmonary disease, bipolar disorder, altered mental disorder, paralytic ileus, dementia without behavioral disturbance, major depressive disorder, pressure ulcer sacral region, and diabetes mellitus type 2. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) 1/24/26 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 02 out of a possible 15 indicating severe cognitive impairment (having significant difficulties with memory, orientation and ability to process information). A review of Resident #9's immunization record showed no information of education, offering or the administration of the COVID-19 vaccine. A review of the clinical record showed no known allergies. Resident #9 was non-interview able for information regarding whether he was educated or offered the COVID-19 vaccine. On 3/4/26 an interview was conducted with the facility's IP (Infection Preventionist). According to the Infection Preventionist she had only been employed for a few months and was trying to catch up on the vaccination status of all residents. A review of Residents #18, 10, 48, and 9 was completed with the IP and she stated she was aware that some residents clinical records were missing vaccine information and she was working to obtain consents for vaccinations and had just recently gained access to (VIIS) the State's Immunization Information System portal in order to access residents vaccination history. A review of the facility's COVID-19 Vaccine policy read in part: Policy entitled COVID-19 Vaccination dated 6/21/2025, reviewed/revised 11/13/25: Policy Explanation and Compliance Guidelines: .11. COVID-19 vaccinations will be offered to residents when supplies are available, as per CDC (Centers for Disease Control), and/or FDA (Food and Drug Administration) guidelines unless such immunization is medically contraindicated, the individual has already been immunized or refused to receive the vaccine. 12. Following assessment for potential medical considerations, COVID-19 vaccinations may be administered in accordance with physician approved standing orders .14. The facility will educate and offer the COVID-19 vaccine to residents, resident representatives and staff and maintain documentation of such . On 3/9/26 during the end of day meeting with the Executive Director, Regional Director of Operations, Administrator-in-Training and Director of Nursing, the above information was shared with them. An opportunity was offered to the facility staff to present additional information. On 3/10/26, the IP (Infection Preventionist) presented copies of vaccine information for Residents #48, #10, #18 and #9 she had printed from the State's VIIS on 3/10/26 but not yet entered into the residents' electronic clinical record. They had no further comments regarding the above information.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to accurately code an MDS (minimum data set) assessment for one Resident (Resident #113) in a survey sample of 46 Residents. The findings included:For Resident # 113, the facility staff failed to code a Stage 4 pressure ulcer on a discharge Minimum Data Set Assessment.Resident #113 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pathological fracture of right femur, a history of malnutrition, B 12 deficiency, adult failure to thrive, need for assistance with personal care, difficulty in walking, lack of coordination and unsteadiness on feet. The most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Review Date of 5/20/2023. The MDS coded the BIMS (Brief Interview for Mental Status as 7 out of 15, indicating severe cognitive impairment. Resident # 113 required assistance with ADLs (Activities of Daily Living.) According to Section M, Skin Conditions, Resident # 113 did not have any pressure ulcers/wounds upon admission. Review of the paper closed clinical record was conducted 3/5/2026-3/10/2026. Pressure ulcers were described interchangeably as pressure ulcers or wounds or pressure injuries in the clinical record. Review of the Physicians Progress Notes, Physician orders and Nurses notes revealed that Resident # 113 was diagnosed with a Stage 3 Pressure wound on 6/1/2023. Resident # 113 was assessed on 6/15/2023 by a Consultant Wound Care Physician who identified a Stage 4 pressure wound on the right heel. The pressure wound on the right heel was listed on the weekly Physicians Progress Notes. The Weekly Pressure Ulcer Wound round notes were reviewed and documented a Stage 4 pressure wound on the right heel was last evaluated on 7/6/2023. The weekly reports stated:6/15/23- Pressure Ulcer Wound rounds -pressure-right heel-4.5 x 2 x nm- Stage 46/22/23- Pressure Ulcer Wound rounds -pressure-right heel-5 x2 x nm-Stage 46/29/23- Pressure Ulcer Wound rounds -pressure-right heel -5 x2 x nm-Stage 47/6/23 - Pressure Ulcer Wound rounds -pressure-right heel-4.5 x 2 x nm- Stage 4The Discharge Plan and Instructions dated 7/7/2023 on page 6 of 13 listed wound care in Section A as one of the services provided during the stay at the facility. The discharge body audit, Skin Condition section on page 12 of 13 documented yes that the the skin was intact. The form was signed by the former Unit Manager (Licensed Practical Nurse # 9) who no longer worked at the facility at the time of the survey.The Discharge MDS dated [DATE] Section M Skin Conditions- M0210- Unhealed Pressure Ulcers/Injuries -Does this resident have one or more unhealed pressure ulcers/injuries? was coded as 0-No indicating Resident # 113 had no pressure ulcers/injuries. The MDS was signed by the former MDS Registered Nurse (Registered Nurse # 4) on 7/15/2023.On 3/10/2026 at 10:45 a.m., interviews were conducted with the Director of Nursing and Regional MDS Coordinator in the Director of Nursing office. They reviewed the clinical record to determine if Resident # 113 had a pressure ulcer/injury at the time of discharge. The Director of Nursing stated there was documentation in the Progress notes about a Stage 4 pressure ulcer identified in June of 2023. On 3/10/2026 at 10:48 a.m., the Regional MDS Coordinator stated the Discharge MDS was coded as no pressure ulcers/injuries. She stated the MDS was incorrect. Both stated it was important for the MDS to accurately reflect the resident's status.No further information was provided.

Based on observation, staff interviews, and review of facility documents, the facility staff failed to prevent the employment of a person who has been convicted of a barrier crime, which disqualifyed the employee from employment in a nursing home for one of twenty-five employees reviewed (certified nursing assistant #3- CNA #3). The findings included: The facility staff permitted a Certified Nursing Assistant (CNA #3) to provide direct care to residents with unrestricted and unsupervised access despite the employee having a conviction for a barrier crime, which prohibits employment in a long-term care facility under regulatory requirements.On 3/6/26 at 11:55 AM, while completing a review of employee records it identified that Certified Nursing Assistant (CNA) #3's Commonwealth of Virginia Department of State Police criminal history and sex offender record read in part: 08/28/2023 Guilty - Felony 18.2 - 474.1 Jail: Delivery of Drugs to Prisoner.On 3/6/26 at 11:56 AM ,an interview was conducted with the Administrator in Training and the Human Resource Coordinator. The findings of CNA #3's criminal history and sex offender record was brought to the Administrator in Training's attention and she stated, Can we please take a break? and exited the room. The Human Resource Coordinator then stated, You do not understand what is going to happen to me. On 3/6/26 at 12:30 PM, an interview was conducted with the Administrator. The Administrator stated that CNA #3 should not be working at the center due to the results of the employees background check. On 3/6/26 at 10:45 PM an interview was conducted with the Administrator in Training. The Administrator in Training stated that CNA #3 was a full time employee on the 11pm - 7 am shift and full-time employment means 35 hours a week. The Administrator in Training also stated that CNA #3 was hired on 11/26/24. The Administrator in Training further stated that CNA #3 worked the prior night 3/5/26 on the 11pm -7am shift. A review of the facilities payroll documentation revealed that CNA #3 worked from 11:22 PM on 3/5/26 until 7:35 AM on 3/6/26. According to the facility's work schedule, CNA #3 was scheduled to work again the night of 3/6/26.On 3/6/26 at 8:10 PM, the facility's Administrator in Training, Director of Nursing, and an Administrator from another facility within the company were informed of the above non-complianceOn 3/6/26, the employee was suspended from employment and subsequently resigned her employment. No additional information was provided.

Based on observation, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for three of forty-six residents in the survey sample (Residents #9, #72 and #113).The findings include:1. Resident #9's plan of care was not revised to include current interventions for pressure ulcer prevention. Resident #9 (R9) was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), sacral pressure ulcer, bipolar disorder, benign prostatic hyperplasia, orthostatic hypotension, schizotypal disorder, chronic kidney disease, ichthyosis, anemia, dementia, hip fracture, psychotic disturbance, mood disorder and protein-calorie malnutrition. The minimum data set (MDS) dated [DATE] assessed R9 with severely impaired cognitive skills. R9's clinical record documented that the resident had a sacral pressure ulcer that was healed as of 12/1/25. Current physician orders for prevention of pressure ulcers included pressure relief cushion to wheelchair, barrier cream to buttocks, a protective silicone foam dressing to sacrum each Monday, Wednesday and Friday and skin prep to heels on Monday, Wednesday and Friday. On 3/3/26 at 4:27 p.m., R9 was observed in bed with a pressure relief mattress in use and the resident's heels/feet were elevated on cushions. R9's plan of care (revised 1/20/26) documented the resident was at risk of pressure injury development due to limited mobility. The interventions for pressure injury prevention included, Monitor/document/report PRN [as needed] any changes in skin status. The plan of care had not been revised to include current interventions for pressure injury prevention including the wheelchair cushion, protective dressing, skin prep to heels, mattress and off-loading of heels/feet. On 3/4/26 at 3:04 p.m. the licensed practical nurse (LPN #6) responsible for MDS and care plan updates was interviewed about R9's plan. LPN #6 stated R9's care plan was most recently reviewed on 1/20/26. LPN #6 reviewed the care plan and stated the plan only listed monitoring for new pressure injuries. LPN #6 stated the current interventions for pressure injury prevention should have been included in the plan. LPN #6 stated she was not sure why the interventions in place had not been added to the care plan. On 3/5/26 at 8:26 a.m., the unit manager (LPN #8) caring for R9 was interviewed about the plan of care. LPN #8 stated R9 currently had no pressure injuries but that a protective dressing was kept on the sacrum for prevention in addition to barrier cream with incontinence care, turning and repositioning, skin prep to heels and elevation of heels/feet. LPN #8 stated she was not sure why the current interventions had not been added to the care plan. This finding was reviewed with the administrator, director of nursing and regional MDS coordinator during a meeting on 3/9/26 at 5:00 p.m. with no further information presented prior to the end of the survey. 2. For R72 who was a fall risk, the facility failed to review and revise the care plan to include the intervention of fall mats to the floor bilaterally. A comprehensive review of R72's medical records included a care plan to address fall risk initiated on 10/30/24. Interventions include: anticipate and meet resident's needs, ensure call light is in reach and encourage resident to use it, bed in low position, and physical therapy to evaluate and treat as ordered and as needed. R72 also has a care plan to address an actual fall that was initiated on 11/3/25. Interventions include: Root Cause: Staff listen to what resident is requesting and exercise program with restorative, NP assess in AM, Review paperwork for any other findings/, reassess by nursing for injuries per the fall protocol, neurochecks, place on 1 to 1 (11/13/24 D/C), adopt a resident for fall prevention safety, determine root cause, treatment as indicated to injuries, hourly checks for 72 hours, lab work/urinalysis, low bed, non-skid socks, place on restorative walking program, and remind resident that staff must assist with transfers and assure all items are within resident's reach. On 3/3/26 at 2:35 P.M., R72 was observed in their room in bed. Floor mats were noted in place to both sides of the bed. During an interview with R72 on 3/4/26 at 8:39 A.M. floor mats were again observed on the ground to both sides of the resident's bed. On 3/5/26 at 9:53 A.M. an interview was conducted with LPN (Licensed Practical Nurse) #6. LPN #6 stated that they update care plans quarterly and as needed for significant changes such as falls. LPN #6 stated that they do not need a physician order for floor mats as it is a fall intervention. LPN #6 acknowledged that R72 had floor mats in place to both sides of their bed. LPN #6 reviewed the care plan for R72 and was unable to locate an intervention for floor mats. LPN #6 stated that the expectation is that this intervention would be placed on the care plan. LPN #6 stated they would add this intervention to the current care plan. No further information was provided prior to exit. 3. For Resident # 113, the facility staff failed to review and revise the care plan regarding a fall with injury on 6/19/2023 Resident #113 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pathological fracture of right femur, a history of malnutrition, B 12 deficiency, adult failure to thrive, need for assistance with personal care, difficulty in walking, lack of coordination and unsteadiness on feet. The most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Review Date of 4/20/2023. The MDS coded the BIMS (Brief Interview for Mental Status as 7 out of 15, indicating severe cognitive impairment. Resident # 113 required assistance with ADLs (Activities of Daily Living.) A review of Resident #113's electronic clinical record was conducted 3/6/2026-3/10/2026. The review of the progress notes revealed documentation of a fall on 6/19/2023. Review of the care plan revealed the care plan had not been reviewed or revised after the fall on 6/19/2023 until 7/11/23 The care plan read: has had an actual fall with no injury-date initiated 5/22/2023. The revision was on 7/11/2023. The three interventions were revised on 7/11/2023. On 3/9/2026 at 9:45 a.m., an interview was conducted with the Director of Nursing who stated the care plans should be reviewed and revised after any falls within 7 days. During the end of day debriefing on 3/9/2026, the Facility Administrator, Administrator in Training and Director of Nursing were informed of the findings. No further information was provided.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 1 Resident (# 68) in a survey sample of 46 Residents.The findings included:For Resident # 68, the facility staff failed to ensure the clock on the bedroom wall was working and had the proper time. Resident # 68 was admitted to the facility on [DATE] with the diagnoses of, but not limited to: congestive heart failure, hypertension, depression, and anxiety.The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 12/29/2025. Resident # 68's BIMS (Brief Interview for Mental Status) Score was 11 out of 15, indicating moderate cognitive impairment.Review of the electronic clinical record was conducted on 3/3/2026 to 3/10/2026. On 3/3/2026 during the initial tour at 1:30p.m., the time on the clock was observed to state 8:20. The hands of the clock were not moving.During subsequent rounds on 3/3/2026 at 3:20 p.m., 3/4/2026 at 9:50 a.m., 3/4/2026 at 12:10 p.m. and 3/5/2026 at various times, the clock continued to show the time of 8:20. On 3/5/2026 at 1:10 p.m., Resident # 68 was observed lying in bed. The television was on but Resident # 68 was not watching the television. When asked what time lunch was served, Resident # 68 expressed being unsure, looked at the clock, and stated the clock did not work.On 3/5/2026 at approximately 4:15 p.m., the Director of Nursing toured the unit with the surveyor. The Director of Nursing noted the clock in Resident # 68's room showed the time as 8:20. The Director of Nursing stated the clock was wrong and that it was important for the clocks to be correct in the residents' rooms.During the end of day debriefing, the facility Administrator, Director of Nursing, Regional Director of Clinical Services and Corporate [NAME] President were informed of the findings. No further information was provided.

Based on resident interview, staff interviews, clinical record review, and facility documentation review, the facility failed to provide proper notification of a resident room transfer for one of 46 residents (resident #13). The facility failed to give Resident #13 proper notification of room transfers 10 of 14 times and have documentation of notification of room transfers. The findings included:On 03/3/2026 at 2:00 PM, an interview with Resident #13 (R13) was conducted and R13 said, The facility moved me to this room from my previous room without notification. The staff put all of my belongings on the bed and wheeled me into this room. They wanted to fix up my previous room. On 3/6/2026 at approximately 11:35 AM a staff interview was conducted with the Director of Social Work (DSW) and the Assistant Social Worker (ASW). The DSW and ASW were asked to provide evidence that R13 was provided with notification prior to a room change on 8/12/2025. Neither could find documentation of notification to R13 for a room transfer. On 3/10/2026 at 9:00 AM, an interview was conducted with the DON (Director of Nursing). The DON was asked Do you know about R13's room transfers. The DON stated that R13 does have previous room transfer notification but could not locate a room transfer notification for 8/12/2025. The DON found a nursing progress note dated 8/12/2025 that read, ABT (antibiotics) complete, Pt (patient) to move back to original room, nurse made aware, no drainage noted to eyes, Pt made aware of return to room. There was no note of what room R13 was in or what room he was being transferred to. On 3/10/2026 at 9:05 AM, a medical record review was conducted with the DON. According to R 13's record, R13 had been diagnosed with PTSD (Post Traumatic Stress Disorder) and for staff to decrease triggers for R13 in their plan of care. Notification of three room transfers for R13 occurred on 4/23/2021, 2/17/2025, 5/14/2025 and each was signed by R13. There is one nursing progress note on 8/12/2025 at 14:35 (2:35 PM) noting Resident #13 of a room transfer but no signed notification from Resident #13. The resident stated he was not notified of the room transfer on 8/12/2025. The census tab of R13's chart noted, ten (10) of fourteen (14) room transfers for Resident #13 without documentation of notification: 5/20/2021, 6/1/2021, 9/1/2021, 9/24/2021,1/10/2022, 1/19/2022, 2/26/2025, 5/21/2025, 8/5/2025, 8/12/2025, and 2/4/2026. Review of facility policy and procedure titled, Change of Room or Roommate with a date of implementation 6/1/2025 and reviewed/revised 11/14/2025, read in part: . 3. Requests for changes in room or roommate should be communicated to the Social Services Designee. 4. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible. 5. The notice of a change in room or roommate will be provided in writing, in a language and manner the resident and representative understands and will include the reason(s) why the move or change is required . On 03/10/26 at approximately 12:30PM, during an end of day debriefing held with the VPO (Vice President of Operations), Administrator, AIT (Administrator in Training), and Director of Nursing (DON) the above findings were reviewed. The facility staff stated they had nothing further to provide.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to assess and ensure it was clinically appropriate for the self-administration of medications for one resident (Resident # 73) in survey sample of 46 residents.Findings included:Resident #73 was admitted to the facility on [DATE], with a most recent readmission on [DATE]. Resident #73's diagnoses included but were not limited to: spinal stenosis, lumbar region with neurogenic claudication, type 2 diabetes with diabetic neuropathy, muscle weakness, need for assistance with personal care, mild cognitive impairment, dependence on wheelchair, ocular hypertension. Hypertension and chronic pain syndrome.Resident # 73's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1/12/2026 was coded as a quarterly assessment. Resident #104 was coded as having had a BIMS (brief interview for mental status) score of 12 out of 15, which indicated moderate cognitive impairment. The Resident was also coded as requiring extensive assistance of staff with Activities of Daily Living.During the initial tour of the facility on 3/3/2026, a resident interview was conducted with Resident # 73. A tube of Neosporin Ointment was observed in a bin on the overbed table. When Resident #73 was asked what it was, Resident # 73 stated, cream for my fingers when I clip my fingernails. Resident # 73 stated a family member brought it in as requested by the resident. Resident # 73 stated I know I am not supposed to have it, but I want to use it whenever I need it. I like using it Resident # 73 told the surveyor don't get me in trouble. Review of the electronic clinical record was conducted 3/3/2026-3/10/2026.Review of Resident # 73's clinical record, to include but not limited to: physician orders, care plan, nursing notes, assessments, and interdisciplinary team meeting notes revealed there was no indication that Resident # 73 had been assessed for and/or determined to be safe to self-administer medications. During rounds on each day of survey, staff members were observed providing care, administering medications, passing water and ice and passing trays in Resident # 73's room. The Neosporin ointment was clearly visible on the front left in the bin during each observation. There were no observations of any staff member addressing the concern of medications at the bedside.On 3/4/2026 during the end of day debriefing with the Administrator, Director of Nursing and Administrator in Training, a request was made of nursing administration for any self-administration of medication assessments for residents. The Director of Nursing stated she thought there was only one resident with the self-administration assessment. The name mentioned was not Resident # 73.On 3/5/2026 during the end of day debriefing, the Administrator, Director of Nursing and Administrator in Training were asked again if any residents had assessments for self-administration of medications. The Director of Nursing stated there were no residents who were assessed and approved for self-administration of medications.On 3/6/2026 at 9:55 a.m., the Director of Nursing was interviewed about Resident # 73 and the Neosporin at the bedside. The Director of Nursing stated Resident # 73 had not been assessed for self-administration of the medication. She stated Resident # 73 was alert and oriented and would be assessed.The facility policy on Self-Administration was requested but not received prior to exit.No further information was provided.

Based on interview and facility record reveiw the facility staff failed to provide services that meet professional standards of quailty for one resident (Resident #121-R121) in a survey sample of 22 residents.The findings included:For R121 the facility staff failed to ensure all medications were taken and consumed by the resident prior to leaving the room.R121 was admitted to the facility on [DATE] with diagnoses that included but were not limited to multiple sclerosis, opioid dependence, hypertensive heart disease and history of stroke. R121's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/9/26 coded R121 as having a BIMS (Brief Interview of Mental Status) score of 14 out of 15 indicating no cognitive impairment. R121's MDS also coded the resident as needing partial to moderate assistance with most ADL activities including transfers, toileting, bathing, dressing and grooming.On 4/47/26, a review of the clinical record revealed the following note: 4/25/26 10:30 am - Nurse went to give resident her morning meds and found a suboxone [a medication used for substance use disorder / opiate withdrawal] and two Tylenol in her room. She said she just dropped them, the suboxone was slightly wet in one cup and they 2 Tylenol were in another cup on top. The nurse told the resident she would have to do a room sweep looking for other medications, the resident refused and started getting agitated. Nurse attempted to educate the resident on why it's dangerous not to take medication, but she did not want to hear anything the nurse had to say . Predisposing Situation Factors: Not taking meds pretending she is letting it dissolve and taking it out after nurse leaves.A review of the clinical record revealed R121 had the following order:Suboxone Sublingual film - 8-2 MG (Buprenorphine HCL - Naloxone HCL Dihydrate) Give 1 film sublingually three times per day for opioid use disorder stand and wait until the resident fully swallows with water / take med cup up.On 4/27/26 at 2 pm R121 refused interview with surveyor.On 4/27/26 at 2:15 pm an interview with licensed practical nurse #3 (LPN3) was conducted. LPN3 stated that medications should be administered and taken in front of the nurse before the nurse leaves the room. LPN3 stated that she does not ever leave medications at the bedside. LPN3 was asked why this was important and she stated that medications left at bedside could be taken by someone else or a resident could forget to take them. When asked when sign off is done in the electronic medical record she stated that sign off should be done once the medications have been administered and the nurse has seen them being taken by the resident.On 4/28/26 at approximately 9:00 am an interview was conducted with the DON. The DON stated that it is the facility's expectation that all nurses ensure medications are taken in the presence of the nurse. The DON stated that [NAME] was the professional standard used by the facility.According to [NAME] Nursing Center website: (Lippincott Nursing Center, 2018), it referenced the standard for medication administration as: Right Patient: Use two identifiers (e.g., name, birthdate) and check against the ID band.Right Medication: Check the medication label against the medication administration record (MAR).Right Dose: Verify the dose, check for appropriateness, and perform double-checks (e.g., calculations).Right Route: Confirm the order for the specified route (e.g., IV, oral) and that it is appropriate.Right Time: Check frequency, ensure the medication is given at the correct time, and verify the last dose.Right Documentation: Document the medication immediately after administration, including time, dose, and any required assessments.Right Reason: Understand the rationale for the medication and the patient's history.Right Response: Monitor the patient for the intended effect and any adverse reactions. On 4/28/26 during the end of day meeting the Administrator was made aware of the concern and no further information was provided.

Based on observations, staff interviews, and clinical record review, the facility staff failed to develop and institute measures to prevent pressure ulcer development for an individual known to develop pressure ulcers to the left foot/ankle for 1 of 4 residents with pressure ulcers (Resident #26), in the survey. A. The facility staff failed to promote healing of deep tissue pressure ulcer to the left lateral plantar foot and to conduct a complete assessment, reassess and document the status of the pressure ulcer once the wound bed was exposed which resulted in deterioration as evidenced by eschar and drainage at various times, which constituted harm. B. The facility staff failed to promote healing of deep tissue pressure ulcer by not obtaining a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #26 was originally admitted to the facility 11/18/2014 and the resident had never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/20/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #26's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total physical assistance of one person with toileting, extensive physical assistance of two plus persons with bed mobility and transfers, extensive physical assistance of one person with dressing and bathing, supervision with physical assistance of one person with eating and activity didn't occur with walking, locomotion, personal hygiene. A review of the facility's matrix revealed Resident #26 had facility acquired pressure ulcers and during the initial tour on 8/28/22 at approximately 5:15 p.m., Resident #26 was observed in his room with Kling wrap to the left lower extremity. The right foot as observed with an increased amount of [CONDITION(S)] (swelling), and black and blue discoloization. The resident was unable to state what had occurred to either extremity. Historical documentation from the resident's record revealed the resident had experienced repeated pressure ulcers and skin impairment to the left lower extremity including the left proximal foot 6/8/22, a DTI of the left pinky toe 6/2/22, the left outer ankle pressure ulcer 5/18/22, 4/26/2022 left ankle wound infection, 4/5/22 Skin tear to left ankle. On 8/30/22 at approximately 12:35 p.m., the resident was observed in bed reclined on a standard mattress with non-skid shoes to bilateral feet. He was lying on his left side and the left foot was positioned so the left 5the digit and ankle were making contact with the bed and the left great toe was up. On 8/31/22 at approximately 1:10 p.m., Resident #26 was observed in bed again lying on his left side with his left foot, the 5th digit and ankle down against the mattress and the great toe up. No positioning/ offloading devices such as wedges, or pillows heel floats were in use. On 8/31/22 at approximately 11:08 a.m., an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated Resident #26 was a long term resident and he is normally cooperative with care, often restless, and attempts to reposition himself. She stated the resident was currently with right foot bruising and swelling and had a bandage on his left foot. CNA #1 stated she had never used positioning devices with the resident. On 8/31/22 at approximately 11:17 a.m., an interview was conducted with Certified Nursing Assistant (CNA) #2. CNA #2 stated he normally gets the resident out of bed in the morning and his gown is usually off and the resident is only a brief and socks. CNA #2 stated the resident is usually lying on his side to face the window (his left side) and there are no positioning devices. CNA #2 also stated the resident had stopped walking when he returned to the unit in June and because of open areas to his foot he doesn't wear his brown dress shoes any longer. He also stated when the resident experiences discomfort related to his contracture he will become resistant. The following active pressure ulcer orders were on the current August 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 7/8/22- Iodosorb Gel 0.9 % (Cadexomer Iodine) Apply to the bottom of the left foot wound topically, one time a day every Monday, Thursday, and Saturday for the left ankle wound. 8/12/22- Left plantar foot and left ankle wound. Cleanse with normal saline. Pat dry, apply Iodosorb to the wound bed, cover the wound with bordered gauze one time a day every Monday, Wednesday, Friday to the left plantar wound. A. left lateral plantar foot: At the time of the Pressure Ulcer Wound Round on 6/15/22 no weekly skin assessments had been completed since 4/20/22 and there were no nurse's notes or other documentation in the resident's record concerning the resident's left lateral plantar's foot deep tissue injury. It appeared the resident's left lateral plantar's foot pressure ulcer was identified when another pressure ulcer to the left foot was being assessed during wound rounds and left lateral plantar's foot pressure ulcer was first assessed during wound rounds with the wound care physician during Pressure Ulcer Wound Rounds on 6/15/22. The left lateral plantar's foot wound was identified as an unstageable deep tissue injury with intact skin, measuring 1.1 centimeters (cm) by 2.0 centimeters by 0 centimeters. The assessment further revealed the wound bed was without drainage or odor, the wound edges were firm and without redness, and the periwound skin area was intact. The treatment was to cleanse the wound with normal saline, pat dry, apply skin prep and off load, one time a day. The left lateral plantar's foot pressure ulcer was reassessed 6/22/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 1.0 cm by 2.0 centimeters by 0 centimeters. The assessment further revealed the wound bed was without drainage or odor, the wound edges were firm and without redness, and the periwound skin area was intact. The treatment was changed to cleanse with normal saline, pat dry and apply [MEDICATION(S)] wipes and offload one time a day. The left lateral plantar's foot pressure ulcer was reassessed 6/29/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 1.0 cm by 2.0 centimeters by 0 centimeters and the wound bed was identified with black eschar, no drainage or odor, the wound edges were firm, without redness, and the periwound was intact. The treatment remained the same. The wound was now with nonviable tissue, eschar. The left lateral plantar's foot pressure ulcer was reassessed 7/6/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.5 cm by 0.9 centimeters by 0 centimeters with a pink wound bed and without redness, drainage or odor. The periwound was intact. A treatment was to start 7/822 to cleanse with normal saline. Pat dry and apply Iodosorb and cover the wound with a dressing one time a day every Monday, Wednesday, and Friday. The wound bed was pink making it observable and the pressure ulcer should have been staged. The left lateral plantar's foot pressure ulcer was reassessed 7/13/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.5 cm by 0.8 centimeters by 0.1 centimeters and the wound bed was without drainage or odor but the wound bed's tissue type and color were not documented, the wound edges were firm and without edges and the periwound was intact. The treatment remained the same. The left lateral plantar's foot pressure ulcer was reassessed 7/20/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.5 cm by 1.5 centimeters by 0.1 centimeters. The wound bed tissue type and color were not documented but a small amount of clear serous drainage was documented, the wound edges remained firm and without redness and the periwound was intact. The treatment remained the same. The wound showed deterioration in the width and was now draining. The left lateral plantar's foot pressure ulcer was reassessed 7/27/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.5 cm by 1.0 centimeters by 0.1 centimeters. The wound bed tissue type and color were not documented but the wound was with a small amount of clear serous drainage, the wound edges remained firm and without redness and the periwound was intact. The treatment was changed to cleanse with normal saline, pat dry, apply silver alginate to wound and cover with a silicone foam dressing one time a day every Monday, Wednesday, Friday. The left lateral plantar's foot pressure ulcer was reassessed 8/3/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.5 cm by 1.0 centimeters by 0.1 centimeters. The wound bed tissue type and color were not documented but the wound continued with a small amount of clear serous drainage, the wound edges remained firm and without redness and the periwound was intact. The treatment was changed to cleanse with normal saline, pat dry, apply Iodosorb to the wound bed, and cover the wound with bordered gauze one time a day every Monday, Wednesday, and Friday. The left lateral plantar's foot pressure ulcer was reassessed 8/10/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 1.0 cm by 2.0 centimeters by 0.1 centimeters. The wound bed tissue type and color were not documented, it was without drainage or odor, the wound edges were firm and without redness and the periwound was intact. An order was given to start on 8/12/22 read; cleanse with normal saline, pat dry, apply Iodosorb to the wound bed, and cover the wound with bordered gauze one time a day every Monday, Wednesday, and Friday. This wasn't a change in the wound order. The left lateral plantar's foot pressure ulcer was reassessed 8/17/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.5 cm by 1.5 centimeters by 0.1 centimeters. The wound bed tissue type and color were not documented, it was without drainage or odor, the periwound was intact, the edges were firm and without redness. The treatment remained the same. The left lateral plantar's foot pressure ulcer was reassessed 8/24/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.1 cm by 0.1 centimeters by 0.1 centimeters. The wound bed tissue type and color were not documented, it was without drainage or odor, the periwound was intact, the edges were firm and without redness. The treatment remained the same. On 8/30/22 at approximately 12:40 p.m., a wound care observation was conducted with Licensed Practical Nurse (LPN) #5. LPN #5 removed a dressing from Resident #26's left lateral plantar's foot pressure ulcer. The left lateral plantar's foot pressure ulcer pressure ulcer was opened, measuring approximately 0.4 cm by 0.4 cm by 0.2 cm and presented with a pale pink wound bed with no drainage, and no odor. The wound was surrounded by new skin from a previously opened area. LPN #5 cleaned the left lateral plantar's foot pressure ulcer with normal saline, applied Iodosorb Gel and a border dressing. The left lateral plantar's foot pressure ulcer was reassessed by the NP on 8/31/22 at approximately 1:10 p.m., and determined to be opened and without the wound bed was observable to be staged. The NP assessment wasn't made available to the survey team prior to the conclusion of the survey. B. Left great toe: A review of the Pressure Ulcer Wound Rounds documentation revealed Resident #26 was assessed on 8/10/22 with an unstageable deep tissue injury of the left great toe, which measured 0.3 cm by 0.5 cm by 0.1 cm. The wound bed tissue type and color were not documented, it was without drainage or odor, the wound edges were firm and without redness and the periwound was intact. The 8/10/22 NP progress note stated the left lateral great toe was with granulation tissue. A pressure ulcer with granulation tissue should be staged. The Pressure Ulcer Wound Rounds documentation for 8/17/22 revealed the resident was with an unstageable deep tissue injury of the left great toe pressure ulcer increased in size measuring 0.5 cm by 0.5 cm by 0.1 cm. The wound bed tissue type and color were not documented, it was with a small amount of clear serous drainage but no odor, the wound edges were firm and without redness and the periwound was intact. The NP's 8/24/22 progress note stated the resident had a pressure ulcer of the left lateral great toe with granulation tissue but without slough, eschar and signs of infection. The progress note further read the wound treatment was Iodosorb. There was no Pressure Ulcer Wound Rounds documentation for 8/24/22. This wound was documented as resolved on 8/24/22 by the Assistant Director of Nursing. A review of the August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/30/22 at approximately 12:40 p.m., a wound care observation was conducted with Licensed Practical Nurse (LPN) #5. LPN #5 removed a dressing from Resident #26's left lateral great toe. The left lateral great toe pressure ulcer had an open area approximately 0.2 cm by 0.2 cm by 0.1 cm, with a pink wound bed and presented with light yellow drainage. Immediately around the left lateral great toe pressure ulcer was fragile new skin and distally there was blanchable red skin. LPN #5 cleaned the left lateral great toe pressure ulcer with normal saline, applied Iodosorb Gel and a border dressing. The left lateral great toe pressure ulcer was reassessed by the NP on 8/31/22 and determined to be opened with drainage. The NP's assessment wasn't made available to the survey team and a wound care order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/31/22 at approximately 11:23 a.m., an interview was conducted with the treating NP and the Wound Care Registered Nurse (RN). The NP stated she didn't change her documentation from deep tissue injury with intact skin because she was under the impression that once a pressure ulcer was classified it had to remain whatever it was identified as until it healed, not that if the wound bed became observable the staging should be changed. The NP also stated she was unaware there had been no treatment orders in place for the resident's left great toe and she thought the resident's left great toe was healed. Upon the NP's reassessment of the resident's left great toe on 8/31/22 at approximately 1:10 p.m., it was identified as opened and with drainage. The NP further stated she was aware the resident favored lying on his left side and the resident's pressure ulcer development was always to the left lower foot and ankle but she hadn't thought to develop a plan to protect the left foot in order to prevent additional pressures ulcers. The NP stated she had ordered nutritional support (Prostat and Juven) to aid in healing of the resident's pressure ulcers. The current care plan had a problem dated 4/22/22 which read; (name of the resident) has a potential for skin impairment related to smoking dry/fragile skin and use of [CONDITION(S)] medication. The goal read; (name of the resident) potential for impaired skin integrity will be minimized through the review date. The interventions included; float heels as tolerated while in bed. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The current care plan had a problem dated 7/19/22 which read; resident has a deep tissue injury of the left pinky toe. The goal read; the resident's DTI will be healed by the review date. The interventions included; Treatment as ordered and monitor for effectiveness of treatment. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Wound consult as ordered. Braden scale completed 6/2/22 revealed Resident #26 had a low risk for pressure ulcer development. It revealed the resident responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. Skin is occasionally moist, requiring an extra linen change approximately once a day. Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered. Moves in bed and in chair independently and has sufficient muscle strength to lift up. On 9/1/22 at approximately 4:00 p.m., the above findings were shared with the Administrator, Director of Nursing and the Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no information was provided and no concerns were voiced. M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Step 2: Identify Unstageable Pressure Ulcers 1. Visualization of the wound bed is necessary for accurate staging. 2. If, after careful cleansing of the pressure ulcer/injury, a pressure ulcer's/injury's anatomical tissues remain obscured such that the extent of soft tissue damage cannot be observed or palpated, the pressure ulcer/injury is considered unstageable. 3. Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed, should be classified as unstageable, as illustrated at http://www.npuap.org/wp-content/uploads/2012/03/NPUAP-Unstage2.jpg. 4. If the wound bed is only partially covered by eschar or slough, and the anatomical depth of tissue damage can be visualized or palpated, numerically stage the ulcer, and do not code this as unstageable. 5. A pressure injury with intact skin that is a deep tissue injury (DTI) should not be coded as a Stage 1 pressure injury. It should be coded as unstageable. (CMS's RAI Version 3.0 Manual, Chapter 3 page M-8) COMPLAINT DEFICENCY

Based on a resident interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide scheduled around the clock [MEDICATION(S)] for greater than 24 hours, resulting in constant chest pain with periods of a hammering chest pain which made breathing difficult and increased anxiousness for 1 of 38 residents (Resident #14), in the survey sample. The findings included: Resident #14 was originally admitted to the facility 4/4/22 for rehabilitation and the resident had never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/7/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring limited physical assistance of one person with transfers and toileting, supervision physical assistance of one person of one person with bed mobility and walking in the room, supervision with set-up help only with walking off the unit, locomotion, personal hygiene and bathing. During an interview with Resident #14 on 8/31/22 at approximately 1:30, p.m., the resident stated he thought he would have to go to the hospital overnight because of severe chest pain rating 7 out of 10 after receiving the scheduled [MEDICATION(S)]. He stated he experienced periods of constant chest pain, then there was periods of a hammering chest pain which made breathing difficult and increased anxiousness. The resident stated he didn't think to apply his [CONDITION(S)] when his breathing was compromised because he felt a transfer to the hospital was the only answer. The resident voiced these symptoms, in the past, had required transfer to the hospital to manage the pain until it was controlled. The resident stated he had been without the scheduled [MEDICATION(S)] since receiving the last dose on 8/29/22 at approximately 9:00 p.m., until 6:00 a.m., that morning, 8/31/22. Resident #14 stated the nurses said the [MEDICATION(S)] hadn't been delivered from the pharmacy. Resident #14 stated the same thing happened approximately 2 months ago but it didn't take as long for the medication to arrive to the facility. The resident stated the nurses don't understand when he has been without the [MEDICATION(S)], when he does receive it doesn't control the pain again for at least a day or two. An interview was conducted with Registered Nurse (RN) #2, on 9/1/22 at approximately 11:15 a.m. RN #2 stated on 8/31/22 when she accepted the assignment which included Resident #14 she wasn't informed the [MEDICATION(S)] wasn't available to the administered and hadn't been available since 8/29/22 at 9:00 p.m. RN #2 stated at approximately 1:00 p.m., when she began passing the 2:00 p.m., medications that she was unable to locate the ordered [MEDICATION(S)] for Resident #14 but, she saw [MEDICATION(S)] in the narcotic box for the resident therefore she explained her finding to the Nurse Practitioner (NP) and the NP gave her a onetime order for [MEDICATION(S)]. RN #2 stated there was no order on the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 additionally stated she made no other attempts to obtain the [MEDICATION(S)] and she didn't discuss not having the [MEDICATION(S)] available to administer with anyone after speaking with the NP, including the pharmacy staff. On 9/1/22 at approximately 2:40 p.m., an interview was conducted with the Director of Nursing (DON), regarding the [MEDICATION(S)] for Resident #14. The DON stated she wasn't aware there was a concern regarding the [MEDICATION(S)] until the surveyor asked for documents referencing the drug. The DON stated obtaining a onetime dose of [MEDICATION(S)] wasn't a substitute for not having the scheduled medication and it wasn't likely to control the Resident's pain. The DON stated she had no further information to present regarding the unavailable [MEDICATION(S)]. A review of the Physician Assistant - Certified (PA-C) progress note dated 8/15/22 stated the resident's pain didn't improve with use of the [MEDICATION(S)] therefore a rotation of [MEDICATION(S)] and an increase in [MEDICATION(S)] were instituted to achieve effective pain control. The August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no information referencing parameters for this medication. A review of the nurse's progress note revealed no supporting documentation for the above codes (9, 11) and no assessments indicating the resident's status without administration of the scheduled doses of [MEDICATION(S)]. A review of the current care plan dated 8/2/22 had a problem which read; (name of the resident) has complaints of chest and neuropathic pain. The goal read; (name of the resident) will have well-controlled pain through review date, 9/11/2022. The interventions included; administer medication/treatment as ordered. Monitor/document side effects and effectiveness. Monitor vital signs during reported chest pain episode (at least q 5 min). On 9/1/22 at approximately 4:00 p.m., the above findings were shared with the Administrator, Director of Nursing and the Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no information was provided and no concerns were voiced. [MEDICATION(S)] is a strong analgesia used to relieve severe, acute pain or moderate to severe, chronic pain. (pubchem.ncbi.nlm.nih.gov/compound/ 935) [MEDICATION(S)] capsules, oral solution (liquid),and extended-release (long-acting) tablets are used to relieve neuropathic pain (pain from damaged nerves) that can occur in your arms, hands, fingers, legs,feet, or toes if you have diabetes and postherpetic neuralgia (PHN; theburning, stabbing pain or aches that may last for months or years after anattack of shingles) (https://medlineplus.gov/druginfo/meds/a 5.html)

Based on a complaint investigation, clinical record review, staff and family interview, and facility documentation, the facility staff failed to ensure 1 of 43 residents (Resident #287) with an indwelling urinary catheter received care and services to include prompt recognition of signs and symptoms of a urinary tract infection [MEDICAL CONDITION]. The facility staff failed to demonstrate ongoing assessment and monitoring, as well as implement UTI/Sepsis protocols for Resident #287 who presented as symptomatic for UTI [MEDICAL CONDITION]. The resident was diagnosed in the local hospital with severe urosepsis and AKI (acute kidney injury/acute kidney failure) resulting in harm. The finding include: Resident #287 was originally admitted to the nursing facility on [DATE] with a principle [DIAGNOSES REDACTED]. Other significant [DIAGNOSES REDACTED]. Resident #287's most recent hospital stay was on [DATE] through [DATE] for complaints of chest pain and readmitted to the nursing facility with [DIAGNOSES REDACTED]. Resident #287's Minimum Data Set (MDS) in effect prior to the [DATE] discharge from the facility was a quarterly dated [DATE]. The resident was coded a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated she was cognitively intact in the skills needed for daily decision making. The resident had the ability to fully understand the staff and was understood. The resident was not coded to reject care that included lab work, taking medications or Activities of Daily Living (ADL) assistance. Resident #287 was assessed to require total dependence on two staff for bed mobility, transfers, toilet use, dressing and bathing. She was coded to need total assistance from one staff for eating, locomotion on and off the facility and personal hygiene. A wheelchair was coded as her main mobility device. The resident was assessed to have an indwelling urinary catheter and was frequently incontinent of bowel. The care plan dated as last revised on [DATE], included Resident #287 had a focus area related to altered bladder elimination and the goals set by the staff was that the resident would not develop symptoms of UTI, and that the resident's risk for [MEDICAL CONDITION] would be minimized/prevented via prompt recognition and treatment of [REDACTED]. The care plan did not indicate a [DIAGNOSES REDACTED]. Some of the interventions the staff would employ to accomplish these goals included monitor and report to MD (medical doctor) PRN (as needed) for signs and symptoms of UTI that included supra-pubic pain, cloudy urine, altered mental status, abnormal vital signs and behavioral changes. Obtain and monitor labs and diagnostic work as ordered by the physician, report results to MD and follow up as indicated. The nurse's notes dated [DATE] at 6:53 a.m. was written by the ,[DATE] Licensed Practical Nurse (LPN) #9 (schedule shift at 11 p.m. on [DATE] through 7:00 a.m. on [DATE]) indicated the following: Resident c/o (complaint of) vaginal burning, peri care and catheter care administered. Shower given on ,[DATE] shift. Effective. Continuing to monitor. The same LPN #9 entered the follow-up nurse's note on [DATE] at 7:12 a.m.: Resident has been displaying behaviors during shift. Hollering out. Resident c/o pain, medications administered, ineffective. Resident continues to holler disturbing roommate and causing agitation. Continuing to monitor. LPN #9 was not available for interview, no longer employed by the nursing facility. The facility initiated an investigation on [DATE] into the Resident Representative's (RR) concerns about delay in care ,[DATE]-,[DATE] and LPN #9 wrote a statement. The statement indicated when she reported to work for the ,[DATE] shift ([DATE] at 11:00 p.m. through [DATE] at 7:00 a.m.) the resident was yelling out some. She wrote she and the CNA gave the resident a shower because of her complaints of vaginal burning, performed peri care, administered pain medication between 5:00 a.m. and 6:00 a.m. and reported off to LPN # 10 ([DATE]-,[DATE] shift). LPN #10 who took over as the assigned licensed nurse responsible for Resident #287's care on [DATE] for the ,[DATE] shift was not available for interview, no longer employed by the nursing facility. LPN #10's written statement was not included in the investigation file provided to this surveyor. The Certified Nursing Assistants (CNA's) that were assigned to the resident on [DATE] and [DATE] for all three shifts were not available for interview, no longer employed by the nursing facility. The [DATE]-,[DATE] shift CNA indicated in a written statement that she was told by the ,[DATE] shift CNA that the resident had some screaming during the night. She wrote she got the resident up in the chair for breakfast and she only ate 25 % of he breakfast, ate only a few bites for lunch and ask to go lay down, she was tired and wanted to rest. There were no nurse's notes that demonstrated further assessments and monitoring took place on either the ,[DATE] shift on [DATE] or the ,[DATE] shift prior to the SBAR (Situation/Background/Assessment/Recommendation report on [DATE] at 6:12 p.m. The SBAR report indicated the following vital signs: Blood pressure (BP)= ,[DATE] (marginally low); pulse=120 ([MEDICAL CONDITION]; respiratory rate=20 and temperature=98.2 F (Fahrenheit) obtained axillary (underarm), oxygen saturation=90% on room air (,[DATE]=normal range). The narrative nursing note portion of the SBAR included the following: Sister in to visit resident (5:46 p.m. on [DATE]) and noted change in her. Resident awake with altered mental status. Resident was assessed and had a heart rate of 120 and O2 sat (Oxygen saturation) of 90% on room air and she was put on O2 @ 5L (liters)/minute via n/c (nasal cannula) & (and) SATs increased to 95%. BS (blood sugar)-113. She will be transferred to (local hospital's name) E.R. (emergency room ), 911 called and report called to transfer center. It was annotated on the SBAR that the aforementioned assessment was reported to the physician. The resident had a current operational DNR (do not resuscitate order). LPN #2 signed off as the the licensed nurse who completed the SBAR report, as well as the nurse who was assigned responsible to provide care for Resident #287 on [DATE] for the ,[DATE] shift. On [DATE] at 3:45 p.m., an interview was conducted with LPN #2. She stated she could not remember if she was given a report on Resident #287 when she started the ,[DATE] shift on [DATE]. She stated the resident was pleasant and she did not recognize any physical problems. She stated she could not remember if she got out of bed for dinner on [DATE] as usual. She stated the Administrator and Director of Nursing (DON) told her the RR indicated in a letter that a minister had come in during the ,[DATE] shift and said he told someone about Resident #287's decrease in responsiveness and ask if she assessed the resident due to the minister's concern. She further stated she did go into the room at that time and asked the resident is she was okay, as she was looking out the window at the birds. When asked why she did not take the opportunity to make an assessment of the resident and document it in the nurse's note's she said, I maybe should have. On [DATE], LPN #2 wrote a statement for the Administrator and DON that on [DATE] (no time) the resident was in bed and that the priest who visited stayed in the room no more than 2 minutes and came to her saying the resident was not making much sense. She wrote in her statement that she checked on the resident and asked it she was okay and that the resident said yeha, 20 minutes later she was being sent to the E.R. This information was not shared with the Administrator or the DON prior to the start of the investigation on [DATE]. During the interview with this writer, LPN #2 stated she could not remember whether the resident was up for dinner, but wrote in her statement the resident was in bed at the time she checked on her, which would have been between 5:00 and 6:00 p.m. LPN #2 also wrote that on the previous day ([DATE] during the ,[DATE] shift) the resident's urine was dark and cloudy with sediment, but that it had always been that way since she had the catheter. LPN #2 further stated during the above interview that although she signed the SBAR, she was not the person who performed the assessment on [DATE] at 6:12 p.m., other nurses were present and she recorded their findings. She said the RR came to the nurse's station [DATE] to ask that someone come to assess Resident #287 because she was not very responsive. She stated she knew the signs and symptoms of a urinary tract infection to include restlessness, behavioral changes, color and sediment of the urine, as well as a possible elevated temperature. She stated she was not sure of signs and symptoms [MEDICAL CONDITION], but did attend the recent skills fair on [DATE] but was sure that was not one of the topics. This surveyor verified the skills fair [DATE] did not include signs and symptoms of UTI/sepsis. Recent mandatory inservices were conducted on [DATE] and [DATE] as a requirement for a partnership merger with an organization that assist with strategies to decrease in unnecessary resident readmissions to hospitals. One of the required training's included [MEDICAL CONDITION]. Out of 60 nursing staff, four RN's attended, two of the RNs were the DON and the Assistant Director of Nursing (ADON), 7 LPNs and 16 CNAs. LPN #2 did not complete the mandatory inservice on [MEDICAL CONDITION]. On [DATE] at approximately 9:30 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON). They stated on [DATE] the RR showed up in the building and wanted to meet with the both of them and that she was tearful and expressed that the resident died the previous day. They stated they started an investigation on [DATE] after the Resident Representative (RR) delivered a letter under their door on [DATE] alleging neglect in care for Resident #287. The letter which indicated that the RR was told by the visiting minister that checked in on [DATE] around 2:56 p.m. that he went to the resident's room to find her moaning and staring in space. The letter indicated the minister approached the nurse's station to let them know of her condition and even mentioned it to the activities director. The activities director wrote a statement [DATE] that indicated on [DATE] at 3:45 p.m., a church volunteer told her he informed a nurse that the resident was not well and she thanked him for making the staff aware. The activities director was no longer employed by the facility and was not available for interview. The letter indicated no one checked on Resident #287 or if they had they would have taken immediate action based on her level of consciousness. The letter also indicated that when the RR arrived [DATE] at 5:15 p.m., she found the resident in bed and not in the dining room as per her usual routine for dinner. The RR indicated in the letter she found the resident in the same condition as the minister and unable to communicate to her what happened, thus she approached the nurse's station to report her condition at which time the the Administrator, DON and a few nurse's went to the resident's room to assess her. The letter indicated the resident was sent to the E.R. admitted to the hospital's ICU and diagnosed with [REDACTED]. The letter indicated the RR visited the resident in ICU the following day and told her she would be back, but the resident died 1.5 hours later. She alleged gross neglect by the facility. The facility concluded their investigation on [DATE] conducted by the Administrator and DON that consisted of interviews with staff, review of facilities policy and procedures and review of medical record. They found the allegation to be unsubstantiated based on their investigation. During the aforementioned interview, the DON was asked what was the expectation of the nursing staff in review of the nurse's notes and the documented change in condition during the ,[DATE] shift (,[DATE]-,[DATE]). The DON first stated, Maybe there was no need to document anything because she was a long-term care resident and we only document by exception. They washed her up and she felt better. Upon taking a closer look, she agreed there were no documented assessments that would reflect monitoring of a possible UTI after it was noted the resident complained of burning and pain which was a potential symptom. The signs of UTI would have come from nursing actions, which would have been the results of their assessment and monitoring (e.g., vital signs, behaviors, appearance of urine) which was not evident in the clinical record (e.g., nursing notes, vital sign records). The DON agreed that there was no follow-up after pain medication administered in the early morning hours of the ,[DATE] shift was documented in the nurse's notes as ineffective, as well as further follow-up on hollering and behaviors exhibited during the shift. Additionally, there were no nurse's notes on the ,[DATE] shift, where in the above CNA's statement she wrote the resident did not eat much, felt bad and requested to go to bed. In addition, the resident did not get up for dinner as usual which exhibited potential decline in physical status and a change in her normal activities. The DON then stated she expected to see vital signs obtained and recorded, level of consciousness documented, further record of the color of the urine, expounding on her behaviors they earlier documented on the ,[DATE] shift, as well as a call to consult with the physician or nurse practitioner to report the findings and accept guidance for any orders. The DON could not explain lack of a documented assessment from LPN #2 during the ,[DATE] shift, especially if she checked on the resident after she stated the minister said the resident was not making sense. She could not explain why there was not evidence of any assessment or monitoring until the RR approached the nursing staff to insist someone address Resident #287's change in condition around dinner time on [DATE]. When this surveyor asked to review the 24 hour reports, the DON stated she would look for them. She and the Administrator returned on [DATE] at 10:30 a.m. with the 24 hour report dated [DATE] for ,[DATE] and ,[DATE] shift which was blank, and the ,[DATE] block indicated the resident was sent to the (local hospital name) E.R. at 6:20 p.m. with altered mental status/[MEDICAL CONDITION] admitted to the ICU. During the above interview, the Medication Administration Record [REDACTED]. The DON stated, She probably gave it and forgot to sign it off on the MAR. The DON stated, I tell nurses, train nurses, but still have problems. We will have to do more. The Administrator and DON presented policies that were in effect during Resident #287's stay that outlined clear guidelines for nursing assessment and monitoring and documentation of such for UTI [MEDICAL CONDITION]. A time line had been presented to this surveyor completed by the regional nurse regarding the resident's output, which was not in question but whether appropriate assessments, monitoring for signs and symptoms of UTI/Sepsis recognized by the nursing staff with notification to the physician/nurse practitioner. The time line revealed there was no assessment or monitoring throughout the ,[DATE] shift or on the subsequent two shifts to include vital signs or a call to the physician based on the residents expressed symptoms of burning and unrelieved pain. The time line noted that the sister (RR) was in to visit and noted a change in the resident, after which the staff performed an assessment, exhibited in aforementioned SBAR dated [DATE] at 6:12 p.m. and sent her out 911. The most recent laboratory results were sent out with the resident that were obtained [DATE], a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) that checked electrolytes, BUN and creatinine (renal function status) none of which warranted treatment. The Administrator and DON stated there were no other labs in (YEAR) to include a U/A or C&S. On [DATE] at 10:45 a.m., an interview was conducted with the current Nurse Practitioner (NP). She stated she was not the NP during Resident #287's stay, but the attending physician was the same and she was currently in practice with him and felt she could give her professional take on the Resident #287's case by review of the clinical record. She also stated she would be covering for the attending over the next two days. From review of the nurse's notes she stated the nursing staff missed many opportunities to make good assessments and call the physician for further guidance. She stated she actually saw no assessments and monitoring even on the ,[DATE] shift with the lack of vital signs, visualization of urine, mental and behavioral status. She stated there appeared that nothing was done on the ,[DATE] and ,[DATE] shift until the RR informed them something was wrong. Upon review of the SBAR, the NP stated the resident had signs and symptoms [MEDICAL CONDITION] to include a temperature that was recorded obtained via axilla at 98.2 which was not reliable and 1.5 to 2.0 points would be added for an accurate temperature reading. She stated the resident had just finished antibiotic therapy on [DATE] for a skin infection which often can yield antibiotic resistant infections, like [MEDICAL CONDITION] (MRSA) or Extended Spectrum Beta-Lactamases (ESBL-in urine) so close assessment and monitoring especially in light of what was already noted was vital with a call to physician or NP to let them know what was going on like the burning, behaviors and ineffective pain management from the medication. The signs and symptoms [MEDICAL CONDITION] was brewing and the nursing staff did nothing from what I can see here. To [MEDICAL CONDITION], the nursing staff have to assess for the signs and symptoms, which it looked like the resident probably had them that required prompt treatment to prevent a septic situation. The NP stated [MEDICAL CONDITION] the resident's BUN and creatinine would have been elevated upon arrival to the ER with potential Acute Kidney Injury (AKI) with systems failure. During the above interview, the NP stated if there had been a call to the physician during the ,[DATE] shift on ,[DATE]-[DATE] there could have been a dip stick urine ordered STAT that would have shown [MEDICATION NAME] and white blood cells. She stated she knows the facility had the reagent strips for the test in the nursing facility accessible to the nurses. Based on those results that are immediate, an antibiotic could have been ordered. She further stated a STAT Urine Analysis (UA) would have come back in a couple of hours at the first of any concern from the nurses that would have shown white blood cells, red blood cells, bacteria which would have also been highly suggestive of a UTI. She stated, the culture and sensitivity report within 3 days would have shown more specificity and possible need to change antibiotic choice based on sensitivity report. She said she would have also ordered a STAT Complete blood count and renal profile to assess renal function or organ failure from systemic infection. She stated if a call had been made to the attending or NP early on, an order could have also been given to the nurses to just send the resident out for evaluation in the E.R. Review of the hospital records indicated the following: Resident arrival [DATE] at 6:35 p.m., vital signs-BP=,[DATE] ([MEDICAL CONDITION]); pulse=112 ([MEDICAL CONDITION]); respiratory rate=22 (tachypnea) and temperature=99.7. Oral mucosa dry. Patient was not able to give information about condition. Labs drawn to reveal blood urea nitrogen (BUN), an indicator of renal function, of 60 (,[DATE]=normal range); Creatinine, also an indicator of renal function, of 2.1 (0XXX,[DATE].0=normal range); venous lactic acid, an indicator of a severe infection such [MEDICAL CONDITION] and septic shock, of 6.36 (XXX,[DATE].20=normal). The U/A revealed large amounts of blood (negative is normal), positive [MEDICATION NAME] (negative is normal); 40 WBC (,[DATE]=normal); RBC TNTC (Too numerous to count) with ,[DATE]=normal; and 15 [MEDICATION NAME] (negative=normal). The final results of the culture and sensitivity report came back on [DATE] that indicated an antibiotic resistant organism in the urine of ESBL greater than 100,000 and proteus mirabilis greater that 100,000. The resident was diagnosed with [REDACTED]. The resident was started on Intravenous Fluids (IV) for hydration and kidney perfusion, as well as antibiotics. Resident #287 was diagnosed with [REDACTED]. She expired on [DATE] at 10:00 p.m. and the cause of death was recorded due to severe urosepsis. On [DATE] at 12:15 p.m., a telephone interview was conducted with the RR. She stated on [DATE] at around 5:15 p.m. she went to the dining room to feed the resident per her normal routine, but did not see the resident. She stated the resident loved to eat and was always up for meals to include the dinner meal. She stated she went to the resident's room to find her listless and unable to communicate as usual, after which she immediately went to the nurse's station to inform the nurse. She said several nurses converged in the room and started to make assessments. She said she made a suggestion that the resident be sent out to the hospital and that the nursing staff agreed with her and took action. She stated she went to the hospital visited the resident and she was not very responsive to her. She stated the resident died the following day [MEDICAL CONDITION]. The RR said she visited the nursing facility on [DATE] to share some of her concerns. When she left the meeting, she stated she met a staff person in the parking lot who said she was sorry about her loss and told her a minister had been in and saw the resident in the same state, notified the nursing staff and nothing was done, no one went down to assess the resident. She said she went in to retrieve the name of minister from the visitor's log and made a phone call to him once she returned home. According to the RR, the minister recounted exactly what was told to her by the staff person in the parking lot (no longer employed by the facility). The RR stated she gathered her thoughts about what she observed and what the minister observed and felt there was delay and neglect in the care of the resident. She stated she came back to the facility on [DATE] with a letter and a request to address the Administrator and the DON. She said they told her You have already spoken to us about the matter and there is nothing more to talk about. She stated she was more upset about that inference that she could not talk to them than anything, so she slipped the letter under the door and heard no further word from them. This surveyor reviewed the visitor's log that verified a minister from the church and same name she indicated visited residents on [DATE] from 2:35 to 4:25 p.m. On [DATE] at 2:13 p.m., another surveyor completed the infection control review with the DON and the ADON. This surveyor stated the DON and ADON told her regardless of whether a resident had a indwelling urinary catheter or not, they expected assessment and monitoring to take place for resident's that exhibited signs and symptoms of UTI to ensure prompt treatment and to [MEDICAL CONDITION]. They told the surveyor the physician should be called, and a urine dip stick could be ordered by the physician for immediate results and or a U/A and C&S. They indicated during the interview changes in condition that warranted immediate attention related to [MEDICAL CONDITION] included elevated temperature, low BP, confusion, behavioral changes and pain, abnormal O2 saturation, increased respiratory rate, and a results of a glucose finger stick if diabetic, as well as a call to the physician. They showed the surveyor an algorithm (dated 2014) the facility used to recognize UTI/sepsis that indicated the same, in addition to evaluation of the ordered labs by the physician and decision to treat in the facility with Oral, IV or subcutaneous fluids if needed for hydration, as well as antibiotics, close monitoring with further evaluation in the E.R. The facility's policy and procedures titled Infections-Clinical Protocol dated revised (MONTH) (YEAR) indicated that infection may be suspected based on clinical signs and symptoms and/or temperature. The policy indicated for anyone suspected of having an infection (abrupt change in function, appetite, mental status, etc.), nursing staff will obtain a complete set of vital signs (temperature, heart rate, blood pressure, and respiratory rate) and will identify and document specific details of symptoms and physical findings. Nursing will notify the physician or provider of all pertinent details about the residents condition. The nursing staff will continue this form of monitoring and assessment. The nursing staff and physician or provider will identify possible complications of infection such [MEDICAL CONDITION] and [MEDICAL CONDITION]. Based on the preceding information, the decision would be made by the physician or provider whether additional testing (CBC, U/A to check for WBC, pus and [MEDICATION NAME] level) is indicated and whether other active conditions related to infection also need treatment. COMPLAINT DEFICIENCY

Based on observation, staff interview, clinical record review and facility document review the facility staff failed to provide the necessary care and services to prevent the development and promote the healing of facility acquired pressure ulcers for 1 of 20 residents in the survey sample, Resident #3. Resident #3 was discovered with a stage III facility acquired pressure ulcer to the left buttock on [DATE]. The facility failed to re-evaluate the treatement plan and to modify current iterventions. Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. The findings included: Resident #3 was admitted from the hospital following treatment for [REDACTED]. The resident's [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) with an assessment reference date of [DATE] coded the resident as scoring a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The resident was dependent on two staff for bed mobility, and required extensive assistance of two staff for dressing and bathing. The resident was coded as incontinent of urine and occasionally incontinent of bowel. The resident was wheelchair bound. Skin conditions section M. indicated the resident was admitted with two (2) stage II pressure ulcers, and two (2) unstageable pressure ulcers. The resident's weight was 240 pounds. Weight loss was coded as no or unknown. Review of the nursing admission data collection evidenced pressure ulcers were located as follows: right and left heels-unstageable, left lower leg-stage II, left ankle-stage II and sacrum-stage II. Stage II - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Unstageable- Due to coverage of wound bed with slough and/ or eschar (dead tissue). An initial nutritional evaluation was conducted on [DATE] by the registered dietician (RD). The resident was identified with increased nutritional needs based on the pressure ulcers and low *[MEDICATION NAME] of 3.1, normal lab reference is 3XXX,[DATE].7. The clinical record evidenced another [MEDICATION NAME] was obtained on [DATE] and was 2.82. The RD recommended for wound healing to implement a multivitamin once a day, 60 ml (milliliters) of med pass supplement three times a day between meals for weight maintenance and 30 ml of sugar free protein to improve skin integrity and protein stores. The registered dietician documented on [DATE],"admit wt of 240.2#-question accuracy of admit wt (sign for with) wt received next week being 214.4#". Further review of the record evidenced the resident's clinical condition allowed for healing of the pressure ulcers despite the resident's co-morbities and nutritional risk factors. The sacrum ulcer healed on [DATE]. The left lower leg ulcer and left ankle ulcer healed on [DATE] and the right heel healed on [DATE]. Review of the clinical record and comprehensive plan of care evidenced interventions put in place to prevent pressure ulcer development and promote wound healing included to administer treatments as ordered, monitor for effectiveness, notify the physician for change in condition, turn and reposition, application of barrier cream after each peri-care, cushion for the wheelchair, low air loss mattress, notify the nurse of any new skin breakdown. According to a SBAR (situation, background, assessment, request) communication form dated [DATE] the resident was identified with an open area to the right sacral area. The area was noted by a certified nurse aide while changing the resident. The nurse documented treatment was initiated. The treatment was obtained from the standing orders for wound care and initiated. The wound was cleansed with normal saline, *hydrogel was applied and the wound was covered with a dry dressing. The nurse indicated the information would be placed on the 24 hour report to be followed by the wound care nurse. *Hydrogel dressing: A dressing used to create or maintain a moist environment to aid in wound healing of pressure ulcers. On [DATE] the wound care nurse (licensed practical nurse #3) assessed the wound. She documented on the Pressure Ulcer Record the location of the new pressure ulcer was to the left buttock (not the right sacral area as documented by the nurse on the SBAR). The wound measured 2.2 cm (centimeters) x 1.2 cm x 0.1 cm. The wound bed tissue was documented as having [MEDICATION NAME] tissue (new skin growth) and slough (devitalized tissue) with serosanguineous drainage. The wound nurse changed the treatment according to the facility wound protocol to cleanse the wound with normal saline, pat dry and apply Santyl (an enzymatic [MEDICATION NAME] agent) to the wound bed once a day and as needed. The wound was staged as a stage III due to the slough. The left buttock pressure ulcer was assessed weekly by the wound nurse. According to the Pressure Ulcer Record the left pressure ulcer wound bed remained unchanged, and continued with [MEDICATION NAME] tissue and slough from [DATE] to [DATE]. On week four, [DATE] the wound measured 2.8 cm x 2.5 cm x 0.1 cm, the treatment remained the same. On week five, [DATE] the wound size increased in size and measured 6 cm x 4 cm x 0.1 cm. The wound bed was documented as having slough and [MEDICATION NAME] tissue. The wound worsened as evidenced by the increase in size and did not show signs of healing as it continued to have slough. The topical treatment was not changed. There was no documentation of the rationale for continuing the present treatment despite worsening of the wound. A Foley catheter was ordered on [DATE] to aid in wound healing. A Foley catheter is a plastic tube inserted into the bladder for drainage. The wound nurse assessed the wound on [DATE] week six (6). The wound measured the same as on [DATE], the treatment was not changed or modified. The wound bed continued to have devitalized tissue. There was no documentation of the rationale for continuing the present treatment. On [DATE] week seven (7) of the wound, a wound care specialist visited the facility for the first time. Orders were received for the wound care specialist to consult and treat. The wound care specialist physical exam revealed the resident's appetite was good. The resident did not have any [MEDICAL CONDITION]. The assessment indicated the left buttock pressure ulcer was a stage III facility acquired. There was some deep tissue injury. The wound measured 7 cm x 5 cm x 2 cm. The wound bed had 10% thick adherent black necrotic tissue, 45% thick adherent devitalized necrotic tissue and 45% granulation. The wound required sharp surgical **debridement of the necrotic and devitalized tissue. The low air loss mattress was discontinued and a Dolphin mattress was ordered on [DATE]. According to the manufacturer, the Dolphin mattress system simulates the effects of a body floating in a fluid, significantly reducing vertical shear, which deforms soft tissue and constricts blood flow. On [DATE] at 10:45 A.M., the wound nurse was interviewed. The above findings was shared. The wound nurse was asked why the treatment to the wound was not changed after 6 weeks of no indication of healing and worsening of the wound. She stated, " I felt like we had everything in place, labs, cushions, mattresses...the only thing we did not do was a change in treatment". The director of clinical services was interviewed on [DATE] and asked if a pressure ulcer should be discovered as a stage III. She stated, "Definitely not, we want to catch it as a stage I to prevent any further damage..." The director of clinical services stated the stage III facility acquired pressure ulcer and any subsequent pressure ulcers for Resident #3 were unavoidable. She indicated the medical director had signed a Guidelines For Unavoidable Wounds Form on [DATE] that was dated [DATE]. She indicated the resident had multiple co-morbidities such as diabetes and was nutritionally compromised. The form was checked for: history of pressure ulcers, chronic bowel and/or bladder incontinence, hgb***(hemoglobin) <11mg/dl, serum [MEDICATION NAME] <3.1 or pre-[MEDICATION NAME] >18, and [MEDICAL CONDITION]. The [MEDICAL CONDITION] was resolved as noted on the [DATE] nurse practitioner (NP) progress note. The NP documented, "(Pt. (patient) also had 2+ BLE (bilateral lower extremity [MEDICAL CONDITION] per nurses notes.) No [MEDICAL CONDITION] on exam today". The NP also documented, "No new/acute issues per nursing. Wound to sacrum and (B) (bilateral/both) feet/heels". The NP did not address the newly acquired stage III left buttock pressure ulcer. The labs obtained on [DATE] evidenced the resident's hemoglobin was 10.8 (normal lab reference is 12XXX,[DATE].0), serum [MEDICATION NAME] was 2.82 (normal lab reference is 3XXX,[DATE].7) and pre-album obtained on [DATE] was 14 (normal lab reference is ,[DATE]). The ****serum [MEDICATION NAME] obtained on [DATE] improved at 3.1. Subsequently, on [DATE] Resident #3 was identified as having developed a stage II pressure ulcer to the right buttock area. The wound nurse assessed the wound and documented on the Pressure Ulcer Record. The wound measured 4 cm x 3.6 cm x 0.1 cm. The wound bed was pink with [MEDICATION NAME] tissue. Treatment was obtained per the standing wound care orders to clean the wound with normal saline, pat dry and apply hydrogel and cover with a dressing daily and as needed (PRN). The wound nurse assessed the stage II pressure ulcer weekly. On week three (3), [DATE], the wound nurse obtained orders to change the treatment to Santyl every day and PRN. The wound measured 2.5 cm x 3 cm x 0.1 cm. The wound bed tissue type was documented as [MEDICATION NAME] and pink. On [DATE] at 10:40 A.M., the wound nurse was interviewed. She was asked why the treatment was changed to Santyl. She stated there had to have been a change in the wound bed. She stated she only applies Santyl to a wound if it has slough (devitalized tissue). When asked why she did not document the change of the wound bed on the assessment she stated, "I must have dropped the ball". She also stated she should have re-staged the pressure ulcer as a stage III but did not. The following weekly pressure ulcer assessment on [DATE] also indicated the wound bed was pink with [MEDICATION NAME] tissue and staged as a stage II. The wound nurse stated this assessment of the wound bed was also not correct. She stated there was devitalized tissue in the wound bed and it should have been correctly identified as a stage III. She stated the documentation was incorrect for both of these assessments. On [DATE] the wound care specialist assessed the pressure ulcer to the right buttock. The wound measured 4 cm x 4 cm x 0.2 cm. The wound bed was covered with 30% thick adherent necrotic tissue and 70% granulation tissue. A sharp surgical debridement of the devitalized tissue was performed. The above findings was shared with the administrator, the director of clinical services (DCS) and the regional director of clinical services at the pre-exit meeting. The 1994 AHCPR (Agency for Health Care Policy and Research) Guidelines & current literature indicate that a clean pressure ulcer with adequate blood supply & innervation should show evidence of stabilization or some healing within ,[DATE] weeks. Evidence accumulating since 1962 indicates that management of wound exudate coupled with a clean, moist wound environment allows a chronic wound (e.g., pressure ulcer) to lay down healthy granulating tissue more efficiently. If a pressure ulcer fails to show some evidence of progress toward healing within ,[DATE] weeks, the pressure ulcer (including potential complications) & the resident's overall clinical condition should be reassessed. Re-evaluation of the treatment plan including determining whether to continue or modify the current interventions is also indicated. Results may vary depending on the resident's condition & interventions/treatments used. The complexity of the resident's condition may limit responsiveness to treatment or tolerance for certain treatment modalities. The clinicians, if deciding to retain the current regimen, should document the rationale for continuing the present treatment (for example, why some, or all, of the plan's interventions remain relevant despite little or no apparent healing). The facility should have a system/procedure to ensure assessments are timely and appropriate; interventions are implemented, monitored, and revised as appropriate; and changes in condition are recognized, evaluated, reported to the practitioner, and addressed. Reference: * [MEDICATION NAME] is a protein made by the liver. WWW.nlm.nih.gov/medlineplus/ency/article/ 0. **Surgical debridement (also known as sharp debridement) uses a scalpel, scissors, or other instrument to cut necrotic tissue from a wound. Debridement of non-viable tissue is performed to reduce the amount of wound debris or non-viable tissue and to reduce the risk [MEDICAL CONDITION]. Removal of necrotic tissue should enhance wound healing. http://www.surgeryencyclopedia.com/Ce-Fi/Debridement.html#ixzz368ZkatTD <http://www.surgeryencyclopedia.com/Ce-Fi/Debridement.html> ***Hemoglobin: A protein in red blood cells that carries oxygen. www.nlm.nih.gov/medlineplus/ency/article/ 5.htm ****NPUAP (National Pressure Ulcer Advisory Panel) Advances In Skin & Wound Care & Vol. 23. No 2. Although serum [MEDICATION NAME] levels have long been used clinically they are a poor indicator of visceral protein status related to [MEDICATION NAME]'s long half-life (,[DATE] days) and numerous factors that decrease [MEDICATION NAME] levels even in the presence of adequate protein intake.

Based on observation, clinical record review and staff and resident interview it was determined for Residents #1 and #2, two of 20 residents in the survey sample that facility staff failed to provide supervision during care resulting in falls with major injuries. 1. Resident #2 rolled out of bed during personal hygiene care resulting in a fractured hip. 2. Resident #1 had a fall which resulted in a fractured left tibia due to only one CNA (certified nursing assistant) transferring the resident with a mechanical lift which required two CNAs to perform the transfer safely. The findings included: 1. Resident #2 rolled out of bed during personal hygiene care on January 20, 2014. The 1/6/14 quarterly Minimum Data Set evidenced she was a 15 (cognitively intact) on the brief interview for mental status exam and for activities of daily living (ADLs) required the total assistance of two for bed mobility. Resident #2 was [AGE] years old and had been a resident of the facility since 2009. Her [DIAGNOSES REDACTED]. Review of the facilitate's 1/21/14 fall investigation evidenced that the fall happened at 5:20 AM, while the resident was "lying in bed." The written statement from the Certified Nursing Assistant providing the care was also reviewed. "While doing Resident #2 ADL care I was telling her to roll over and she rolled to (sic) far rolled out of the bed. I tried my best to grab her but I couldn't (sic)." The 1/22/14 radiology (x ray) report evidenced, " Acute appearing intertrochanteric (hip) fracture with displacement. The remainder of the femur is intact. " Prior to the fall the 1/6/14 MDS evidenced the resident required the full assistance of two persons (code 4/3)for bed mobility and transfers. The fall investigation report evidenced that the staff was educated on, "2 man assist with ADL care staff educated." Under CONCLUSION (what may have caused the accident) was "only 1 staff member providing ADL care." A nursing note of 1/22/14 evidenced, "Resident slid to floor while receiving ADL care. Aide states "she rolled over too far and slid off the bed." A mandatory inservice on 1/22/14 evidenced for the the topic synopsis, "when performing ADL care on (Resident #2) there is to be 2 staff members to assist while turning her in bed." During interviews with Resident #2 on the morning of 6/24/14 and the afternoon of 6/26/14 the resident related to the surveyor that indeed she had rolled out of bed. It happened on the "graveyard shift" (11 to 7) and she was half asleep but two girls came into change her and "it was a freak accident" and she rolled out of bed between the bed and the wall. Resident #2 stated that she can turn on her side in bed "only with a great deal of difficulty" because of weakness. The Resident stated that usually two CNAs come in to help her but "sometimes" there is only one, and added a second one is not always available. She can grab the rail and really only assists in turning. The resident repeated the same information on both interviews. On the afternoon of 6/26/14 LPN #1 was interviewed on how she assures that Resident #2 has two CNA for ADL care. She stated that she had inserviced the staff and watches to assure that two CNAs go into the room. The information was also on the cardex, a sheet with ADL information available for the CNAs use. An examination of the cardex evidenced that Resident #2 was marked as needing the assistance of two for transfer but only one for ADL care. The LPN looked at the discrepancy when it was pointed out by the surveyor and she stated "that is wrong" and changed the 1 to a 2. Following the 1:15 p.m. interview with LPN #1 the surveyor noted the door to Resident #2's room was closed. The surveyor was invited in and observed one CNA #3 alone behind the pulled curtain around Resident #2 bed. She stated to the surveyor that she was just setting up that she would get a second CNA before beginning care. During a meeting with the DCS and Administrator on 6/26/14, they were interviewed regarding information that was obtained from interviewing Resident #2. The DCS stated that the resident was not interviewed because of her mental illness history and they felt the staff was a better source of information. After the meeting the surveyor was provided a copy of the fall section of the resident's care plan. The care plan had been revised on 1/29/14 following the fall. The approaches were to assure a clear pathway (the resident does not walk), assure adequate lighting, proper fitting shoes (resident does not walk), involve resident in activities, call bell in reach ( fall happened during care), a second adequate lighting, 1/4 rails for mobility, mechanical lift (resident was not being transferred), dycem (non-slip material) in wheelchair (resident fell from bed) and therapy services. 2. Resident #1 had a fall which resulted in a fractured left tibia due to only one CNA (certified nursing assistant) transferring the resident with a mechanical lift which required two CNAs to perform the transfer safely. Resident #1 was originally admitted to the facility 09/19/2007 and the most recent readmission was 03/26/14. [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed an Annual MDS (minimum data set-an assessment protocol) with an ARD (assessment reference date) of 09/30/13. The resident's BIMS (brief interview for mental status) score was coded as 15 which means at the time of the interview during the assessment period the resident was cognitively intact. The assessment further noted the resident was verbally abusive to staff and rejected care. Further review revealed the resident required extensive assistance with one to two staff members for bed mobility. The resident was also coded as being totally dependent on two staff members for transferring, bathing and toileting. The resident was able to feed self with set up, and did not ambulate. For locomotion on and off the unit the resident used an electronic wheelchair. Further, the resident was coded as being frequently incontinent of bladder and bowel. Under the section for balance during transitions and walking the resident was coded as the following: A. Moving from seated to standing position-8-Activity did not occur B. Walking-8-Activity did not occur C. Turing around and facing the opposite direction while walking-8-Activity did not occur D. Moving on and off toilet-2-Not steady, only able to stabilize with human assistance. E. Surface to Surface transfer (transfer between bed and chair or wheelchair)-2-Not steady, only able to stabilize with human assistance. For Range of Motion noted the following: A. Upper extremity (shoulder, elbow, wrist hand)- 1-Impairment on one side B. Lower extremity (hip,knee, ankle,foot)-2-Impairment on both sides. A Transfer/Mobility Status Criteria dated 06/24/13, was reviewed and noted: "Resident's request is sit to stand. Safest mode of transfer is Hoyer lift." A Significant Change MDS with an ARD of 11/22/13 was in the residents clinical record. The Significant Change MDS noted the resident had had a fall and had sustained a major injury. Review of Resident #1's clinical record revealed an SBAR Communication form (incident report) dated 11/06/13. It was noted: "At 2:15 am, Resident was being transferred from her bed to her wheelchair with a sit to stand mechanical lift. Stated her knees felt weak while on the sit to stand lift, then she fell on the floor in her room. Did assessment on resident, appears to be in lot of pain." Further documentation noted the staff notified the physician and received a 911 Stat order to send the resident to the hospital for evaluation and treatment. Review of the resident's care plan did not address that a fall had happened, that a major injury had occurred and did not include interventions for the care of the fractured leg or safe transferring with a mechanical device. What was revealed in the resident's current care plan was the following: 09/30/13-Impaired physical mobility related to inability to stand-latent effect of stroke. Goal date was 12/30/13. Approaches were not marked or addressed in any way. 09/30/13-Self Care Deficit Ambulation-Related to: Unaware of safety-refusal of Hoyer Lift (mechanical lift not requiring resident to bear weight on lower extremities), Does not bear weight. Safest mode of transfer is the Hoyer lift. Resident refuses to use it and request the sit to stand to transfer. Goal included: Resident will use the Hoyer lift to transfer daily target date 12/30/13. Under Approaches and Interventions noted: Provide assistance as needed with ambulation (it is noted the resident did not ambulate in the clinical record during period of 9/30/13 to 12/30/13.) Assistive devices as indicated-Specify: Wheelchair; Sit to Stand. 09/30/13-At Risk for falls related to: Fall risk greater than 10, History of falls, Unable to stand. Goal dated 09/30/13 to 12/30/13, Resident will have no falls within the next 90 days. No where on the Fall Prevention Care Plan was it noted the resident had sustained a fall on 11/06/13, resulting in a left tibia fracture. An observation was made on 06/25/14 at approximately 8:45 am, of Resident #1 while lying in bed eating breakfast. The resident's feet could be seen and it was noted that both of the resident's feet had internal rotation and severe foot drop. The resident was asked if she remembered the fall with the lift and the resident stated: "It was nobody's fault. It was just an accident. I felt bad the CNA (certified nursing assistant) was fired because she was moving me by herself." Review of the "Stand Up Patient Lift" was obtained and on page 16 it was noted: WARNING: Individuals that use the standing patient sling MUST be able to support the majority of their own weight, otherwise injury may occur. This device was the device used by one staff member at the time of the resident's fall with major injury and causing the resident to have a significant change. Review of the facility's policy at the time of the incident noted: "Policy and Procedures-Safety Policy: It is the policy of the company to utilize a low lift program to eliminate the need for manual resident transfers by using mechanical lifting devices and aids. Two staff members are required when using a mechanical lift." This policy was in effect when the resident had the fall and major injury. The policy time frame was 01/07/12 through 06/10/2014. The current policy dated 06/10/14 through 06/10/15 noted the following: "Policy-It is the policy of the care center to identify the transfer and lifting needs of the resident to enable the opportunity to safely and comfortably transfer according to their individualized needs." An interview was conducted on 06/26/14 at approximately 9:05 am, with the Administrator, DCS and RN Consultant. When asked about the safety issues regarding the use of the sit to stand the general consensus was the offending employee who did not follow policy was terminated. It was further stated that the resident did not want to use the Hoyer lift. The resident had been changed to the Hoyer lift after the fall with major injury. Education of staff was performed on safe lift usage however, documentation of inservices, signatures of staff receiving the education was not able to be verified by additional documentation. When asked if additional interventions, monitoring for resident safety, complete evaluation of the resident's safety awareness were implemented the general consensus was "No".

Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure residents who entered the facility without pressure ulcers did not develop them unless they were unavoidable for 4 of 25 residents in the survey sample, Residents #6, #5, #14 and #13. 1. The facility staff failed to provide care to prevent heel pressure ulcers for Resident #6. A left heel pressure ulcer was first identified by the nurse as unstageable. The left heel pressure ulcer did not improve and the resident underwent [REDACTED]. The resident also acquired a large right heel blister. b) The facility staff failed to follow standard infection control measures during a pressure ulcer dressing change. 2. The facility staff failed to provide services to prevent pressure ulcer development and promote healing for Residents #5's facility acquired unstageable pressure ulcer to the left heel and a stage II pressure ulcer to the right buttocks. 3. The facility staff failed to provide services to prevent pressure ulcer development and promote healing for Resident #14's facility acquired unstageable pressure ulcers to both heels. 4. The facility failed to implement preventative measures to prevent pressure ulcer development and failed to promote healing of a facility acquired stage II left heel pressure ulcer for Resident #13. The findings include: 1. Resident #6 was admitted to the nursing facility on 10/7/11 with [DIAGNOSES REDACTED]. The resident was not admitted with pressure ulcers. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident on the Basic Interview for Mental Status (BIMS) with a score of 7 (severely impaired in cognitive performance). The resident required extensive assistance from two staff for bed mobility, dressing and personal hygiene. She was assessed totally dependent on two staff for transfer, toilet use and bathing, as well as functional limitation in range of motion in both legs. The resident was frequently incontinent of bowel and bladder. The resident was coded at risk for pressure ulcers, but had none. On 6/20/12 at 2:15 PM, an interview was conducted with the Coordinator. She stated a correction request was completed on 6/13/12 and submitted to the State on 6/17/12. According to the presented corrected MDS, the areas of correction were in the M section (skin conditions). The resident's correction MDS was sent in coded for one or more unhealed pressure ulcers, one Stage II pressure ulcer upon admission or readmission to the facility. The Stage II pressure area was coded to have pink or red tissue with a shiny, moist, granular appearance. Ulcer care was added and applications of dressings to feet with or without. During the interview, the MDS coordinator said she used chart documentation to complete the assessment, and the information would have a 7 day look back period including 3/20 through 3/26/12. Upon examination of the documentation, there was a nurse's note entry dated 3/21/12 identifying a Stage II left outer heel ulcer with Santyl (topical debrider) as the treatment; and, an entry on Pressure Ulcer Record dated 3/21/12 identifying the left outer heel as unstageable with slough (soft necrotic tissue). The nurse's note also identified a fluid filled blister on the right heel. The MDS coordinator stated, "(Licensed Practical Nurse #5's name) did the initial assessment (3/26/12) that reflected all zero's. I did the correction and submitted it to the State on 6/17/12. I corrected the assessment to code for two Stage II's, the left outer heel and the right heel blister." The MDS was also incorrect because it coded the resident to have one of the pressure ulcers upon admission. The resident acquired all pressure ulcers after admission to the nursing facility, as well as an inaccurate assessment for the "scabbed" left outer heel was by Resident Assessment Instrument (RAI) assessment unstageable. Check RAI and add info about that here. LPN #5 and the MDS coordinator were interviewed together on 6/20/12 at 2:50 PM. LPN#5 did not know why she coded "0" for pressure ulcers. They both stated they review all nursing documentation and if they see a discrepancy, they question the nurse and or the Unit Manager for clarification and also said they could have gone to examine the resident's skin. The MDS submitted on 6/17/12 for the look back period 3/20-26/12 did not capture the unstageable area. The MDS coordinator stated, "I was never taught to stage "scabbed" areas. That sounds more like eschar. I used the nurse's note of 3/21/12 which stated the left heel area was a Stage II, as well as the one on 3/25/12 which said there was a Stage II on the right heel." She could not explain why she coded one on admission and one acquired. She was not aware of the previous 2/15/12 or 2/22/12 documentation and depended on the nurse's note documentation during her assessment window to be correct. The 2/15/12 nurse's note identified a "scabbed" area on the left heel and the Pressure Ulcer Record dated 2/22/12 indicated the same area was assessed as unstageable. The resident's Quarterly Data Collection tool dated 3/26/12 was completed by a licensed nurse assessed the resident with minimal risk for pressure ulcers when the resident had at least two existing pressure ulcers. The admission care plan dated 10/7/11 identified pressure sore preventative measures and to immediately report any redness or skin breakdown to charge nurses. The revised care plan dated 4/12/12 identified Resident #6 was at risk for skin breakdown due to a Braden Score of less than 11 and cognitive status. The goal was the resident would have no breakdown in the next 90 days. The care plan dated 2/23/12 was revised on 4/10/12 identified pressure ulcers on the left outer heel, left heel and right heel. Target dates for this care plan were 5/23/12 and 7/10/12. The goal was the resident's ulcer would show improvement. Some of the approaches to accomplish this included record on the Pressure Ulcer Record document weekly stage, length x with x depth, odor and progress and review at the weekly skin meetings, heel floats, treatment as ordered and vascular consult. A yellow highlighter was marked through this care care plan and "[MEDICAL CONDITION]" written on it. Another care plan was presented dated 5/8/12 for alteration in tissue perfusion: [MEDICAL CONDITION] identifying left heel and abscess to right outer knee. Some of the approaches included heel lifts, treatment as ordered and vascular consult as needed. During an orientation tour of the unit on 6/13/12 at 9:00 am, the current Rosewood Unit Manager stated all of the heel ulcers on the unit were classified as vascular ulcers to include Resident #6. The RUM stated the resident's left heel was unstageable and necrotic and wound care was performed once a day during the 7/3 shift. She stated the resident was on a pressure reduction mattress which was the standard mattress throughout the facility. On 6/13/12 at 12:20 PM, wound care was observed, as performed by RN #1, to the left heel. She stated the left heel was considered to be one wound. One of the family members was in the room during the treatment observation. The resident moved the right leg slightly and was able to bend it with help , but no movement of the left leg. The family member offered to help the nurse hold the leg during the dressing change. Upon inspection a large amount of drainage could be seen through the dressing on the left heel ulcer, as well as detection of a foul odor. During this observation, when the old dressing was removed a large black leathery area was observed that encompassed most of the resident's heel. The odor from the wound was extremely pungent. The edges of the outer heel was soft and mushy like, and shifted around when the nurse wiped over the area with saline soaked gauze sponge. RN #1 measured the area as 7 centimeters (cm) by (x) 6-7 cm. Santyl mixed with [MEDICATION NAME] (antibiotic ointment) was applied to the left heel ulcer, covered with 4 cm x 4 cm gauze sponges, which did not cover the entire wound, secured with Kling wrap and paper tape. The right heel ulcer had healed. The first indication of a area on the left heel was through a nurse's noted dated 2/15/12: "9:00 PM upon skin assessment resident noted to have scabbed area to left outer heel. No pain to touch. N/O (new order) Skin Prep (is a liquid film-forming dressing-Smith and Nephew) to left outer heel every shift til (sic) healed." The Licensed Practical Nurse (LPN) #4 that entered the above nurse's notes was interviewed on 6/19/12 at 3:40 PM. She stated she found the area on the left heel during the weekly skin assessment day 2/15/12. She said she was not told by the Certified Nursing Assistants or in shift report the area existed. According to LPN #4 the left outer heel area was dry hard and black, and she did not measure it. She stated she classified it as "scabbed" and should have had someone else look at it, but that the Unit Manager was responsible for the weekly assessment tracking and measurements of any identified pressure areas. She stated the heels should have always been floated because the resident did not move them to relieve pressure. LPN #4 also wrote a nurse's note on 2/22/12 at 8:20 PM to discontinue Skin Prep to left outer heel and start Santyl (topical debridment for devitalized/dead tissue). LPN #4 said she called the physician on 2/15/12 and obtained an order for [REDACTED]. She stated Skin Prep toughened the skin provided a barrier on the surface of the skin to prevent further breakdown and allow healing to take place. She stated, "We usually apply Skin Prep to reddened, boggy or soft heels." She said she documented the information on the 24 hour report and expected the Unit Manager make further assessments/measurement and possibly obtain further treatment orders from the physician. The LPN said she wrote the 2/22/12 nurse's note after she performed the weekly skin assessment and the treatment to left outer heel had changed to the topical debrider, Santyl ointment. The past Unit Manager first documentation on the Pressure Ulcer Record dated 2/22/12 the left outer heel was unstageable measuring 3.3 cm x 2.9 cm and the tissue type was necrotic (dead). There was no previous documentation from the Unit Manager on 2/15/12 through 2/21/12 when this left outer heel was first discovered by LPN #4 on 2/15/12. The Unit Manager at the time of survey no longer worked at the facility. The nurse's notes dated 2/22/12 documented both heels elevated on pillows. On 3/30/12 a newly acquired left medial pressure ulcer was identified on 3/30/12 and documented on the Pressure Ulcer Record as unstageable and measured 7 cm x 7 cm. On 4/4/12 the area was assessed as a Stage IV with the same measurements. Pressure Ulcer Record tracking stopped on 4/18/12; the wound remained as a Stage IV with the same measurements and slough (soft necrotic tissue). The nurse's notes dated 4/19/12 indicated the left outer heel was necrotic with slough in the center; left medial heel pink with < 25 % slough. A telephone order was written on 3/27/12 to elevate the left heel in a blue boot. The physician's progress notes dated 4/16/12 documented "unstageable heel ulcer to left heel, right heel ulcer." The nurse's note dated 5/4/12 does not differentiated between the two areas on the left heel, but indicates drainage, odor and necrotic areas in the wound bed. On 5/7/12 the physician ordered [MEDICATION NAME] 500 mg mixed with and Santyl to wound bed every day times 7 days. Arterial studies ordered to rule out peripheral artery disease (PAD). The resident had the arterial studies performed on 5/8/12 with results of moderate to diffuse [MEDICAL CONDITIONS]. The vascular specialist evaluated the resident on 5/14/12 and noted necrotic heel ulcer and to continue current wound protocol and he would follow-up in one month. An angiogram was deferred with Podiatry to follow up on the wound. The Podiatrist followed-up with the resident on 5/16/12 and documents necrotic ulcerations on left heel x 2; no further orders. The nurse's notes dated 5/26, 27, 28, 30, 31/12 indicated foul odor from the left heel and wound necrotic, dark, black in color with yellow and bloody drainage. On 5/31/12, the attending physician wrote new left heel wound orders for [MEDICATION NAME] and Santyl mix. A vascular consult was ordered on [DATE] and appointment scheduled for 6/8/12. The nurse's notes dated 6/9/12 at 3:00 PM indicated the resident seemed to be in pain during the treatment and the physician called to have pain medication increased. There was no evidence if the physician was called about an increase in pain medication. The current anti-pain medication dated 5/18/12 was scheduled [MEDICATION NAME] (narcotic pain reliever) with Tylenol 5 mg/325 mg for 9:00 am and 9:00 PM. Nurse's notes dated 6/9, 10, 13/12 continue to document left heel odor, black color and drainage. The resident had a vascular surgeon appointment on 6/14/12 and a Podiatrist on 6/15/12 at 8:15 am. After the second opinion with a different Podiatrist on 6/15/12, the resident was sent to the local hospital and did not return to the nursing facility. The current Rosewood Unit Manager was interviewed on 6/15/12 at approximately 11:00 am. She stated the resident returned from the first appointment on 6/14/12 with no information about the visit. She stated Resident #6 had not returned from the second visit with the Podiatrist on 6/15/12 and had no information regarding the resident's status. On telephone interview was conducted with Resident #6's Responsible Party/ Power of Attorney (RP/POA). She stated the vascular surgeon's appointment on 6/14/12 resulted in the surgeon wanting to amputate the left leg above the knee. She stated she had a second opinion based on the gravity of the situation. According to the POA, the second opinion Podiatrist offered no further hope in salvaging the left leg and if she did not have the surgery she would probably die. The Podiatrist progress note on 6/15/12 indicated an odorous left posterior heel ulcer with gangrenous changes, undermining of the left foot, local [MEDICAL CONDITION] of left heel and acute osteo[DIAGNOSES REDACTED] involving the ankle and the foot. Plan included probable left above the knee amputation. The resident had been sent directly from the Podiatry visit on 6/15/12 to the local hospital and admitted and underwent a aka on 6/18/12. An additional heel pressure ulcer was identified, as indicated in the nurse's notes dated 3/25/12. LPN #4 documented an intact fluid filled blister to the right heel and skin prep ordered for treatment. There was evidence skin prep was started to the right heel blister on 4/1/12 and discontinued 4/15/12. The right heel treatment was changed per physician on 4/16/12 to cleaning the blister with normal saline followed by [MEDICATION NAME] ointment and dry dressing. The previous Unit Manager first recorded, on Pressure Ulcer Record dated 3/30/12, the aforementioned right heel blister as a Stage II and measured 7 cm x 7 cm. The nurse's notes dated 4/12/12 indicated less than (<) 10 percent (%) slough (soft necrotic tissue) with necrotic edges. The Pressure Ulcer Record dated 4/22/12, indicated the right heel tissue type had both slough and necrotic tissue. There was no further tracking documentation of the right heel on the Pressure Ulcer Record. The right heel was considered healed on 5/3/12 with treatment to apply [MEDICATION NAME] ointment and leave open to air. The physician ordered Keflex 250 milligrams (mg) every 6 hours for 5 days. The resident was seen by the Podiatrist on 3/27/12. Blister was noted to heel, as well as left heel ulceration. Recommendations were to continue current treatment and he would follow up to monitor foot pathologies. An interview was conducted with the IDCS (Interim Director of Clinica Services) and the Corporate Director of Clinical Services (CDCS) on 6/19/12 at approximately 10:30 am. The IDCS and the CDCS could not locate the Skin Prep telephone order nor locate the transcribed treatment on the TAR for the left heel "scabbed" area after 2/15/12. The IDCS stated the next month, the treatment for [REDACTED]. On 6/19/12 at 3:00 PM, the IDCS stated she had a discussion with the previous Unit Manager regarding the issue of what was being done to prevent pressure ulcers prior to discovering them. She said she did not document the discussion, but also had them during daily meetings. She stated she would have not documented "scabbed" heels, but would have known it was eschar. She stated she expected the facility to float all resident's heels that had mobility issues and were bed bound. She also said, she expected communication from the CNA's to the nurses about any areas; and, the nurse's to accurately assess all areas, report correct information and implement the physician's orders [REDACTED]. On 6/20/12 at 10:30 am, the Regional Director of Clinical Services (RDCS) stated she took seriously what the survey team was finding regarding pressure ulcers, so she took charge and did a sweep of the building on 6/16/12 and started inservice training. She stated, "When I found out they had crossed through the pressure ulcer documentation (referring to Resident #6) and changed the wording to vascular ulcer, and stopped tracking them on the Pressure Ulcer Records; I told them, 'You can't do that!' You can have [MEDICAL CONDITION] and still have pressure ulcers; it was just an added diagnoses." b) During the Pressure ulcer dressing change to Resident #6's left heel, the nurse failed to follow standard infection control practices to prevent the possible transmission of infection. On 6/13/12 at 12:20 PM, wound care was observed, as performed by RN #1, to the left heel. She stated the left heel was considered to be one wound. The RN pulled the treatment cart into the room by the resident's bedside. She did not clean off the cart or prepare a clean field. The RN went to her tote bag in the nursing office and removed her personal scissors. Upon inspection a large amount of drainage could be seen through the dressing on the left heel ulcer, as well as detection of a foul odor. Without disinfecting the personal scissors, she cut off the soiled dressings, after which she laid the scissors on top of the treatment cart. The RN did not remove her gloves after she cut off the dressing, but repeatedly opened common drawers to reach in and obtain supplies needed for the dressing change and sat them on the top of the treatment cart. The RN washed her hands and donned new gloves before proceeding with with wound care. During the cleaning of the wound, she had great difficulty holding the resident's leg and repeatedly allowed the heel to fall back on the bed. One of the family members was in the room during the treatment observation and offered to hold the leg during the remainder of the dressing change procedure. The RN used the same soiled scissors to cut the new dressing. After the pressure ulcer treatment procedure, the RN did not disinfect her personal scissors, but placed them along with her stethoscope inside the Treatment Administration Record (TAR) binder and pushed the cart into the hallway. She did not disinfect the top of the cart before or after the procedure. She stated she had other resident's treatments to complete. 2. Resident #5 was a [AGE] year with multiple admissions to the facility and a most recent readmission date of [DATE]. Resident #5's [DIAGNOSES REDACTED]. Resident #5's most recent MDS (minimum data set) was a quarterly with a reference date of 5/24/12. Resident #5 was assessed as being modified independent for making everyday life decisions. Resident #5 was assessed as being totally dependent on one staff for bed mobility, eating, bathing and personal hygiene. Resident #5 was coded as being bedfast all or most of the time. The quarterly assessment documented Resident #5 as having stage IV pressure ulcers. Resident #5's most recent admission history included the following: ? 12/29/12 - admission to facility ? 1/19/12 - hospital admission ? 1/23/12 - admission to facility ? 5/14/12 - hospital admission ? 5/19/12 - admission to facility ? ? On 6/14/12 at 8:45 AM, Resident #5's clinical record was reviewed ? ? Review of the Nursing Admission Data Collection Form dated 5/19/12 on the clinical record evidenced the following under the skin section: ? left heel 1 cm x 3, red ? ? The Nursing Admission Data Collection Form dated 5/19/12 on the clinical record evidenced the following under "Risk for Pressure Ulcers": ? pressure reduction devices for bed, ulcer sore care ? "Risk" - Total score of 14 (moderate risk) ? ? Review of the attending physician admission orders [REDACTED] ? barrier cream to reddened areas as needed ? Skin Prep (a liquid that, when applied, dries to become a protective film and barrier to skin) bilateral heels each shift ? ? Review of the Skin Prevention Care Plan dated 5/23/12 on the clinical record evidenced the following interventions under at risk for skin breakdown: ? Assess for history of pressure ulcers ? document change in skin color, turgor ? weekly skin checks by licensed nurse ? report any red areas to nurse immediately ? use protective devices ? pressure reducing cushion to wheelchair ? assess previous sites for potential breakdown ? completed a head to toe assessment to assure skin is in tact ? ? Review of the Weekly Skin Integrity Checks on the clinical record evidenced the following: ? 5/24/12 - No New change of condition, documentation already established on all existing wound/skin conditions ? 5/31/12 - No New change of condition, documentation already established on all existing wound/skin conditions ? 6/8/12 - No New change of condition, documentation already established on all existing wound/skin conditions ? There was no evidence in the review of the Weekly Skin Integrity Checks on the clinical record the nursing staff identified and assessed the development the pressure areas to advanced the stages. ? ? Review of the weekly nursing progress under "skin" on the clinical record evidenced the following: ? 5/23/12 - 5/27/12 - no weekly nursing progress note ? 5/31/12 - Skin Prep to heels ? 6/8/12 - Skin Prep to heels ? There was no documentation in the review of the Weekly nursing notes on the clinical record the nursing staff identified and assessed the development the pressure areas to advanced the stages. ? ? Review of the weekly nursing progress notes on the clinical record between 5/19/12 to 6/12/12 evidenced: ? no documented changes in skin color, turgor ? no consistent weekly skin checks by the licensed nurse ? no reporting of any red areas to nurse immediately by the Certified Nursing Assistants (CNA's) ? no use of protective devices such as body pillows, moon boots, cradle boots, or lamb skin heel protectors. ? no assessment of previous sites for potential breakdown ? no completion of a head to toe assessment to assure skin was in tact ? ? Review of the Treatment Administration Record (TAR), on the clinical record between 5/19/12 to 6/12/12 evidenced: ? no documented changes in skin color, turgor ? no weekly skin checks by licensed nurse ? no notation of any red areas to nurse immediately ? no use of any protective devices such as body pillows, moon boots, cradle boots, or lamb skin heel protectors. ? no assessment of previous sites for potential breakdown ? no completed head to toe assessment to assure skin was in tact ? ? A review of the daily activities of daily living (ADL's) log sheet completed each shift by the Certified Nursing Assistant (CNA's), evidenced that Resident #5 received total assistance with bathing, dressing, bed mobility, toilet use and transfer from 5/19/12 to 6/12/12. ? ? A review of Resident #5's clinical record evidenced that between 5/19/12 and 6/12/12, there was no CNA notification to the nursing staff that Resident #5 had acquired: ? changes in skin color and turgor ? or that there was the application of any protective devices such as body pillows, moon boots, cradle boots, or lamb skin heel protectors ? or there was ongoing assessment of previous sites for potential breakdown ? or no completed head to toe assessment to assure skin was in tact ? ? A review of the "TAR", on the clinical record evidenced that the nursing staff documented the application of :Skin Prep" only to Resident #5 bilateral heels each shift (7AM to 3PM, 3PM to 11PM, and 11PM to & AM) for 5/19/12 to 6/12/12. ? ? A review of the Pressure Ulcer Record on the clinical record evidenced: ? On 6/11/12 Resident #5 was assessed as having a unstageable pressure sore to the left heel - 6X3 with dark purple coloring ? On 6/12/12 Resident #5 was assessed as having a stage #2 to the right buttock with pink coloring ? ? On 6/14/12 the attending physician wrote new treatment orders for the treatment of [REDACTED]. ? ? Resident #5 developed a pressure ulcer that was not identified until it was unstageable to the left heel 23 days after readmission to the facility. The resident also developed a stage 2 pressure ulcer to the right buttocks 24 days after readmission to the facility. ? ? There was no documentation or other evidence nursing staff assessed and identified the progressive deterioration of the pressure areas to more advanced stages such as: ? Redness not redness not resolving within 30 minutes of pressure relief ? Partial thickness tissue loss involving epidermis and possible dermis (appears as shallow skin ulcer ? Full thickness skin loss extending through the dermis. such as necrotic tissue, undermining, sinus tract formation, exudates and/or infection ? Deep tissue destruction extending through subcutaneous tissue and may involve muscle, joint and/or bone. ? ? During a scheduled dressing change on 6/14/12 at 10:35 AM, it was evidenced Resident #5 received treatment to the unstageable left heel pressure ulcer which presented as full-tissue thickness loss in which the base of the ulcer was covered by slough and some eschar and to the right buttocks 1 x 5 sm stage 2 pressure ulcer which presented as a superficial pale pink wound bed with no drainage. ? ? An interview was conducted on 6/14/12 at 3:00 PM, 6/19/12 at 9:40 AM and on 6/20/12 at 8:40 PM with the Corporate RN and the Director of Nursing (DON) and the aforementioned information was presented. The Corporate Nurse stated that the Administrator would be advised. ? ? The facility staff presented no additional evidence by the end of the survey on 6/20/12 at 5:30 PM that demonstrated the nursing staff identified and assessed the advancing deterioration of the pressure areas to obtain treatment for [REDACTED]. ? ? ? ? 3. Resident #14 was a [AGE] year readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. ? ? Resident #14's most recent MDS (minimum data set) was a quarterly dated 5/3/12. Resident #14 was assessed as being cognitive impaired. Resident #14 was assessed as being extensive dependent on one staff for bed mobility, eating, bathing and personal hygiene. Resident #14 was coded as being bedfast all or most of the time. ? ? Review of the Nursing Admission Data Collection Form dated 2/2/12 on the clinical record evidenced the following under the skin section: skin condition noted as warm, dry, bruises noted and ecchymosis (blood escaping into the tissues from ruptured blood vessels ? ? The Nursing Admission Data Collection Form dated 2/2/12 on the clinical record evidenced the following under "Risk For Pressure Ulcers": "Risk" - Total score of 11 (high risk) ? ? Review of the attending physician admission orders [REDACTED] ? barrier cream to buttocks PRN (as needed) ? Skin Prep (applies a protective barrier to heels) bilateral heels each shift ? pressure reducing mattress, check placement every shift Review of the Skin Prevention Care Plan dated 2/2/12 with updates to 5/4/12 on the clinical record evidenced the following interventions under at risk for skin breakdown: completed a head to toe assessment to assure skin is intact, assess for history of pressure ulcers, assess previous sites for potential breakdown, weekly skin checks by licensed nurse, document change in skin color and turgor, report any red areas to nurse immediately, use protective devices, and pressure reducing cushion to wheelchair. Review for the Weekly Skin Integrity Checks that was to placed on clinical record evidenced the following: 2/6/12 to 6/6/12 - no Weekly Skin Integrity Checks that documented the development of the pressure area to the left heel. Review of the weekly nursing progress notes under "skin" on the clinical record from 2/2/12 to 6/6/12 evidenced no change in documentation that identified and assessed the development of the pressure area to the left heel, only Skin Preps to heels each shift. Review of the weekly nursing progress noted on the clinical record between 2/2/12 to 6/6/12 evidenced: no completion of a head to toe assessment to assure skin was intact, no documented changes in skin color and turgor, no assessment of previous sites for potential breakdown, no consistent weekly skin checks by the licensed nurse, no assessment of previous sites for potential breakdown, no reporting of any red areas to nurse immediately by the Certified Nursing Assistants (CNA's), and no use of protective devices such as body pillows, moon boots, cradle boots, or lamb skin heel protectors. Review of the Treatment Administration Record (TAR), on the clinical record between 2/2/12 to 6/6/12 evidenced: no documented changes in skin color and turgor, no weekly skin checks by licensed nurse, no notation of any red areas to nurse immediately, no use of any protective devices such as body pillows, moon boots, cradle boots, or lamb skin heel protectors, no assessment of previous sites for potential breakdown, and no completed head to toe assessment to assure skin was intact. A review of the daily activities of daily living (ADL's) log sheet completed each shift by the Certified Nursing Assistant (CNA's), evidenced that Resident #14 received total assistance with bathing, dressing, bed mobility, toilet use and transfer from 2/2/12 to 6/6/12 and no documentation of the development of an unstageable pressure sore to the left heel. A review of Resident #14's clinical record evidenced that between 2/2/12 and 6/6/12, there was no CNA notification to the nursing staff that Resident #14 had acquired: changes in skin color and turgor, or that there was the application of any protective devices such as body pillows, moon boots, cradle boots, or lamb skin heel protectors, or there was ongoing assessment of previous sites for potential breakdown, and or no completed head to toe assessment to assure skin was intact. A review of the "TAR", on the clinical record evidenced that the nursing staff documented the application of Skin Prep" to Resident #5 bilateral heels each shift (7AM to 3PM, 3PM to 11PM, and 11PM to & AM) from 2/2/12 to 6/6/12. A review of the Pressure Ulcer Record on the clinical record evidenced: On 6/6/12 Resident #14 was documented as having an unstageable pressure sore to the right heel - [MEDICAL CONDITION] (centimeters) with purple blisters. A review of the Pressure Ulcer Record on the clinical record evidenced: On 6/6/12 Resident #14 was documented as having an unstageable pressure sore to the left heel - [MEDICAL CONDITION] with purple blisters. On 6/8/12 the nurse practitioner wrote new treatment orders for the treatment of [REDACTED]. Resident #14 developed an unstageable pressure ulcer to the left heel and right heel 127