Every finding on record at Parkview Care Center

Based on observation, interview and document review, the facility failed to provide physical therapy and occupational therapy as ordered for 5 of 5 residents (R2, R8, R13, R25, R26) reviewed for rehabilitation and restorative services. Findings include: R2's face sheet printed 6/4/26, indicated diagnoses of acute heart failure, chronic pain syndrome, and kidney disease. R2's care plan dated 2/17/26, indicated acute and chronic pain related to lower leg ulcers and chronic pain syndrome with interventions of non-medicated pain relief measures such as massage, physical therapy, and strengthening and stretching exercises. R2's physician's orders dated 5/29/26, indicated occupational and physical therapy eval and treat. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, rejection of care one to three days, use of wheelchair, dependent on staff for toileting hygiene, lower body dressing, and personal hygiene. R8's face sheet printed 6/4/26, indicated diagnoses of dysphagia (difficulty swallowing), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right side impairments due to stroke). R8's care plan dated 4/14/26, indicated activities of daily living (ADL) assistance needed for transfers due to recent stroke, with intervention on one assist for transfers and occupational and physical therapy to eval and treat. R8's physician's orders dated 4/14/26, indicated occupational, physical, and speech therapy eval and treat. R8's admission MDS assessment dated [DATE], indicated moderately impaired cognition, no behaviors, use of wheelchair, dependent on staff for bathing, toileting hygiene, and dressing. R13's face sheet printed 6/4/26, indicated diagnoses of end stage kidney disease, heart failure, and diabetes mellitus. R13's care plan dated 9/26/25, indicated desire to go home after meeting goals in therapy with interventions of evaluating and discussing the prognosis for independent or assisted living. R13's physician's orders dated 5/29/26, indicated physical and occupational therapy eval and treat. R13's admission MDS assessment dated [DATE], indicated intact cognition, no behaviors or rejection of care, use of wheelchair, dependent for transfers and dressing, set up for personal hygiene. R25's face sheet printed 6/4/26, indicated diagnoses of surgical aftercare following skin surgery, diabetes mellitus, kidney disease, and obesity. R25's care plan dated 5/27/26, indicated desire to return home following short term rehabilitation with interventions of evaluating motivation to return to community with assistance on home care. R25's physician's orders dated 5/26/26, indicated occupational and physical therapy eval and treat. R25's admission MDS was not yet completed. R26's face sheet received on 6/4/26, included diagnoses of polyarthritis (arthritis affecting five or more joints at the same time), chronic obstructive pulmonary disease, or COPD (lung disease that restricts airflow making it hard to breathe), obesity and history of falling. R26's admission MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R26 required supervision or partial assistance with activities of daily living (ADLs), required substantial assistance moving from chair to bed, was dependent upon staff for dressing, and did not walk distances due to medical condition or safety concerns. R26 used a wheelchair for mobility. R26's care area assessment for ADLs indicated R26 was admitted for short term rehabilitation following hospitalization. The goal was to improve functional abilities and return to prior living situation. R26's admission orders from the hospital dated 5/20/26, included occupational and physical therapy evaluation and treatment. Meaning occupational and physical therapy professionals would meet with R26 and evaluate therapy needs and establish a treatment plan. R26's care plan dated 5/20/26, indicated an ADL self-care deficit related to weakness/illness and chronic pain related to osteoarthritis of both knees causing joint pain which could lead to impaired physical mobility and inability to care for herself. R26 was considered a moderate risk of falling due to deconditioning, gait and balance problems. During interview on 6/2/26 and 2:39 p.m., R2 stated he had recently been hospitalized and returned to the facility. R2 stated he was supposed to be doing therapy, but there was no therapy available at the facility. R2 further stated he chose to return to the facility because he had been living there previously and didn't want to go anywhere else. R2 stated he was fine with waiting for the facility to get new therapy services. During interview on 6/2/26 at 3:00 p.m., R8 stated he was at the facility for therapy and planned to go home when done. R8 stated he was informed that therapy was not available anymore and wanted to go to a facility in a different town. R8 stated the facility was helping him get that arranged. During interview on 6/2/26 at 4:10 p.m., R13 stated she had recently been readmitted from the hospital and was supposed to be getting therapy services. R13 stated the facility told her they didn't have therapy right now, but she wanted to remain in the facility and wait until they hired new therapists. During interview on 6/3/26 at 10:40 a.m., R25 stated he was supposed to be doing therapy at the facility but didn't think he really needed it. R25 further stated he wanted to be in the facility and didn't want to go anywhere else. R25 stated he was going to remain at the facility until they got new therapy services. During an interview on 6/2/26 at 3:34 p.m., R26 stated she was there for short term rehabilitation but didn't get walked in the hall, adding she had arthritis in both knees and needed to get stronger so she could go home. During record review, a handwritten progress note dated 5/29/26 at 4:00 p.m., written by the director of nursing (DON) indicated R26 had been informed of therapy services being discontinued at the facility. The note indicated the DON had met with R26 and explained options including moving to another facility to receive therapy services. The note indicated R26 had been concerned she was getting kicked out of the facility and was informed she could stay if she desired, but if she wanted to continue therapy services, she could transfer to a facility in another town. R26 stated she wanted to think about it and would let the DON know. During record review, R26 had received a Notice of Medicare Non-Coverage form indicating her therapy services were ending on 5/31/26. The form had been signed by R26 on 5/29/26. The form indicated R26's Medicare provider and/or health plan had determined Medicare would probably not pay for current skilled services after the effective date of 5/31/26, and that R26 may have to pay for any services received after that date. During record review, a progress note dated 6/3/26 at 1:38 p.m., written by social service designee (SSD)-A indicated there had been a meeting with R26, family member (FM)-A, county case worker (CW)-G, the DON and SSD-A. CW-A had explained R26's options and if she were to stay long term, what her finances would look like. R26 agreed to continue therapy services at the facility and once graduated, would potentially stay long term. During a telephone interview on 6/3/26 at 9:58 a.m., medical director (MD)-D, stated he learned the facility no longer had therapy services (physical, occupational and speech therapy) when doing rounds at the facility on 5/28/26. MD-D stated he had not been brought into discussions about the reason therapy services had been discontinued nor the plan going forward to provide services to residents. MD-D stated it was a significant issue, and residents and families needed to be informed of alternate options for receiving therapy services. MD-D stated there was concern for residents declining in strength and potentially developing pneumonia or pressure sores. MD-D stated he would have expected leadership staff to have informed him of the changes in therapy services as soon as they became aware in order for him to lend guidance and be part of developing alternate plans. During an interview on 6/3/26 at 10:33 a.m., the director of nursing (DON) stated she learned about therapy services discontinuing services via an email on 5/28/26. Prior to that, the DON stated in an email dated 5/20/26, therapy services had informed the facility they would no longer be providing in-person therapy and would be switching to services via telehealth. The DON stated this came as a surprise as there had been no prior communication about changing or discontinuing services. Then in an email on 5/28/26, therapy services indicated everything was on hold, including services via telehealth. The DON stated the administrator asked her to reach out to MD-D to ask about sharing therapy services with the hospital he was affiliated with. In the meantime, the DON stated she and social worker designee (SSD)-A had started talking to residents and families who were affected by therapy services, offering assistance to receive services off-campus or moving to a different facility. During a telephone interview on 6/3/26 at 11:44 a.m., chief executive officer (CEO)-E of corporate services stated he became aware therapy services had discontinued services on 5/28/26, due to a significant outstanding balance owed to therapy services. CEO-E stated it had taken about seven to nine months to accumulate the bill and during the first four or five months had been working with therapy services about a payment plan. Time went by without communication from therapy services, and then recently (last week), the two parties had worked out a payment plan and had set up automatic bank withdrawal. Following that, therapy services discontinued all services. CEO-E stated decisions about which bills to pay came down to residents' safety and care was #1, which included electricity, water, gas. Paying food vendors was #2, and payroll was #3. Beyond that, we pay what we can to outstanding vendors with cash on hand. During an interview on 6/3/26 at 12:03 p.m., the regional director of skilled nursing facility operations (RD)-F stated she first learned of changes to therapy services when on 5/20/26, someone at a sister facility had been informed therapy services would be changed to telehealth visits. From 5/21/26 to 5/29/26, RD-F stated she had attempted to reach out to therapy services via phone, email and text but received no response. RD-F stated therapy services pulled their services without providing notice. RD-F stated she had been aware the facility owed therapy services a significant amount of money and knew CEO-E had been trying to work something out. During an interview on 6/3/26 at 1:02 p.m., the administrator stated she learned therapy services were being discontinued via an email on 5/28/26. The administer had been aware therapy services initially moved to telehealth therapy from in-person visits before discontinuing services altogether. The administrator had been aware a payment plan with therapy services had been set up. The administrator stated right away, the DON started looking at the possibility of utilizing therapy services at a nearby hospital but nothing had been determined. During an interview on 6/4/26 at 8:40 a.m., the DON stated therapy services had last been in the facility providing services on 5/22/26, and it was business as usual. The DON stated therapy services, either occupational therapy or physical therapy, were in the building Monday through Friday. An email from therapy services dated 5/20/26, indicated they would be conducting therapy visits via telehealth, then on 5/28/26, the facility received an email that telehealth was on hold until further notice. The DON stated she had informed MD-D about this change on 5/28/26, when doing rounds. The DON admitted she had not asked MD-D to see and/or talk to affected residents and their families, or to review therapy orders of affected residents to determine an interim course of action. The DON stated she had not thought to do that and acknowledged the potential risk for residents to decline without a plan for continued therapy. During an interview on 6/4/26 at 8:54 a.m., the assistant administrator stated she became aware of therapy services discontinuing services when the State survey team arrived on site on 6/2/26. She had been aware therapy services initially moved to telehealth therapy from in-person visits. The assistant administrator stated facility leadership discussed therapy services at their daily IDT (interdisciplinary team) meetings on 5/21/26 and 5/26/26. They had discussed details of the situation, why it was happening, a way to expedite payment to therapy services and the role of nurses to facilitate the process of therapy via telehealth until things could be sorted out. The assistant administrator acknowledged leadership did not think to bring MD-D into the discussion to inform him of what was happening and why, and how to determine a course of action to prevent residents from declining without therapy services. During a telephone interview on 6/4/26 at 11:47 a.m., RD-F stated she had met with a local therapy group who had agreed to provide therapy services, and would be signing a contract on 6/4/26, or on 6/5/26, and services would start sometime the following week. During record review, an email dated 5/20/26 at 8:58 p.m., from therapy services indicated due to ongoing lack of payment, therapy services would be implementing a reduction in services effective 5/25/26. All therapy services would be delivered via telehealth, with sessions being facilitated by a facility employee. Treatments would be 15 minutes in length and require a designated facility employee present. Services would be limited to specific days of the week and times. Services would be limited to skilled residents only. When current long-term care clients came off therapy, they would not be adding new part B therapy clients. Therapy services had enjoyed providing care to the facility; however, this was how therapy services must move forward due to payment issues while still trying to meet clients' immediate skilled needs. During record review, an email dated 5/27/26, at 6:04 p.m., from therapy services indicated no telehealth therapy would be provided tomorrow (5/28/26), and therapy services would not be rescheduling appointments. Someone would get back to the facility about on-going plans. According to the DON, that was the last communication received from therapy services. Review of agreement between facility and therapy services entered into on 5/11/23, and signed by both parties on 5/18/23, indicated therapy services (known as Contractor) may terminate the agreement upon ten (10) days' written notice to the facility (known as HCP or health care provider), if HCP failed to pay Contractor any fee, expense or other sum of money when due; provided, however, if HCP has defaulted three (3) times in the performance of its payment obligations during any twelve (12) month period, the Contractor may provide notice of termination, effect immediately, on the first day after the date of such written notice is given to HCP, and an opportunity to cure shall not be granted unless explicitly permitted in writing by the Contractor. Facility assessment dated 5/2026, indicated the facility offered both inpatient and outpatient therapy and rehabilitation services. Therapy services offered a wide variety of therapy services for residents, including physical therapy, occupational therapy and speech therapy. Therapy services were provided under contract and included licensed physical and occupational therapists and speech-language pathologists. Facility Therapy Evaluation policy dated 2025, indicated the licensed therapist would perform an initial resident evaluation upon physician referral and any reevaluation where indicated. The rehabilitation department would be notified when a physician order was written for therapy evaluation and treatment. The licensed therapist would perform a chart review and initiate the evaluation.

The facility failed to maintain complete and accurate accounting records of resident personal funds for 10 of 10 residents (R17, R18, R19, R20, R21, R22, R23, R12, R9, R11) whose funds were maintained in a commingled facility trust account. Findings include:The facility provided resident trust statements for all the residents who had given the facility to manage. The trust statements only had the balance with no accounting of credits or debits from the account. Further the trust statements did not identify and/or account for interest earned if any. R17's trust statement dated 4/3/26, identified a balance of $94.73.R18's trust statement dated 4/3/26, identified a balance of $85.00.R19's trust statement dated 4/3/26, identified a balance of $1,899.11.R20's trust statement dated 4/3/26, identified a balance of $100.00.R21's trust statement dated 4/3/26, identified a balance of $349.00.R22's trust statement dated 4/3/26, identified a balance of $100.00.R23's trust statement dated 4/3/26, identified a balance of ($15.00). This indicated the balance was negative.R12's trust statement dated 4/3/26, identified a balance of $45.00.R9's trust statement dated 4/3/26, identified a balance of $77.00.R11's trust statement dated 4/3/26, identified a balance of $58.00.The facility checking account statement ending 1/30/26, identified a beginning balance on 1/1/26, of $5,315.53 and ending balance of $5,125.53. On 1/2/26, a deposit was made under R17's name. The statement did not account for any other resident debits or credits. The facility checking account statement ending 2/27/26, identified a beginning balance on 1/31/26, of $5,125.53 and ending balance of 5028.96. On 2/3/26, a deposit was made under R17's name for $1,145.00. The statement did not account for any other resident debits or credits. The facility checking account statement ending 3/31/26, identified a beginning balance on 2/28/26, of $5,028.96 and ending balance of 4700.02. On 3/3/26, a deposit for $1,145.00 was made under R17's name. The statement did not account for any other resident debits or credits.The facility Business Savings account statement ending 12/31/25, identified a balance of $401.53. Interest earned from 10/1/25-12/31/25 was $0.05 with a year-to-date interest balance of $0.20.The facility Business Savings account statement ending 3/31/26, identified a balance of $401.53. Interest earned was $0.05, bringing the balance to $401.58.During an interview on 4/2/26 at 3:14 p.m., activity director (AD)-A stated she manages the funds for seven residents. AD-A does not have access to the account and it is a non-interest bearing account. AD-A manages the accounts by paying for items monthly for residents such as haircuts. AD-A pays the hairdresser with checks she has and then gives them to the Administrator. Within the electronic record facility there is an area to record deposits and withdrawals. AD-A was unaware how to record this information, so the information does not match the actual bank statements. AD-A prints off the balances from the electronic record and mails them to families every three months.During an interview on 4/7/26 at 10:28 a.m., Administrator stated the business office (BO)-A at a sister facility managed the trust accounts. BO-A deposits the money in savings and when funds are needed transferred them to checking. Administrator acknowledged the bank statements identified R17 was the only resident represented on the bank statement. Administrator acknowledged the facility needed education on how to track and deposit resident funds with a ledger which identified each individual residents expenditures.

Based on interview and document review the facility failed to notify the physician of recurrent refusals of physician ordered medication for 1 of 1 residents (R21) who required lactulose for treatment and management of constipation and hepatic failure/alcoholic cirrhosis. Findings include R21's face sheet dated 4/3/26, identified diagnoses of chronic hepatic failure without coma, and alcoholic cirrhosis of liver without ascites.R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had no cognitive impairment. R21 rejected cares 1-3 days.R21's care plan dated 9/4/25, identified R12 had diagnoses of constipation and is at risk for constipation when refuses medication for constipation, is receiving laxatives-Lactulose and MiraLAX for management related to diagnoses of cirrhosis of liver. Will refuse other medications for bowels. Interventions included administer medications as ordered. Document if he refuses. Encourage R21 to sit on toilet to evacuate bowels if possible. Follow facility protocol for bowel management. Document if R21 refuses to follow protocol to help evacuate bowels. R21's care plan dated 1/26/26, identified R21 can be resistive to cares. Often refuses medications and hygiene. Interventions included to allow R21 to make reasonable decisions about treatment regime to provide sense of control.R21's physician orders signed 3/19/26, identified an order for Lactulose. Give 45 milliliters (ml) by mouth three times a day related to hepatic failure.R21's medication administration record (MAR) dated 3/2026, identified Lactulose scheduled at 8:00 a.m., 2:00 p.m., and 8:00 p.m. All administrations reviewed from 3/1/26-3/31/26, identified R21 was administered only 19 doses of the physician ordered lactulose of 93 doses that were ordered. R21's Provider Notification Form dated 3/18/26, identified R21 continued to refuse medications. Medical doctor (MD)-A replied he would address on nursing home rounds.R21's physician visit note dated 3/19/26, did not identify or address R21's medication refusals as per the provider notification.R21's MAR dated 4/2026, identified Lactulose scheduled at 8:00 a.m., 2:00 p.m., and 8:00 p.m. All administrations reviewed from 4/1/26-4/7/26 at 8:00 a.m., were signed with a 2, which indicated drug refused.Review of R21's progress notes for 4/2026, did not identify and/or address R21's lactulose refusals nor evident physician was notified of R21's refusals.During an interview on 4/3/26 at 1:21 p.m., trained medication aide (TMA)-A stated if a resident refused a medication, the nurse needed to be notified right away. TMA-A was unable to articulate why R21 took Lactulose and what staff should monitor for when he refused it.During an interview on 4/3/26 at 1:39 p.m., licensed practical nurse (LPN)-A stated R21 took Lactulose for chronic constipation. R21 would refuse a lot and would need coaxing to take medication. If medications were refused for three days the doctor should be notified. LPN-B could not find anything in R21's care plan for the management of hepatic failure/cirrhosis aside from bowel management and was unable to articulate R21's risks associated with the diagnosis of hepatic failure/cirrhosis and unable to identify appropriate associated monitoring systems for sign/symptoms of worsening condition. During an interview on 4/3/26 at 3:03 p.m., registered nurse (RN)-B stated R21 took Lactulose for an alcoholic liver. R21 refused medications often. Physician should be notified right away of refusal of medications through the Physician Notification Form; education and explanation of the need to take medication should be provided to R21, along with writing a progress note.During an interview on 4/7/26 at 9:36 a.m., director of nursing (DON) was unaware if staff had been documenting refusals of medications in the progress notes recently but knew it had been done in the past. DON did not realize R21 did not have a care plan regarding cirrhosis of liver.The facility Notification of Changes policy revised 12/2025, identified the facility promptly informs the resident, consults the residents physician, and notifies, consistent with his or her authority, the residents representative when there is a change requiring notification.The facility abuse policy was requested on 4/2/26 at 3:02 p.m. but not received.

Based on observation, interview, and document review the facility failed to revise behavioral care plan after resident-to-resident altercation for 1 of 1 resident (R11) reviewed for abuse. In addition, the facility failed to revise the care plan to reflect ongoing pattern of medication refusals for 1 of 1 resident (R21) who was prescribed a clinically significant medication used to treat a diagnosis of cirrhosis/hepatic failure. Findings include:R11's face sheet dated 4/2/26, identified diagnoses of Alzheimer's disease with late onset, anxiety disorder, mild cognitive impairment, and blindness of right eye.R11's physician order dated 6/12/24, identified to monitor and note behavior in progress note of irritability, verbal aggression, stating he feels down or blue, not visiting with others, walking the halls, and not eating.R11's physician order dated 6/8/25, identified to check R11's room daily for weapons such as scissors, knives, forks, etc. after recent episodes of aggression.R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had some difficulty with hearing and speech clarity. R11 was rarely understood and had severe cognitive impairment. R11 had inattention and disorganized thinking. R11 had behavioral problems which included physical behavioral symptoms directed towards others and verbal behavioral symptoms directed towards others. R11 rejected care and wandered 1-3 days. R11 was independent with a wheelchair.R11's care plan dated identified, R11 exhibited a behavior of inappropriate touching of females dated 5/28/24 with associated interventions that included administer medication as ordered; caregivers provide opportunity for positive interaction and attention; Stop and talk to R11 when passing by; Intervene as necessary to protect the rights and safety of others; Approach/speak in a calm manner. Divert attention; Remove from situation and take to alternate location as needed; Monitor behavior episodes and attempt to determine underlying cause; Monitor R11's whereabouts when his room entry motion sensor alarm goes off to see if his is leaving his room to monitor where he is going; Social service designee will discuss behavior with resident and explain/reinforce why it is inappropriate and/or unacceptable to touch other residents, especially females inappropriately one day every week.R11's care plan dated 6/1/25, identified R11 had incidents of verbal aggression with resident 1120. R11 had been asked to move tables in the dining room and refused. R11 and resident 1120 get along much of the time. Interventions included analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Do not wake R11 when sleeping as this can agitate him. Monitor/document/report as needed any signs/symptoms of R11 posing danger to himself and others. Staff to monitor R11's whereabouts and what he is doing when out of his room and around resident 1120. If able, try and get R11 to leave situation. If it is mealtime, tell R11 he can come back in a little while.R11's progress note dated 12/29/25 at 10:26 a.m., identified R11 had been agitated all day. At 8:30 a.m., R11 was outside of his room, in hallway and another resident walked by. R11 swung at the other resident. The other resident ducked. R11 did not make contact with his fist on the other resident. Staff members observed and went to residents. Went to R11's room and he pointed at his bed which appeared wet. Wondered if R11 thought the other resident had wet his bed. The other resident appeared frightened. It was also reported that when nursing staff was assisting R11 to the breakfast table, he hit out at another resident sitting next to him but did not make contact. Later in the morning, the other resident that R11 had previously struck out at, was in the dining room. R11 went up to the resident and was mumbling in anger. The other resident was frightened and put his arms up and walked away from R11 to the other side of the dining room without his walker because R11 was close to the walker. Staff intervened and got the other resident his walker.In review of R11's record it was not evident care plan interventions were evaluated for effectiveness after the incident and R11's care plan did not identify the new aggression toward another resident and staff nor new interventions to manage the behaviors R11 displayed on 12/29/25.During an observation on 4/2/26 at 1:19 p.m., R11 was in his room. R11's room was located on the opposite side of facility as R12.During an interview on 4/2/26 at 1:20 p.m., nursing assistant (NA)-D stated R11 was both aggressive and not aggressive depending on time of day and approach. NA-D had never seen R11 aggressive towards residents, only staff. R11 would kick and hit at staff. NA-D tried to maintain a healthy distance away from R11 if R11 was being aggressive. NA-D would allow R11 to calm down before reapproaching for cares if he was aggressive. NA-D was unaware of incident between R11 and R12 in December.During an interview on 4/2/26 at 1:25 p.m., NA-B stated R11 could be aggressive but had never witnessed aggression towards other residents. R11 would show aggression to staff if NA's woke him up before he wanted to get up, when that would happen it would affect R11's whole day. R11 would be upset and chase the NA's around the facility. R11's Kardex identified to intervene as necessary, to protect and approach in calm manor, remove from situation, and take to an alternate location as needed. NA-B stated she would intervene before R11's agitation escalated, engage calmly in conversation and approach later if needed.During an interview on 4/7/26 at 9:36 a.m., director of nursing (DON) stated after the incident on 12/29/25, R11 and R12 were separated from each other and asked to stay away from each other as much as possible. DON did not revise R11's care plan interventions after the altercation to identify aggressive/agitative behaviors toward R12 and staff. Root cause of incident was that R11 did not know or realize what he was doing. R21's face sheet dated 4/3/26, identified diagnoses of chronic hepatic failure without coma, and alcoholic cirrhosis of liver without ascites.R21's care plan dated 9/4/25, identified R12 had diagnoses of constipation and is at risk for constipation when refuses medication for constipation, is receiving laxatives-Lactulose and MiraLAX for management related to diagnoses of cirrhosis of liver. Will refuse other medications for bowels. Interventions included administer medications as ordered. Document if he refuses. Encourage R21 to sit on toilet to evacuate bowels if possible. Follow facility protocol for bowel management. Document if R21 refuses to follow protocol to help evacuate bowels. Provide pericare after each incontinent episode.R21's care plan dated 1/26/26, identified R21 can be resistive to cares. Often refuses medications and hygiene. Interventions included to allow R21 to make reasonable decisions about treatment regime to provide sense of control.R21's quarterly MDS dated [DATE], identified R21 had no cognitive impairment. R21 rejected cares 1-3 days.R21's physician orders signed 3/19/26, identified an order for Lactulose. Give 45 milliliters (ml) by mouth three times a day related to hepatic failure.R21's medication administration record (MAR) dated 3/2026, identified Lactulose scheduled at 8:00 a.m., 2:00 p.m., and 8:00 p.m. All administrations reviewed from 3/1/26-3/31/26, with only 19/93 administrations administered.R21's Provider Notification Form dated 3/18/26, identified R21 continued to refuse medications. Medical doctor (MD)-A replied he would address on nursing home rounds.R21's physician visit note dated 3/19/26, did not address the medication refusals as indicated by the physician notification form dated 3/18/26. R21's MAR dated 4/2026, identified Lactulose order which was scheduled at 8:00 a.m., 2:00 p.m., and 8:00 p.m.; 19 of possible 19 administrations reviewed from 4/1/26 through 4/7/26 at 8:00 a.m., were signed with a 2, which indicated drug refused.Review of R21's progress notes between 4/1/26 through 4/7/26 did not include follow-up and/or address R21's refusals of Lactulose. R21's record reviewed between 3/4/26 through 4/7/6 revealed even though R21 had ongoing refusals of lactulose (74 doses) according to March 2026 MAR, April MAR and R21's Provider Notification Form dated 3/18/26, that identified R21 continued to refuse medications there was no indication the care plan for refusals was reviewed and evaluated for effectiveness and updated to address R21's treatment needs, associated risks (i.e.- encephalopathy), patterns of the refusals and individualized interventions to manage the behavior. During an interview on 4/3/26 at 1:21 p.m., trained medication aide (TMA)-A stated if a resident refused a medication, the nurse needed to be notified right away. TMA-A was unable to articulate why R21 took Lactulose and what staff should monitor for when he refused it.During an interview on 4/3/26 at 1:39 p.m., licensed practical nurse (LPN)-A stated R21 took Lactulose for chronic constipation. R21 would refuse a lot and would need coaxing to take medication. If medications were refused for three days the doctor should be notified. LPN-B could not find anything in R21's care plan for the management of hepatic failure/cirrhosis aside from bowel management and was unable to articulate R21's risks associated with the diagnosis of hepatic failure/cirrhosis and unable to identify appropriate associated monitoring systems for sign/symptoms of worsening condition. During an interview on 4/3/26 at 3:03 p.m., registered nurse (RN)-B stated R21 took Lactulose for an alcoholic liver. R21 refused medications often. Education and explanation of the need to take medication should be provided to R21, along with writing a progress note.During an interview on 4/7/26 at 9:36 a.m., DON was unaware if staff had been documenting refusals of medications in the progress notes recently but knew it had been done in the past. DON did not realize R21 did not have a care plan regarding cirrhosis of liver.

Based on observation, interview, and record review the facility failed ensure comprehensive assessments for appropriate sling sizes for full body mechanical lift according to manufacturer guidelines to ensure safe transfers to mitigate the risk of injury for 2 of 2 residents (R16, R10) reviewed for safety.Findings include:R16R16's face sheet dated 4/2/26, identified diagnoses of encounter for closed fracture with routine healing, and muscle weakness.R16's admission MDS dated [DATE], identified R16 had severe cognitive impairment. R16 was dependent on staff for dressing, rolling, and transfers. R16 did not move from sitting to lying, lying to sitting, or sitting to standing.R16's Baseline Care Plan dated 2/5/26, identified R16 required staff assistance to transfer but did not identify how the transfer would be accomplished.R16's care plan dated 3/3/26, identified R16 required a mechanical lift with assist of two people for transfers. R16's care plan did not identify sling size to use prior to start of survey. During an observation on 4/2/26 at 9:05 a.m., R16 was in bed. R16's mechanical lift sling tag had the printing dissolved and unable to read the sling size.During an observation on 4/2/26 at 10:50 a.m., licensed practical nurse (LPN)-A and nursing assistant (NA)-A transferred R16 with the unmarked sling and mechanical lift from bed to wheelchair.During an interview on 4/2/26 at 11:10 a.m., NA-A stated NA's decide what sling to use by resident weight. R16 was a medium sling based on weight which had brown straps. The slings used to say what size they were, but they have become worn from washing. The Kardex should include what size sling to use with the lifts. NA-A reviewed R16's and R10's Kardex and verified neither had a sling size identified on the Kardex. NA-A went to the linen closet and identified a sign from the mechanical lift company that stated small slings that had gray straps were for 70-100 pounds, beige straps for medium sling with weight 90-220 pounds, burgundy straps for large with weight 190-320 pounds, and extra-large green straps with weight 280-450 pounds. The signage also included measurements from base of neck to tailbone. Small 21 inches, medium 24 inches, large 26 inches, and extra-large 28 inches. NA-A did not acknowledge the measurement of neck to tailbone in the calculation for sling size when she determined what sling to use. NA-A then reported to LPN-A that R10's and R16's Kardex did not include what size sling to use. During an interview on 4/2/26 at 1:53 p.m., RN-A provided a Comprehensive Assessment for Sling Sizing she had just created. The facility would begin utilizing this immediately.In review of R16's record, there was no indication of a completed comprehensive assessment to determine sling size prior to the start of the survey on 4/2/25. R16's record on 4/2/26 included a completed Comprehensive Assessment for Sling Sizing for Total Lift dated 4/2/26, identified R16 weighed 101.9 pounds and measurement from base of neck to tailbone was 22 inches. R16's sling size was medium.On 4/2/26, R16's care plan was updated to include use of medium mechanical lift sling.R10's face sheet dated 4/2/26, identified diagnoses of spinal stenosis (narrowing of spaces within the spinal canal), lumbago with sciatica on left and right side (pain in lower back and legs due to nerve compression), and age-related physical debility.R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had no memory issues. R10 was dependent on staff for dressing, rolling side to side, sitting to lying, sitting to standing, chair/bed transfers.R10's care plan revised 8/18/25, identified R10 required a (full body) mechanical lift with two staff assist for all transfers. R10's care plan did not identify the size of sling to use with the liftIn review of R10's record, there was no indication of a completed comprehensive assessment to determine sling size prior to the start of the survey on 4/2/25. R10's record on 4/2/26 included Comprehensive Assessment for Sling Sizing for Total Lift dated 4/2/26, identified R10 weighed 143.3 pounds and measurement from base of neck to tailbone was 22 inches. R10's sling size was medium.R10's Kardex dated 4/2/26, identified R10 transferred with the mechanical lift using a medium sling.During an interview on 4/2/26 at 1:25 p.m., NA-B stated sizes of the sling are on the slings. Each sling has a weight limit and the sign in the linen closet would tell them what size sling to use based on weight.During an interview on 4/2/26 at 3:10 p.m., NA-C stated she was unsure how to determine what size of sling to use on residents but if they are bigger get a large, if smaller get a small. NA-C thought the sling sizes would be included on residents Kardex.During an interview on 4/2/26 at 11:21 a.m., RN-A stated sling sizes should be in the care plan and Kardex. NAs cannot choose size of sling. Sizing of slings should be completed by therapy or nursing department. Sizing would be determined by measuring from neck to tailbone and current weight of resident. RN-A expected the sling sizes to be included in the care plan and Kardex for staff.During an interview on 4/7/26 at 9:36 a.m., DON stated staff are trained on mechanical lift upon hire. The NA's are able to train staff on mechanical lifts. DON measured sling sizes for residentsThe facility Safe Resident Handling/Transfers undated, identified the facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents and that residents will be measure correctly as per the manufacturer's instructions on proper sling size.The EZ Way Smart Lift Operators Instructions undated, identified for safe operation, operators should watch the training video, read through this manual, complete the competency checklist, and practice on fellow staff members before use with patients. As patients vary in size, shape, weight, and temperament, these conditions must be taken into consideration when deciding which sling is suitable for each patients needs. The size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of a patient. A proper fit will involve the judgement of the caregiver. *it is important to evaluate the width of a patient in relation to the width of the sling. **it is important that no portion of the patient overlap the sides of the sling.

Based on observation, interview, and record review, the facility failed to comprehensively assess, monitor, timely develop and revise a care plan, and follow physician-ordered treatments for a surgical wound for 1 of 3 residents (R1) reviewed for non-pressure related skin injuries. The facility's failures resulted in actual harm, as evidenced by documented deterioration of R1's surgical wound from partial to complete dehiscence, with measurable increases in wound depth and tunneling, increased pain, and the need for ongoing treatments. Findings include: R1's face sheet dated 1/29/26, identified diagnoses of malignant neoplasm (cancer) of the anal canal. R1's hospital Discharge summary dated [DATE], identified R1 had been hospitalized from [DATE] through 1/2/26 for a planned robotic-assisted abdominoperineal resection (a major surgery removing that anus, rectum, and part of the sigmoid colon) with a permanent colostomy. R1's hospital After Visit Summary dated 1/2/26, included the following post procedure after care orders for the abdominal perineal resection: -No donut pillows - Avoid sitting on hard surfaces for prolonged periods of time. -Be careful when transferring from sitting to standing to avoid shearing. -It is recommended you change positions frequently in order to reduce friction or pressure. -You may sit normally on a regular pillow for ten minutes at a time in an hour period for the next 2-3 weeks. In review of R1's record between 1/2/26 through 1/13/26 there was no indication the aforementioned Hospital's aftercare orders/interventions had been transcribed into R1's facility physician orders. R1's admission Skin assessment dated [DATE], identified a drawing of the perineal area with 7 lines (indicating an incisional line) and a comment of closed due to anal cancer. No additional information was included. During an interview on 1/28/26 at 8:46 a.m., registered nurse (RN)-B stated she had observed R1's coccyx incision on admission and it was closed with sutures and did not observe any dehiscence at that time. R1's baseline care plan dated 1/3/26, did not identify any skin integrity issues and/or the incision to R1's rectal area. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact, had no behaviors of rejection of care, was independent with bed mobility, needed set up or clean up assistance for transfers, had a recent surgery that required active skilled nursing facility care that involved the gastrointestinal tract, had a surgical wound that did not have any surgical wound care. R1' s corresponding Care Area Assessment (CAA) signed 1/13/26, did not identify a trigger for any skin issues. Review of R1's record between 1/2/26 through 1/13/26, indicated even though R1's hospital discharge documents and MDS identified R1 had a recent surgery that required active skilled nursing there was no indication of a corresponding baseline and/or comprehensive care plan developed that addressed and/or specified the necessary nursing care/services/or management pertaining to R1's gastrointestinal tract and/or address R1's surgical wound until 1/14/26 (12 days after admission). Furthermore, between R1's admission date of 1/2/26 and 1/14/26, R1's record did not include comprehensive skin assessments nor monitoring of R1's rectal surgical incision. R1's progress note dated 1/14/26, identified there was concern for purulent drainage from the surgical site, called surgeon, and made an appointment to be seen on 1/15/26. Surgeon stated it was ok to wait until appointment, however, if a temperature, pain, nausea or vomiting develop then send to emergency department. R1's skin integrity care plan initiated on 1/14/26, identified actual impairment of skin integrity of the rectal area which has an open wound which dehisced. Goal to develop clean and intact skin. Interventions as followed: -avoid sitting on hard surfaces for prolonged period of time and change positions frequently to reduce friction or pressure, you may sit normally on a regular pillow for 10 minutes at a time in an hour period for the next 2-3 weeks from admission of 1/2/26. R1's physician orders updated on 1/14/26, identified the following orders: -Do not to be sit up for more than 10 minutes at a time in an hour and should be sitting on a pillow, should be changing positions frequently in order to reduce friction or pressure every shift. R1's Skin Issue assessment dated [DATE] at 9:17 a.m., identified a new skin issue of a surgical wound that was present on admission. Incision approximated with partial dehiscence (the splitting or bursting open of a wound). No healing ridge. Measured 21.71 centimeters (cm) x 2.71 cm, with no undermining or tunneling. Had 40% of epithelial (a process where epithelial cells migrate upwards to repair a wound); 50% granulation (a healing wound filled with new, healthy connective tissue); 10% slough (a moist yellow, or white necrotic tissue); had moderate exudate (drainage) that was serous (clear watery fluid). Exudate had strong odor after cleansing; surrounding tissue was intact; periwound (the skin around the wound edge) was warm; dressing intact; dressing saturated; debridement was mechanical in nature; dressing was non-adherent synthetic. Although R1's skin assessment dated [DATE] identified the usage of a dressing, R1's physician orders did not include wound treatment orders and R1's record did not identify type of wound treatment and how long the treatment had been applied. R1's progress note dated 1/15/26 at 11:53 a.m., identified R1 left for appointment at 9:50 a.m. R1's facility 's appointment communication form dated 1/15/26, identified the facility informed general surgery R1 had not been offloaded as ordered and had been sitting up for more than 10 minutes an hour and not on a pillow or wheelchair cushion. In review of R1's record between 1/2/26 through 1/13/26 there was no documentation R1 had been offered and/or attempted to offload until the order dated 1/14/26 that directed staff of R2's position changes that was recorded as completed on the January 2026 treatment administration record. Further there was no documentation R1 had refused position changes. R1's surgeon physician orders dated 1/15/26 at 11:00 a.m., directed staff to pack rectal wound 1-2 times per day as needed pre drainage with 1/4 iodoform (a cotton gauze impregnated with an antiseptic agent) packing or plain gauze. R1's General Surgery progress note dated 1/15/26 at 12:32 p.m., included R1 was seen for a follow up after a recent robotic abdominoperineal resection (a major surgery that removes the rectum, anus, and part of the sigmoid colon). R1's nursing facility was concerned about purulent foul-smelling drainage from the perineal incision. Perineal examination performed and showed a partially dehisced perineal wound with a 3.0 cm opening at the cephalad (upper part of the body) aspect of the incision and loose sutures at that area. There was no purulence. The top 3 nylon sutures were removed, and the wound was probed showing a sizable cavity within to at least 4.0 cm in depth. The remaining sutures were kept in place as they appeared to be holding the wound together. The wound was packed and instructed to have packing changed at least once daily and as needed. Discussed offloading the wound and avoid sitting for prolonged periods of time. R1's physician orders dated 1/16/26, directed dressing change/wound packing to rectal/anal wound dehiscence-packing changes at least once daily and as needed for drainage with 1/4 inch iodoform packing strip or plain gauze once per day. R1's Skin Issue assessment dated [DATE], identified wound on coccyx had a surgical wound. Wound is listed as stable: wound previously deteriorating; wound characteristics plateaued. Wound was present on admission; however, exact date was identified at 1/15/26 (13 days after admission). Incision not approximated and had partial or complete dehiscence. Wound measurements documented as 1.2 cm x .72 cm x 3.0 cm with no undermining or tunneling with no exudate odor. Surrounding tissue is fragile and had heavy drainage. Dressing intact but saturated with heavy saturation. R1's facility's provider notification form dated 1/20/26, informed that R1's perineal wound was worsening. Call placed to surgeon on 1/20/26, however, had not received a call back yet. Requested order to change order from packing of 1/4 inch iodoform packing strips or gauze to cleanse wound with gauze and saline to pack with 1/2 inch moistened roll gauze and cover with ABD (abdominal pad- a thick highly absorbent dressing). The wound is too large for 1/4 inch strip. R1's physician orders communication dated 1/22/26, included a response from the 1/20/26 order request to implement wound care as it is written in the nursing note, but we do need to stress to make sure they [general surgery] are ok with continuing that wound care and that they do not have something different. R1's general surgery wound nurse note dated 1/23/26, identified R1 was seen for wound care in clinic and agree to continue to changing packing at least twice daily and to change outer dressing when saturated. R1's general surgery orders dated 1/23/26, directed staff to continue to change outer dressing when saturated. Increase packing on side (use more gauze, pack down towards incision and straight back). Change packing at least twice daily. Ultrasound done and no concerns. Use orange bottle of hydrophilic wound dressing around wound for redness. Continue regular diet, encourage fluids, and high protein. R1's physician orders identified an order on 1/24/26 to pack rectal wound with 1/2 inch roll gauze. Pack more gauze down towards incision and straight back twice daily and use hydrophilic (a dressing designed to maintain moisture) wound dressing around wound for redness. Cover with ABD. Change outer dressing when saturated. R1's progress note dated 1/24/26 at 11:04 a.m., identified old dressing removed from rectal area and large amount of serous drainage without odor. Area cleansed with Vahse (a hypochlorous acid solution designed for cleansing, irrigating, moistening, debriding, and removing foreign material), hydrophilic applied around the wound, and new packing inserted. R1's wound care physician orders did not include an order to use Vashe wound cleanser. R1's progress note dated 1/25/26 at 1:46 p.m., identified wound dressing and packing changed. R1 asked not to have too much packed in there because he could not sleep on either side. R1's record did not identify education was provided to R1 about following physicians' orders, did not include description pertaining to the amount of gauze and amount that was used to replace, no indication of any further assessment and/or evaluation of the discomfort the prescribed treatment caused, and not evident physician and surgical service were notified. R1's progress note dated 1/25/26 at 9:31 p.m., identified R1's coccyx dressing had great deal of odorous drainage from old dressing. R1's pants, underwear, and sheets smelled like drainage. R1's record did not include a comprehensive assessment of the wound nor notification to the physician of the odorous drainage and the increase in drainage. R1's progress note dated 1/26/26 at 10:05 a.m., identified during R1's dressing change there was a good amount of yellow/green strong odorous drainage with scant amount of blood on the packing gauze that was removed. Wound cleansed with Vashe (not in accordance with physician orders) and then packed both areas of the wound. R1's record did not include a comprehensive assessment of the wound. R1's progress note dated 1/26/26, identified a fax was sent to the primary care physician related to drainage from rectal slit area. R1's progress note dated 1/27/26, indicated a return fax received from primary care physician that incisional concerns need to be addressed with surgical team. R1's record reviewed 1/25/26 through 1/28/26 did not identify the surgery team had been notified of the change in the wound characteristics. R1's Skin Issue assessment dated [DATE], indicated R1's wound had deteriorated since the 1/20/26 when the measurements were documented as 1.2 cm x .72 cm x 3.0 cm in depth. The assessment on 1/27/26 identified the wound measurements were 4.3 cm x 0.88 cm x 7.0 cm depth. Had undermining at 12 o'clock of the wound. With one tunnel that measured 6.0 cm at 6 o'clock. With 10% epithelial tissue, 90% granulation and had heavy serous exudate with a strong odor after cleansing. R1's record did not include an analysis of the deterioration nor evident the care plan was revised to prevent/mitigate the risk of further deterioration. R1's progress note dated 1/29/26 at 9:21 a.m., identified dressing change to surgical wound refused because was going to wound clinic and stated would perform there. R1's treatment administration record (TAR) identified a physician order1/24/26-1/29/26 to perform dressing change/wound pack to pack with 1/2 inch roll gauze. Pack more gauze down towards incision and straight back twice daily and use hydrophilic wound dressing around wound for redness. Cover with ABD. Change outer dressing when saturated. The TAR indicated the dressings were changed per the order (even though Vashe was used) by checked marked boxes with no other documentation other than the nurses' initials who completed the dressing change. R1's general surgery progress note dated 1/29/26, included R1 was seen for a follow for dehisced perineal wound. R1's wound was completely dehisced at this point and extends to 4-5 cm in depth. The remaining nylon sutures were removed. The wound was only packed with a small amount of half-inch gauze which was completely saturated. This was removed and it was repacked with two pieces of dry 4x4 gauze and then covered with ABD and tape. We will relate to R1's facility how to pack the wound and will have R1 to follow up with our wound nurses for continued wound management. In review of R1's record between 1/23/26 through 1/29/26, even though R1's progress notes indicated monitoring was completed by addressing type of drainage from the wound, the documentation did not identify when the wound completely dehisced and when there had been changes to the wound size. During an observation and interview on 1/30/26 at 10:27 a.m. R1 was seated in a recliner on a pillow; however, his hips were not aligned. His right hip was positioned directly on the pillow while the left hip was elevated, resulting in increased pressure to the right side. R1 had a pressure redistribution and/or relieving cushion in his wheelchair with a pillow on top of the cushion. R1 explained he was sitting the way he was because his bottom was uncomfortable, it hurt but there was nothing anybody could do about it. Using the pillow or the cushion was not very helpful for relieving the discomfort. R1 thought he only worked with therapy but once a week. R1 reported he went to his surgeon yesterday (1/29/26), the doctor told him it would take up to two months to heal because the incision opened. When the dressing changes were done it was pretty uncomfortable. R1 stated the last several days he has had a numbing/tingling feeling going down the right leg- the doctors and nurses did not know what the cause was. During an interview on 1/30/26 at 11:09 a.m., R1 stated he was not instructed since admission to not sit on his bottom for a long period of time, until after his first surgical follow-up, R1 would have followed the instructions had he been aware. As an example of length of time sitting, R1 explained after he was admitted to the facility, every morning he would sit in his chair with a pillow on the seat for 45 minutes while he listened to the radio. R1 reiterated since his bottom opened up it was very uncomfortable and had to spend more time in bed laying on his right side. During an interview on 1/30/26 at 1:23 p.m., licensed practical nurse (LPN)-A stated she had begun to work with R1 soon after he had been admitted to the facility on [DATE]. LPN-A explained until after R1's incision began to open up she had not been aware R1 had a surgical incision and had not been aware he was supposed to stay off his bottom. LPN-A then explained she thought prior to the wound dehiscence R1 was independent, she was not aware he needed assistance and agency nursing assistants (NA's) had reported to her that R1 would refuse to reposition, however, did not know why R1 refused and did not re-approach R1 or find out reason for refusals. LPN-A indicated if a resident refused, re-approach and education should be provided. The refusals should be documented in the medical record, however, LPN-A stated there was no documentation that R1 had refused position changes. Since the wound deteriorated R1 was being prompted by staff to stay off his bottom according to the care plan. During an observation and interview on 1/30/26 at 2:30 p.m. R1 was instructed by DON to lie down in his bed to change the dressing to wound. R1 reported a pain rating 7 out of 10 (10 being the worse pain) when he sat and the pain went down into his legs. R1's rectal wound was covered by an ABD dressing dated 1/30/26. DON lifted the ABD to expose the wound cavity that had a pungent foul odor and the packed gauze which was saturated with greyish colored drainage was not to the brim of the wound leaving approximately 1/4 to 1/2 inch of the wound not packed. DON removed the first piece of gauze from the cavity; the second piece of gauze was folded (not fluffed) covered a portion of the wound base. DON stated the gauze should have been pulled apart and the entire wound cavity packed. Inside the cavity at 2:00 O'clock to the 6:00 O'clock position was string of greyish tacky slough, DON mechanically debrided by using gauze to wipe it away. R1 voiced discomfort. DON did not rinse out the wound, re-packed the wound with two pieces of gauze so that the gauze reached the top of the wound. During an interview on 1/30/26 at 2:31 p.m., registered nurse (RN)-A stated she had been cleaning R1's rectal wound with the Vashe cleanser, however, identified the wound care orders did not give specific instructions on what it should be cleansed with. RN-A stated it had been passed on a while ago by someone to clean the wound with the Vashe, but unable to recall who gave her this instruction. RN-A could not articulate what type of cleanser Vashe was nor the indications for use. During an interview on 1/30/26 at 2:44 p.m., RN-B stated she had been cleaning R1's wound prior to repacking with the Vashe solution also that was not ordered by the physician but could not recall who had directed the instruction. RN-B could not articulate what type of cleanser Vashe was nor the indications for use. During an interview on 1/30/26 at 10:36 a.m., R1's colorectal surgeon (CR-S) indicated R1's surgical wound was at risk for dehiscence and not following the aftercare treatment orders could have contributed to the incision failure, it would not have supported healing, but no way to know for sure. CR-S would have expected the aftercare instructions be followed as written to reduce the risk of complications. CR-S stated on 1/15/26 he had seen R1 in clinic for a follow up and identified R1 rectal wound had begun to have a partial dehiscence and instructed the wound to be packed. CR-S further instructed facility staff to ensure R1 remained off of the surgical area for long periods of time. When R1 was seen on 1/29/26 the wound was completely dehisced and was not packed correctly and indicated there was no communication from the facility. The wound did not have enough packing, and it was completely saturated which could lead to wound deterioration I am not sure that the nurses in the facility had been trained properly in wound packing and had to have one of my nurses call the facility to provide some education about proper procedure for that type of wound. During an interview on 1/30/26 at 12:02 p.m., director of nursing (DON) stated she was responsible for putting new admission orders in the resident's electronic health record (EHR), however, must have missed all of the aftercare interventions R1's hospital after visit summary directed. DON added these orders on 1/14/26 but should have been added upon admission. DON stated R1's anal surgical wound should have had a comprehensive wound assessment on admission and weekly after that, however, this had not been completed until 1/15/26 (13 days after admission) after the wound had begun to open up. During a subsequent interview on 2/3/26 at 12:33 p.m., DON stated there was no documentation of monitoring that fully addressed any changes to the wound between assessments since R1 was admitted . Review of the facility's Wound Treatment Management Policy dated 12/25, identified to promote wound healing of various types, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: -Wound treatments will be provided in accordance with physician orders, including cleansing methods, type of dressing, and frequency of dressing change. -In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. -the effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include lack of progression towards healing; changes in characteristics of the wound; changes in the resident's goals and preferences, such as end of life or in accordance with his or her rights.

Based on observation, interview, and document review the facility failed to monitor, comprehensively assess, develop, and implement individualized interventions to prevent/mitigate the risk of pressure ulcers to /or deterioration for 2 of 3 residents (R2, R3) reviewed for pressure ulcers. This resulted in actual harm for R2 who developed an unstageable pressure ulcer on her right heel and stage 3 pressure ulcer on sacrum. Findings include: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable erythema (redness). Stage 2 Pressure Ulcer: Partial thickness skin loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink, or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. Stage 4 pressure ulcer: Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle tendon, ligament, cartilage, or bone in the ulcer. Slough and /or eschar may be visible on some parts of the wound bed. Unstageable pressure ulcer: Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a stage 3 or 4 pressure ulcer will be revealed. Eschar: dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. Slough: non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. Serosanguinous drainage: is a thin, watery fluid that's often slightly yellow and has a light pink tinge that can ooze from a wound as a part of the wound healing process. Moisture Associated Skin Damage: inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, sweat, wound drainage, saliva or mucus. R2 R2's face sheet dated 2/4/26, identified diagnoses of chronic kidney failure, heart failure, atrial fibrillation, and pressure ulcer of right heel. R2's admission Skin Assessment Tool dated 12/24/25, identified both heels have dry skin and a mepilex (foam dressing) on coccyx. R2's Braden Scale Assessment (Pressure Ulcer Risk) dated 12/25/25, identified R2 was at risk for pressure ulcer due to being occasionally moist, unable to make frequent/significant changes independently and had a potential problem with sheer. R2's Braden Scale Assessment did not identify any clinical suggestions to reduce development of pressure ulcers. R2's baseline care plan dated 12/25/25, identified current skin integrity issues of bruising on arms and dermatitis in pannus (apron like fold of excess skin) region. R2's baseline care plan did identify pressure reduction interventions. R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had no rejection of care, dependent for needs to roll left and right, dependent with transfers from surfaces, at risk for pressure ulcers/injuries, did not have any unhealed pressure ulcers/injuries and had a surgical wound. R2 was not on a turning and repositioning program, no nutrition or hydration interventions, and no dressing or treatments to feet. R2's Care Area Assessment (CAA) Worksheet signed 1/6/26, did not include a Brief Interview for Mental Status (BIMS) evaluation. MDS identified R2 had a potential problem related to pressure ulcers, related to a Braden score of 17 and at risk due to decreased mobility, obesity, need for assistance with mobility, incontinence, and oxygen use. R2's CAA identified to proceed to care plan interventions to minimize risks for pressure ulcer development. R2's Skin Issue assessment dated [DATE], did not identify any wounds on R2's right heel or coccyx. R2's progress note dated 1/9/26 at 7:00 p.m., identified R2 had a pressure area on right heel (no stage of pressure area identified). Reddened area measures 4.5 centimeters (cm) x 2.0 cm. Inside the red area is a blue moon shaped area that measured 2.5 cm x 1.5 cm. Cleansed area, applied skin prep and a mepilex (foam dressing) to area. Also put on puffy boots to protect heels. R2's heels floated. The note did not include any further descriptions of the wound characteristics. R2's progress note dated 1/9/26, identified a message sent to physician requesting order for Liquacel (protein supplement) and Arginaid (powered drink to support wound healing) for wound healing. R2's Incident report dated 1/9/26, identified R2's legs were swollen and upon inspection an unstageable pressure ulcer found on R2's right heel. Immediate action to measure area and puffy boots applied to area. R2's provider notification form dated 1/10/26, identified the facility requested an order for puffy boots for protection due to an unstageable pressure ulcer to right heel that had applied mepilex and puffy boots. Measurements of 4.5 cm x 2.0 cm. R2's skin integrity focus care plan initiated on 1/11/26 (two days after identification of the heel ulcer), identified R2 had a potential/actual impairment to skin integrity of the right heel related to a suspected deep tissue injury. Goal to free from deep tissue injury to right heel. Interventions dated 1/11/26 as follows: -Educate resident/family/caregivers of causative factors and measures to prevent skin injury. -Follow facility protocols for treatment of injury. -Keep linen clean, dry, and wrinkle free. Lowest possible head of bed elevation maintained. No shoes only gripper socks until heel wound healed. -Report any signs of skin breakdown. -Pressure relieving/reducing mattress, pillows. Prevalon (boots that have a cushioned bottom that floats the heel off a surface) heel relieving pressure boots to protect skin while in bed and recliner and in wheelchair. -Turn and reposition every 2 hours and as requested to relieve all pressure points, using pillows between legs and along back while in bed and float heels. -Usa a draw sheet or lifting device to move resident. -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. -Use pressure reducing cushion in wheelchair and pressure reducing mattress on bed. Resident sits in personal recliner as needed. In review of R2's record between 12/24/25 through 1/11/26 did not include a comprehensive assessment that determined R2's tissue tolerance to pressure over time and it could not be ascertained how the turning and repositioning of every 2 hours was determined. R2's provider notification form dated 1/11/26, identified an order request to apply skin prep to right heel twice daily to the pressure area on the right heel. R2's physician communication dated 1/12/26 at 9:19 a.m., identified physician order received for puffy boots to be worn for heel protection. R2's physician communication dated 1/12/26 at 9:32 am., identified message sent (to the physician) that R2 was no longer using mepilex dressing due to got too moist and will apply skin protectant and leave open to air and monitor for changes and Prevalon heel protectors are the boots not puffy boots. Although the communication identified a change to the heel wound, R2's record did not include a corresponding comprehensive assessment. R2's physician communication dated 1/12/26, identified an order was received for skin protectant twice daily and Prevalon boots for heel protection. Treatment approved and may change per licensed nurse discretion as needed, please notify any new/worsening conditions. R2's physician orders dated 1/12/26, identified an order for skin protectant to right heel and monitor for healing progression and symptoms of infection every day. R2's Wound assessment dated [DATE], identified R2 had a new stage 1 pressure ulcer to right lateral heel that measured 2.95 cm x 2.77 cm that had dry flaky skin; was normal in color; no edema present. During an interview on 2/3/26 at 2:12 p.m., director of nursing (DON) reviewed R2's corresponding image from 1/13/26 of R2's and identified the assessment as inaccurate. R2's right heel did not have normal color (was dark purple in color) and should have been identified as a deep tissue injury not a stage 1 pressure ulcer. R2's Wound assessment dated [DATE], identified a new wound of an open lesion on the coccyx. Measurement of 5.4 cm x 0.98 cm with 40% epithelial tissue, 40% granulation, and 20% slough; surrounding tissue excoriated (a superficial, partial thickness skin erosion); fragile; treatment of hydrogel and foam dressing. R2's record did not include an order for this treatment. During an interview on 2/3/26 at 2:12 p.m., DON stated R2's Wound Assessment was inaccurate and was identified as an open lesion when it should have been identified an unstageable pressure ulcer to R1's sacrum not coccyx. R2's Wound Care Clinic note dated 1/15/26, identified R2 was seen for consultation for coccyx pressure ulcer. Clinic note identified R2 had a stage 3 sacral pressure ulcer that measured 1.5 cm x 0.7 cm x 0.1 cm. and required debridement (the medical removal of dead, managed, or infected tissue) of devitalized tissue to facilitate healing. Recommendation of a good cushion for wheelchair to prevent skin breakdown. Check lower extremities/feet daily for new wound. Do not walk barefoot/stocking feet. Do not use band-aid on skin unless recommended by provider. Turn and reposition every 1-2 hours and as needed to help prevent skin breakdown. The wound clinic note did not address the right heel pressure ulcer. After R2's wound clinic visit on 1/15/26 there was no indication R2's turning and repositioning schedule reassessed to determine effectiveness of the existing every two hour repositioning program identified in the care dated 1/11/26. R2's physician orders dated 1/16/26, identified an order to wash hands, remove old dressing, cleanse wound bases with Vashe (a hypochlorous acid solution designed for cleansing, irrigating, moistening, debriding, and removing foreign material) or house wound cleanser; apply Plurogel (to wound base; cover with foam bordered dressing; change once daily to coccyx wound. R2's Wound assessment dated [DATE], identified R2 had a stage 1 pressure injury to right lateral heel that was first identified on 1/13/26. Measurements of 2.2 cm x 1.99 cm with no eschar; no drainage; was dry and flaky; cleansed with normal saline; getting mechanical debridement. It had 100% epithelial tissue. During an interview on 2/3/26 at 2:12 p.m., DON reviewed the assessment with corresponding picture of the wound and stated R2's Wound Assessment was inaccurate and should have been identified as a deep tissue injury not a stage 1 pressure ulcer, had four open areas to the wound, and did not have any epithelial tissue. R2's Wound assessment dated [DATE], identified an open lesion on coccyx that was improving; measured 2.12 cm x 1.02 cm; surrounding tissue intact with no drainage. R2's pressure ulcer focus care plan initiated on 1/20/26, identified R2 had an unstageable pressure ulcer on her right heel and a stage 3 pressure ulcer on her coccyx. Goal of having intact skin, free of redness, blisters, or discoloration. Interventions dated 1/20/26 as follows: -Administer treatments as ordered and monitor for effectiveness. -Equacel (a dry -polymer gel cushion designed for pressure management) cushion on wheelchair for pressure redistribution. Air mattress on bed. -Repositioning-has schedule under tasks to assist in turning and repositioning. - The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Arginaid and Liquacel BID. R2's wound management care plan of pressure ulcer on heel initiated on 1/23/26, identified goal of wound to show signs of improvement. Interventions dated 1/23/26 as follows: -Encourage resident to elevate legs. -Evaluate ulcer characteristics. -Measure ulcer at regular intervals. -Monitor ulcer for signs of infection. -Monitor ulcer for signs of progression or declination. -Notify provider if no signs of improvement on current wound regime. -Provide wound care per treatment orders. R2's Wound assessment dated [DATE], identified an unstageable pressure ulcer that presented as a deep tissue injury that was first identified on 1/13/26 (however was first identified on 1/9/26). Measurement of 4.0 cm x 2.0 cm; had intact skin surrounding wound; no dressing; no drainage; treatment of skin protectant. During an interview on 2/3/26 at 2:12 p.m., DON reviewed wound assessment and corresponding image of R2's right heel on 1/27/26 and stated R2's Wound Assessment was inaccurate and did not identify the open areas and the wound with whitish areas in the center. R2's Wound assessment dated [DATE], identified stage 2 pressure ulcer on coccyx; had 100% slough; measurements of 0.27 cm x 0.17 cm; minimal drainage; receiving Vashe wound cleanser and covered with silicone dressing. During an interview on 2/3/26 at 2:12 p.m., DON stated R2's 1/27/26 sacral wound assessment was inaccurate because the wound clinic identified it as stage 3 pressure ulcer on the sacral wound (not coccyx) and should have remained as stage 3 until it was healed. During an observation and interview on 1/30/26 at 4:47 p.m., R2 was seated in her wheelchair in her room with leg rest on her wheelchair, had gripper socks on both feet. R2's right heel was resting directly on the metal part of the pedal of the leg rest. R2 did not have Prevalon boots on and stated her right heel was sore. R2's right heel had a purple discoloration on her right lateral heel approximately 4.0 cm x 2.0 cm in size. R2 then stood up on a sit to stand mechanical lift and there was no dressing (as per physician order) on the coccyx/sacral area. R2 had an open area on the sacral area approximately 0.5 cm x 0.5 cm. NA-D stated she was unaware if R2 was supposed to have the Prevalon boots on when she was in her wheelchair and believed it was only when she was in her recliner or in bed. During an interview on 1/30/26 at 5:15 p.m., DON stated R2 should have a dressing on her coccyx/sacral area per physician order and heel protectors placed on if her feet if the foot pedals were on her wheelchair to help relieve pressure to the heels. DON stated she would update the care plan. R2's care plan had been revised on 1/30/26 to blue heel floating boots on when in bed; heels floated on pillow when in bed and in recliner; do not wear shoes or tight stocking on right foot to prevent pressure until healed. Wear Prevalon heel boots when in wheelchair when foot pedals are on wheelchair. R2's January 2026 Treatment Administration Record (TAR) identified a physician order dated 1/12/26 for skin protectant to right heel and monitor for healing progression and symptoms of infection every day. R2's TAR identified treatment was not completed on 1/22/26, 1/27/26, and 1/30/26. R2's January TAR identified the physician order dated 1/16/26 to wash hands, remove old dressing, cleanse wound bases with Vashe or house wound cleanser; apply Plurogel to wound base; cover with foam bordered dressing; change once daily to coccyx wound. TAR indicated that treatment was not completed on 1/27/26 and 1/30/26. During an observation and interview on 2/3/26 at 10:16 a.m., R2 was seated in her room seated in her wheelchair. R2's wheelchair did not have leg rests on. R2's wheelchair had a cushion on the seat; however, the cushion was hanging approximately 8 inches in front of the seat. R2 stated This cushion has been slipping out from under my bottom all of the time. NA-E entered R2's room and offered place R2 on the commode. As R2 stood the Equagel cushion was only under about 4 inches of her bottom, and the rest of her buttocks were seated on the wheelchair seat with no pressure reduction present. Nursing assistant NA-E stated R2's cushion needed an antiskid pad under the cushion to ensure it did not slip out from under R2. The placement of the cushion was not providing pressure reduction. NA-E then stood R2 up to use the commode and pulled her pants down. R2's coccyx/sacral area did not have a dressing over the open area (as per physician order). NA-E stated she was not aware if the nurses had been putting a dressing over the area and did not recall seeing one. NA-E indicated she was assigned to care for R2 today (2/3/26) and was unable to articulate if R2 was on a turning and repositioning schedule. During an interview on 2/4/26 at 11:35 a.m., registered dietician (RD) stated she was consultant for the facility and would normally review nutrition needs for residents with pressure ulcers, to ensure a supplement was added to promote wound healing. RD stated she had not been informed of R2's pressure ulcers and did not make any recommendations. During an interview on 2/5/26 at 10:34 a.m., nurse practitioner (NP) stated if a resident was admitted to the facility without a pressure ulcer and identified as a high risk for developing pressure ulcers then interventions should be put in place to attempt to prevent a pressure ulcer from developing. R3 R3's face sheet dated 1/30/26, identified diagnoses of hemiplegia and hemiparesis following cerebral infraction, heart failure, and atrial fibrillation. R3's MDS dated [DATE], identified R3 had moderate cognitive impairment, had no rejection of care, dependent to roll left and right, dependent for transfers from surfaces. R3 was at risk for pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries. Skin and Ulcer/Injury treatments included pressure reducing devices for chair and bed and applications of ointments/medications other than to feet. R3's Braden Pressure ulcer risk dated 1/13/26, identified as high risk for pressure ulcer due to having slightly limited to sensory perception, being constantly moist, was chairfast, and completely immobile for mobility, and very poor for nutrition. R3's skin integrity care plan initiated 9/15/22, identified R3 had potential for skin impairment related to fragile skin. Goal that skin will remain clean and intact. Interventions dated 9/15/22 as follows: -Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. -Encourage resident to be mindful of surroundings when self-propelling in his wheelchair to avoid injury. -Keep linens clean, dry, and wrinkle free. Lowest possible head of bed elevation maintained. -Keep skin clean and dry. Use lotion on dry skin. -Report any signs of skin breakdown. -Use pressure reducing cushion in wheelchair and pressure reducing mattress on bed. R3's hospital Discharge summary dated [DATE], identified R3 had been hospitalized [DATE] through 1/13/26 following a stroke. R3's progress note dated 1/13/26 at 12:00 p.m., identified nurse to nurse report was given due to R3 being re-admitted to facility from the hospital. Hospital nurse reported R3's heels a little red and the hospital had been repositioning and floating heels. R3's readmission skin assessment dated [DATE], did not identify any open areas to bilateral heels. R3's skin integrity care plan was revised on 1/13/26 to turn and reposition every 2 hours and as requested to relieve all pressure points, using pillows between legs and along back while in bed and float heels on pillows to protect the skin while in bed. Heel protector boots on when in bed. The review of R3's record did not include a comprehensive assessment that determined R3's tissue tolerance to pressure over time and it could not be ascertained how the turning and repositioning of every 2 hours was determined identified in the care plan dated 1/13/26. R3's Skin Assessment Tool dated 1/18/26, identified R3 had an open area on right heel, area cleansed, and skin prep and dressing applied. Although R3's Skin Assessment Tool identified a skin prep treatment and a dressing had been applied, the assessment did not specify what type of dressing used and there was no corresponding physician order. R3's Skin Issue assessment dated [DATE], identified a new skin issue on right heel. It was a blister that already reabsorbed the fluid. Wound was acquired in house and was painful. Measured 1.14 cm x 1.47 cm. The skin assessment did not include any other wound characteristics. R3's corresponding image of R3's right heel dated 1/19/26, identified R3's heel was red in color and had blister that had not fluid present in it. At the top of the wound had red material and the wound had an irregular shape. Area was macerated in nature. Heel appeared shiny. R3's hospice admission note dated 1/19/26, identified R3 right heel had a 1.0 cm x 1.5 cm blister that had peeled off and was covered with non-adherent dressing and tape. Ensure heels are floated. Treatment order dated 1/19/26 included to cleanse with soap and water, pat dry, and apply mepilex change weekly with bath and as needed. R3's physician orders did not include any treatments to R3's heel as identified in the hospice note dated 1/19/26 until 1/21/26. -Right heel cover with bordered gauze dressing to protect until resolved once daily (Start on 1/21/26 through 1/21/26) -Right heel cleanse with saline apply skin protectant and cover with bordered gauze dressing to protect until resolved once daily (Start on 1/22/26 through1/23/26) -Wound care to right lateral heel twice weekly with baths and as needed. Cleanse open blister with soap and water and dry with towel. Cover with mepilex and re-evaluate with every dressing change. Every Wednesday and Sunday. (Start 1/25/26) R3's Wound assessment dated [DATE], identified a blister on the right lateral heel. Additional information was that blister that had already reabsorbed the fluid. Wound identified as stable; in-house acquired; measurements of 1.14 cm x 1.9 cm; light serous drainage with foam dressing as treatment. R3's corresponding image of R3's right heel wound dated 1/27/26, identified an open blister that encompassed the lateral heel and extended to the back of heel. Wound edges were irregular in shape, and the base of the wound was red skin under the blister. Heel appeared shiny in color. During an interview on 2/3/26 at 2:12 p.m., DON stated R3's right heel wound assessment completed on 1/27/26 was inaccurate and the image appeared like the wound had worsened since the last assessment and should have ensured R3's heels were floated properly. During an observation and interview on 1/30/26 at 11:16 a.m., R3 was lying in bed with a pillow under both legs and had heel protectors on both heels. R3's right heel was resting directly on the air mattress. Hospice registered nurse (H-RN) stated R3's heel should not be resting on the bed to ensure pressure is relieved. H-RN then removed a foam dressing off R3's right heel and stated the lateral heel had a stage 2 pressure ulcer that measured 1.0 cm x 1.7 cm. R3's back of his heel had a new stage 2 pressure ulcer measuring 1.5 cm x 1.0 cm. H-RN stated this was caused by incorrect repositioning and not ensuring R3's heel was floated off the bed. This would be considered avoidable and will continue the same treatment to the right heel for the second wound. Review of the facility's Pressure Injury Prevention and Management Policy dated 5/25, identified the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injury. Policy Explanation and Compliance Guidelines: -The facility shall establish and utilize a systemic approach for pressure ulcer 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.

Based on observation, interview, and document review the facility failed to revise the care plan for 2 of 3 residents (R1, R2) who were reviewed for non-pressure skin concerns and pressure ulcers. Findings includeR1's face sheet dated 1/29/26, identified diagnoses of malignant neoplasm (cancer) of the anal canal. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact, had no behaviors of rejection of care, was independent with bed mobility, needed set up or clean up assistance for transfers, had a recent surgery that required active skilled nursing facility care that involved the gastrointestinal tract, had a surgical wound that did not have any surgical wound care. R1's activity of daily living (ADL) focus care plan dated 1/11/26, identified R1 had a self-care performance deficit related to gastrointestinal surgery. Goal to improve current level of functioning in ADLs. Interventions for transfers dated 1/11/26 as follows: R2 able to transfer with one staff and front wheeled walker, partial assist bed to chair, chair to bed transfers and sitting to standing. R1's Rehab (Therapy) Communication form dated 1/13/26, identified R1 to transfer independent in room with four wheeled walker. During an interview on 1/30/26 at 10:47 a.m., nursing assistant (NA)-C stated she was responsible for caring for R1 today (1/30/26) and believed R1 could be independent in his room but had not verified R1's care plan/Kardex at the beginning of her shift. NA-C verified R1's care plan that he was supposed to be assist of one for transfers. NA-C then found a clipboard with the Rehab communication form that identified R1 changed to be independent on 1/13/26. During an interview on 1/30/26 at 3:19 p.m., director of nursing (DON) stated R1's care plan with transfers stated R1 needed one assist, however, R1's care plan had not been revised in a timely manner to reflect the 1/13/26 physical therapy recommendation to be independent in room with a walker. DON further stated, I just have not had time to update R1's care plan with the new recommendations. R2's face sheet dated 2/4/26, identified diagnoses of chronic kidney failure, heart failure, atrial fibrillation, and pressure ulcer of right heel.R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had no rejection of care, dependent for needs to roll left and right, dependent with transfers from surfaces, at risk for pressure ulcers/injuries, did not have any unhealed pressure ulcers/injuries and had a surgical wound. R2's activity of daily living (ADL) care plan dated 1/6/26, identified R2 had a self-care deficit related to hip fracture as evidenced by documentation of care needs by direct care staff. Goal to improve current level of function in transfers. Interventions for transfers as follows: -toilet transfer: substantial one staff assist with sit to stand mechanical lift (dated 1/20/26) R2's Rehab Communication Form dated 1/26/26, identified that R2 to discontinue the use of the sit-to -stand mechanical lift and transfer with assist of one with gait belt and wheeled walker. During an observation on 2/3/26 at 10:06 a.m., NA-E was placing R2 on the commode. NA-E then grabbed the walker and applied a gait belt to R2. Surveyor intervened and questioned NA-E about R2's transfer status. NA-E stated R2 was assist of one with transfers with gait belt and walker. NA-E verified that R2's care plan identified R2 needed the sit to stand mechanical lift for transfers to the toilet. NA-E stated she verifies how to transfer a resident with the Rehab communication form verses looking at the care plan/Kardex. NA-E then produced a piece of paper that was identified as Rehab Communication that R2 had been changed to assist of one with gait belt and wheeled walker on 1/26/26. During an interview on 2/3/26 at 10:12 a.m., director of nursing stated R2's transfer status had been changed on 1/26/26 from assist of one with the sit to stand mechanical lift to the use of one with gait belt and walker. DON stated R2's care plan still identified her transfer was with the use of the sit to stand mechanical lift, because she had not had time to update the care plan and this should have been done as soon as the therapy recommendation was received. During an interview on 2/4/26 at 1:17p.m., therapy director (TD) stated that when a resident has a change in transfer status, they provide the nursing department with multiple copies of the Rehab Communication form. TD stated her expectation would be for the residents' care plan to be revised as soon as possible after the recommendation was made and that staff are communicated the change. Review of the facility's Care Plan Revisions Upon Status Change Policy dated 12/25, identified it is the policy of the facility to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: -The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. -Procedure for reviewing and revising the care plan when a resident experiences a status change: Upon identification of a change in status, the nurse will notify the nurse manager, the physician, and the resident representative, if applicable.-The interdisciplinary team (IDT) will discuss the resident conditions and collaborate on intervention options. -The team meeting discussion will be documented in the nursing progress notes. -The care plan will be updated with new or modified interventions. -Staff involved in the care of the residents will report resident response to new or modified interventions. -Care plans will be modified as needed by the DON/nurse manager or other designated staff member. -The nurse manager or other designated staff member will communicate care plan interventions to all staff involved in resident's care.

Based on observations, interviews, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 1 of 3 residents (R4) observed for handwashing/hand hygiene during wound care. Findings include:R4's face sheet dated 2/4/26, identified diagnoses of chronic venous hypertension with ulcer, congestive heart failure, diabetes mellitus with foot ulcer, and atrial fibrillation. R4's Baseline Care Plan dated 1/30/26, identified R2 had venous stasis ulcer to bilateral lower extremities. R4's hospital after visit summary dated 1/28/26, identified R4 had orders for wound care to bilateral lower extremities to cleanse with normal saline or wound cleanser, apply nonadherent dressing to any open areas, cover with ABD pads, and secure with Kerlix. R4's physician orders dated 1/29/26, identified an order to bilateral lower extremities to cleanse with normal saline or wound cleanser, apply nonadherent dressing to open areas then cover with ABD pads and secure with kerlix. During an observation and interview dated 1/30/26 at 10:23 a.m., assistant director of nursing (ADON) performed wound care to R4's bilateral lower extremities. ADON had a gown and gloves on and began removing a dressing off R4's left leg, placed the dressing in the garbage, then proceeded to grab a wound cleanser bottle without removing glove or performing hand hygiene. ADON then proceeded to spray the ulcer and then grabbed gauze and patted the wound with the gloved hand. ADON then removed her gloves and applied a new pair of gloves without performing hand hygiene prior to applying the gloves on. ADON then removed the dressing off the right leg and placed the dressing in the garbage. ADON stated she does not need to perform hand hygiene until she is completed the entire dressing change and stated, How am I supposed to do hand hygiene in between when there is not hand sanitizer in the room. During an interview on 2/4/26 at registered nurse at 11:00 a.m., registered nurse infection preventionist (RN-IP) stated hand hygiene should be done prior to entering a resident room, before applying gloves, in between glove changes, and should be done if touching anything considered soiled such as cleaning a wounds and should be done before touching clean wound supplies. Review of the facility's Hand Hygiene Policy dated 11/11/25, identified all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Additional considerations: The use of gloves does not replace hand hygiene. If a task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene should be done after handling items potentially contaminated with blood, body fluids, secretions, or excretions.

Based on observation, interview, and document review, the facility failed to ensure plates, trays, and plate covers were completely dry before storing, and failed to ensure refrigerated food was disposed of timely to prevent bacterial growth and foodborne illness. This had the potential to affect all 18 residents residing in the facility. Findings include: During initial kitchen observation on 6/23/25 at 6:25 p.m., dietary aide (DA)-A was washing dishes. Clean plates, serving trays, and plate covers were lined up air drying near the dishwasher. During observation and interview on 6/23/25 at 7:00 p.m., DA-A had put all dishes away. DA-A was asked to lift two plates, two serving trays, and two plate covers from where they were placed stacked on top of each other on shelves without space between them to allow drainage or air drying. All plates, serving trays, and plate covers observed had visible water droplets on them. DA-A stated she always put dishes away prior to leaving her shift and thought they were dry when she put them away. During further initial kitchen observation on 6/23/25 at 6:25 p.m., DA-A opened an upright Traulson brand two-door refrigerator. A sign on the left door of the refrigerator indicated food needed to be dated when opened and either eaten, frozen, or disposed of by day seven of refrigeration. The refrigerator contained hot fudge dated 6/14/25, and cheese sauce dated 6/9/25. During interview on 6/23/25 at 6:25 p.m., DA-A stated she did not know who was supposed to dispose of food from the refrigerator. DA-A confirmed the hot fudge and cheese sauce was outdated according to the sign on the refrigerator door. During interview on 6/24/25 at 11:50 a.m., dietary director (DD) stated she expected staff to allow dishes to fully air dry prior to putting them away or to stack them staggered so water could drain off and air could flow through. DD stated open food in the refrigerator should have been removed in 7 days if not used for leftovers and she usually checked the refrigerator but had not had time since the weekend. DD stated letting dishes air dry too prevent bacterial growth and removing outdated food was to prevent foodborne illness. During interview on 6/24/25 at 2:00 p.m., registered nurse (RN)-B also known as the infection preventionist, stated not allowing dishes to air dry could lead to bacterial growth. During interview on 6/24/25 at 2:18 p.m., assistant administrator (AA) stated dishes should not be put away wet and should be allowed to fully dry. During interview on 6/24/25 at 9:37 a.m., administrator (A) stated she expected dietary staff to follow direction of DD for drying dishes and food disposal. Facility Dish Machine Policy and Procedure- Use of Dishwasher dated 7/31/24, stated the following: 4. Once dishes have run through cycles in the dish machine, dishes will be placed on the clean side of the dishwasher to air dry. Facility Date Marking for Food Safety dated 3/25/20, stated the following: 1. Refrigerated, ready-to-eat, time/temperature control for safety food shall be held at temperature of 41 degrees or less for a maximum of seven days. 5. The discard day or date may not exceed the manufacturer's use-by date, or seven days, whichever is earliest. The date of opening or preparation counts as day one. 6. The head cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly.

Based on interview and document review, the facility failed to report the potential theft of money to the State Agency (SA) for 1 of 1 resident (R6) reviewed for personal property. Findings include: R6's face sheet received on 6/25/25, included diagnoses of anxiety and depression. R6's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. No indication of psychosis and no behaviors. R6 was dependent upon staff for most activities of daily living. R6's care plan dated 9/28/23, indicated R6 was at risk for potential abuse, neglect, or exploitation from others. R6 would remain free of documented reports of abuse. Staff would report any physical signs, comments by resident, family members of suspected abuse, neglect or exploitation of resident immediately to their supervisor or other entity as needed. During an interview on 6/23/25 at 7:28 p.m., R6 stated she lost $100 in cash about a month ago. R6 stated, I made the mistake of trusting people. R6 stated she put $100 in various denominations in her billfold. While she was out of her room, someone came in and took it. R6 did not know who took it. R6 stated she received the money from family member (FM)-A who got the cash from the bank from her social security payment. R6 stated she kept the cash in a billfold that she kept in the right side pocket of her recliner. R6 stated she talked to social services director (SSD)-A about it. Review of progress notes from October 2024, to current; facility grievances for the past six months, and facility SA reports, revealed no documentation or reporting of the allegation of potential theft. During an interview on 6/24/25 at 12:48 p.m., registered nurse (RN)-A stated she heard something about R6 missing money about two weeks ago. It had not been reported to her and she did not know anything about it. During an interview on 6/24/25 at 12:49 p.m., nursing assistant (NA)-A stated he did not know anything about R6 missing money. During an interview on 6/24/25 at 3:00 p.m. SSD-A stated she was informed of R6's missing money by FM-A on 6/6/25. SSD-A stated she was unaware R6 had a billfold and money in her possession as residents were discouraged from keeping money in their room. SSD-A stated FM-A informed her the cash was in small bills and did not know how the total amount. R6 liked to use the cash to put in greeting cards. SSD-A told FM-A she would investigate and talk to staff. SSD-A stated she was aware of facility policy to report allegations of missing money, but because FM-A told SSD-A she did not want law enforcement notified, nor did she want anything done about the missing money, she did not think it needed to be reported. Attempts to contact and speak to FM-A were unsuccessful. During an interview on 6/25/25 at 8:48 a.m., the assistant administrator (AA)-C, SSD-A and the director of nursing (DON) were informed of findings - failure to report an allegation of potential theft to the SA and to law enforcement. All were aware of the missing money. The DON stated the missing money had been followed up on by SSD-A. AA-C stated he too had talked to R6 and FM-A. FM-A could not recall how much money R6 had; that it had been in small denominations; nor could either R6 or FM-A recall the last time they saw the money. SSD-A again stated she did not think she needed to report because FM-A told her she didn't want anything done about the missing money. Following discussion, SSD-A stated she acknowledged the missing money should have been reported. The Facility Assessment with review date of 4/17/25, indicated every staff member had knowledge competency in abuse, neglect, exploitation, and misappropriation. Training included procedures for reporting incidents of abuse, neglect, exploitation and misuse of resident property. Facility Abuse, Neglect and Exploitation policy dated 4/17/25, indicated alleged violations would be reported to the state agency and all other required agencies (e.g., law enforcement when applicable) within specified timeframes, no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily harm. The administrator would follow up with government agencies to confirm the initial report was received and to report the results of the investigation when final within five working days of the incident, as required by agencies. Facility Reporting Reasonable Suspicion of a Crime policy with review date of 7/2023, indicated examples of situations that would be considered crimes included theft. The facility would do all that was within its control to prevent occurrences of resident abuse, neglect, exploitation, mistreatment and misappropriation of property. That included policies for reporting such incidents.

Based on interview and document review, the facility failed to investigate the potential theft of money for 1 of 1 resident (R6) reviewed for personal property. Findings include: R6's face sheet received on 6/25/25, included diagnoses of anxiety and depression. R6's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. No indication of psychosis and no behaviors. R6 was dependent upon staff for most activities of daily living. R6's care plan dated 9/28/23, indicated R6 was at risk for potential abuse, neglect, or exploitation from others. R6 would remain free of documented reports of abuse. Staff would report any physical signs, comments by resident, family members of suspected abuse, neglect or exploitation of resident immediately to their supervisor or other entity as needed. During an interview on 6/23/25 at 7:28 p.m., R6 stated she lost $100 in cash about a month ago. R6 stated, I made the mistake of trusting people. R6 stated she put $100 in various denominations in her billfold. While she was out of her room, someone came in and took it. R6 did not know who took it. R6 stated she received the money from family member (FM)-A who got the cash from the bank from her social security payment. R6 stated she kept the cash in a billfold that she kept in the right side pocket of her recliner. R6 stated she talked to social services director (SSD)-A about it. During an interview on 6/24/25 at 03:00 p.m., social services director (SSD)-A, who was responsible for investigating and documenting allegations of theft, stated she was aware of the allegation of R6's missing money and had investigated it. When asked to see documentation of the investigation, SSD-A provided the following: Writer was informed at 230 on June 6th that R6 had money missing by family member (FM)-A. She was unsure of the amount only that they were smaller bills. Writer spoke with licensed practical nurse (LPN)-A, nursing assistant (NA)-C, NA-B and LPN-B about the missing money. LPN-A said that she had seen the wallet out on Thursday, and was surprised because she didn't know she had one here. LPN-B also said she saw it on Thursday. The rest had not seen it they told writer. FM-A said I told her not to have money here but she doesn't listen. She uses the cash for putting in cards. FM-A said she did not want the police involved and did not want anything done, as she knew that R6 shouldn't have cash. Writer did remind her of the trust account. She said I know. The notes were typed on a half sheet of paper, not dated, nor authenticated with the name and title of the author. R6's last name wasn't identified, nor was the name of FM-A. Staff were identified by first name only and no titles. SSD-A verified it had been written by her. Upon continued interview, SSD-A stated she only documented the interview of four nursing staff. A laundry staff interview was not documented, nor was a conversation with the maintenance director who told her he had not seen anything. SSD-A admitted she had not talked to housekeeping staff, activities staff, or other employees who may have been in R6's room and/or who may have seen something. SSD-A admitted she had not interviewed residents to determine if they were missing money or other personal property. SSD-A stated she interviewed R6, but did not document it. SSD-A stated the facility did not have cameras to view activity going on in hallways. SSD-A stated R6's room was searched and no money was found. During an interview on 6/25/25 at 8:48 a.m., the assistant administrator (AA)-C, SSD-A and the director of nursing were informed of findings - failure to investigate an allegation of potential theft. All were aware of the missing money. The DON stated the missing money had been follow-up on by SSD-A. AA-C stated he too had talked to R6 and FM-A. FM-A could not recall how much money R6 had; that it had been in small denominations; nor could either R6 or FM-A recall the last time they saw the money. SSD-A admitted her investigation of the potential theft of R6's money was not thorough, nor was the documentation of her investigation. The Facility Assessment with review date of 4/17/25, indicated every staff member had knowledge competency in abuse, neglect, exploitation, and misappropriation. Training included procedures for reporting incidents of abuse, neglect, exploitation and misuse of resident property. Facility Abuse, Neglect and Exploitation policy dated 4/17/25, indicated an immediate investigation would be warranted when suspicion of abuse, neglect or exploitation, or report of abuse, neglect or exploitation occur. Written procedures for investigation include identifying staff responsible for the investigation, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who may have knowledge of the allegation. Provide complete and thorough documentation of the investigation.

Based on interview and document review, the facility failed to accurately code antipsychotic medication use on Section N of the Minimum Data Set (MDS) for 1 of 5 residents (R16) reviewed for unnecessary medications. Findings include: R16's quarterly Minimum data set (MDS) assessment dated [DATE], indicated no cognitive impairment, diagnoses included schizophrenia diagnosis of diabetes mellitus, and indicated R16 did not receive antipsychotic medications since admission/entry. R16's care plan dated 4/29/25, indicated R16 received an antipsychotic medication olanzapine (antipsychotic medication used to manage symptoms of mental health conditions) for management of schizophrenia. R16's medication administration record (MAR) dated 4/1/25-4/30/25, indicated olanzapine oral tablet 20 mg (milligrams) give 1 tablet by mouth at bedtime related to schizophrenia. On 6/24/25 at 3:46 p.m., the director of nursing (DON) confirmed that she completed R16's MDS dated [DATE], and confirmed section N was inaccurately coded and should have indicated R16 was receiving an antipsychotic medication. The DON stated accurately coding the MDS was important because it reflected the plan of care for the resident. Facility Conducting an Accurate Resident Assessment policy 3/25, indicated : The represent the policy is to assure that all residents receive an accurate assessment reflective of the resident status at the time of assessment by staff qualified to assess relevant care areas, The appropriate qualified health professional will correctly document the residents medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status.

Based on observation, interview, and document review, the facility failed to ensure a fan blowing directly on clean dishes was free of dust and debris. This had the potential to affect all 18 residents residing in the facility. Findings include: During initial kitchen observation on 6/23/25 at 6:25 p.m., dietary aide (DA)-A was washing dishes. Clean plates, serving trays, and plate covers were lined up air drying near the dishwasher. A small oscillating fan was turned on and blowing directly on the clean, wet dishes. The fan had visible dust and debris on the blades and surrounding cage. During observation and interview on 6/23/25 at 7:00 p.m., DA-A had put all dishes away. DA-A stated the fan was very dirty and probably should not have been blowing on the clean dishes. DA-A stated she was unaware of who was responsible for cleaning the fan or when the fan had last been cleaned. During interview on 6/24/25 at 11:50 a.m., dietary director (DD) stated was not aware the fan had gotten that dirty and thought it had just been cleaned last week. DD stated when the air conditioner ran it caused more build-up on the fan. DD stated she did not want the fan there and it had been removed. DD stated letting dishes air dry and not allowing the dirty fan to blow on clean dishes was to prevent bacterial growth. During interview on 6/24/25 at 2:00 p.m., registered nurse (RN)-B also known as the infection preventionist, stated she was not aware a fan was blowing on the clean dishes and did not think that was allowed. RN-B stated she did not know if there was a cleaning schedule for the fan and she would prefer if the fan was removed to prevent spread of infection in the kitchen. During interview on 6/24/25 at 2:18 p.m., assistant administrator (AA) stated he was not aware there was a dirty fan blowing on clean dishes but had been made aware of it and thought the fan should be removed from the clean dish area. During interview on 6/24/25 at 9:37 a.m., administrator (A) stated she expected dietary staff to follow direction of DD for drying dishes and fans. Facility Dish Machine Policy and Procedure- Use of Dishwasher dated 7/31/24, stated the following: 4. Once dishes have run through cycles in the dish machine, dishes will be placed on the clean side of the dishwasher to air dry. No air circulation assistive devices (i.e. fans) will be used in the dish drying area.

Based on observation, interview, and document review the facility failed to comprehensively assess, monitor, and provide interventions to prevent pressure ulcer development, promote healing, and prevent deterioration for 1 of 3 residents (R3) who had pressure ulcers. The facility's failures resulted in harm when R3 developed a stage 2 pressure ulcer (PU) that deteriorated to a stage 3. Findings include: STAGING Staging of a PU/PI is performed to indicate the characteristics and extent of tissue injury, and should be conducted according to professional standards of practice. Determining whether damage to the skin and underlying tissue is a PI or PU depends on the staging of the damaged tissue. Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable UP/PI. R3's face sheet dated 4/23/25, identified diagnoses of edema (swelling caused by excess fluid). R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had no memory issues, did not reject cares, was dependent on staff for putting on and taking off footwear, R2 was at-risk for pressure injuries but did not have any. R3's care plan dated 3/25/25, identified R3 had a whirlpool bath weekly and required 1-2 staff to assist with bathing. The care plan identified a potential for skin impairment dated 10/13/23, identified interventions of Braden risk assessment, keep skin clean and dry, report any signs of skin breakdown, weekly treatment documentation to include measurement of each area of skin breakdowns width, length, depth, type of tissue and exudate and any other notable changes or observations. R3's podiatry evaluation dated 12/17/24, identified there was a small stage II ulceration to the right medial 4th toe. An offloading pad/dressing was applied. Keep the right foot dry in the shower and sponge bathe for now. Offload the area, keep dressing intact. If dressing falls off apply iodine, gauze and kling daily. Return to clinic in 3-4 weeks or sooner if problems arise. An addendum to the note on 12/17/24, identified R3's family did not want to transport R3 to the clinic and preferred the facility to treat the wound. Therefore, requested the nurse dressing daily, (but) wait to removal of initial dressing for two weeks. Then cleanse the ulcer daily and apply iodine, gauze, kling and paper tape. Keep the foot dry in the shower and sponge bathe until the ulcer is healed. Call the office with any questions of if the ulcer is getting worse or not healing for an appointment or go to the nearest hospital. Review of R3's progress notes dated 12/17/24 through 12/31/25 did not identify the dressing was left in place for two weeks as ordered. According to R3's treatment administration record the order for daily wound care dated 1/1/25 was discontinued on 1/2/25; R3's record did not include an assessment and/or documentation the wound had healed. During an interview on 4/23/25 at 1:39 p.m., licensed practical nurse (LPN)-B stated she could not remember if she discontinued the treatment on 1/2/25 but recalled that a dressing had been in place between the 3rd and 4th toes. They were told to monitor and after a couple of days to take the dressing off and discontinue the order. LPN-A stated when the order was discontinued on 1/2/25, the area did not appear healed. The area was scabbed over but not macerated. R3's toes were always puffy and so was her foot so ace wraps were used. R3 had a weekly bath and the NA's (nurse aides) got her feet in there to let them soak. LPN-B observed her skin after the bath but had not looked between the toes where the UP/PI was located. R3's bath skin assessment dated [DATE], identified a handwritten note that stated toe in parenthesis. R3's record did not identify a wound assessment was completed on the pressure ulcer between the 3rd and 4th toes of right foot between 12/17/24-4/21/25. R3's podiatry evaluation dated 4/22/25, identified stage III pressure ulcer to the medial right 4th toe, with maceration, no signs of infection. Debrided the ulcer at visit. Orders included to cleanse ulcer daily with saline damp gauze, dress daily with iodine, gauze, kling, and paper tape. Keep dry in the shower. Follow-up in the office in four weeks, call with questions or concerns. Add one package of Arginade per day. R3's progress note dated 4/22/25 at 9:01 a.m., identified podiatry was in house and ordered right medial 4th toe ulcer to cleanse daily with saline damp gauze, apply iodine, gauze, kling, and paper tape. Keep dry in the shower and follow up in four weeks. Add one packet of Arginade daily. At 9:59 a.m., spoke with family member (FM)-B in regards to the pressure injury worsening and the risks involved with wounds of the sort and difficulty of healing. Daughter requested to continue treating at facility. R3's care plan dated 4/23/25, identified pressure ulcer on the medial aspect of right 4th toe related to immobility and edema. Interventions included to measure length, width, and depth where possible, document wound perimeter, wound bed and healing progress. Report improvements and declines to medical doctor. Due to difficulty of visualizing the wound for proper assessment, do dressing change and assessment when lying in recliner or bed. If unable to get right toe gauze to stay in place, apply lambs wool between 4th and 5th toes of right foot instead but it is important to cushion with one or the other. R3's weekly wound observation tool dated 4/23/25, identified pressure ulcer stage III to right 4th toe webbing acquired at facility. Wound had begun as a stage II. Wound tissue was moist with 100% slough (dead tissue presents soft, yellow, or white) present. No odor or drainage present. Wound measured 0.3 centimeters (cm) x 0.4 cm x 0.2 cm depth, depth approximate due to slough covering wound and unable to see base of wound. Surrounding skin is macerated (moist) and erythematosus (red). 4+ edema on top of right foot, fluid filled thin skin, 3+ edema in right mid-calf to knee. Inflammation is present with redness and discomfort at wound site. Treatment included to cleanse the ulcer with saline damp gauze, apply iodine, gauze, cling, and secure with paper tape. Keep dry in the shower. Updated order included that iodosorb (iodine gel primarily used to clean wounds and promote healing) could be applied to wound bed and lambs wool in between toes if gauze does not stay in place. Do not wrap multiple toes together to avoid added pressure. R3's progress note dated 4/23/25, identified right foot 4th digit wound assessed and dressing completed. Wound is in the web of fourth and fifth digit, difficult to dress. Notified podiatry of difficulty dressing and ease of unintentional removal of dressing with sock, ace wraps, and slippers on/off. Do not wrap toes together as this could compromise wound be adding additional pressure. Additional orders received for wounds and tentative appointment scheduled. Dressing changed to bedtime so foot is not dependent and wound would be easier to visualize. During an interview on 4/23/25 at 11:18 a.m., R3 was sitting in her wheelchair with her feet on the floor and wearing slippers. R3 stated she had her toes looked at on 4/22/25 by podiatry and they saw a sore on her toe. R3 thought she had the sore for awhile. R3 did not think the nurse had changed the dressing today. During an interview on 4/23/25 at 11:22 a.m., licensed practical nurse (LPN)-A stated skin is checked weekly after showers. The nurse will look at bruises, open skin, and dressings. LPN-A reviewed R3's medical record and did not see anything identified as a pressure ulcer. During am interview on 4/23/25 at 11:28 a.m., nursing assistant (NA)-B stated R3 had the toe wound since 4/18/25. The dressing is not on right now since R3 just had a bath. NA-B would notify the charge nurse for any wounds. During an observation on 4/23/25 at 1:14 p.m., registered nurse (RN)-A entered R3's room to complete wound care. R3 was sitting in a wheelchair with her feet dependent on the floor. R3 stated the wound does not hurt. RN-A removed the ace wrap that was on R3's leg from toes to calf. There was +4 pocketed edema on the top of right foot. No dressing was on the pressure ulcer to remove. The 4th toe was red and the wound is located inside on the web of the toe in between the middle toe and fourth toe and going up a little of the 4th toe. It measured 0.3 cm x 0.4 cm. unable to determine depth as the wound was covered in a white substance. RN-A stated she could smell an odor during the dressing change. R3 stated it tickled but did not hurt. RN-A explained all of R3's toes had a large amount of edema and were pressed together and difficult to separate to see between. During an interview on 4/23/25 at 3:44 p.m., NA-D stated she discovered R3's toe on 4/18/25. The wound was between the toes. The toes were really red, swollen, and warm to touch. NA-D had not noticed it before. The nurse put triple antibiotic ointment on the wound and NA-D reported the area in the shift to shift report and told the oncoming staff about it. During a subsequent interview on 4/24/25 at 8:42 a.m., NA-B stated R3's sore had been there but it had not been open like it was currently. It opened again on 4/18/25. NA-B described the wound as a scab prior to 4/18/25. During an interview on 4/23/25 at 5:06 p.m., RN-B could not recall a pressure ulcer on R3's 4th toe. RN-B stated most of the wound treatments are done on the day shift and if a treatment is required the TAR would reflect it. During an interview on 4/24/25 at 9:05 a.m., RN-A stated a stage II pressure ulcer presenting with a scab over it would not be considered healed and would be troublesome as it would be eschar tissue. RN-A took over the wound treatments for the facility the week of 4/15/25, and had not been aware of the pressure ulcer until the podiatry noted it on 4/22/25 during their rounds. During a follow-up phone interview on 4/29/25 at 1:56 p.m., RN-A verified that R3's pressure ulcer is between the third and fourth toes, not the fourth and fifth toes as was documented. During a phone interview on 4/29/25 at 8:44 a.m., medical doctor (MD)-B stated the stage II pressure ulcer is the same location as the stage III pressure ulcer. The wound is the same width and diameter but appeared a little bit deeper on examination 4/22/25 compared to 12/17/24, when MD-B last saw it. There were no dressings on the wound prior to MD-B's examination. MD-B's expectation was that the facility would follow the order to not get the foot wet. The water just gets trapped between the toes due to the size of her toes. MD-B had not had any communication with the facility on R3's pressure ulcer in between 12/17/24 and 4/22/25. During an interview on 4/24/25 at 10:36 a.m., director of nursing (DON) stated wounds should be assessed at a minimum weekly and measurements included. If a wound was healed it would be documented in the progress notes, weekly wound assessment or the skin assessment tool. There was not a protocol in place to monitor a wound for any specific amount of time after it healed, only that the floor nurses should be aware of the healed wound and lay eyes on the location on weekly bath assessments. It was determined that R3's pressure ulcer had healed in January, but no documentation on the wound being healed. If the wound had a scab over it, the wound would be considered unstageable and not healed. The nurses were to communicate to the NA's that R3's right foot was not to get wet. It is the expectation that nurses look between resident toes on bath days. The facility Wound Treatment Management policy revised 4/2025, identified to promote wound healing of various types of wounds, the facility would provide evidence-based treatments in accordance with current standards of practice and physician orders. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include lack of progression towards healing, changes in wound characteristics, and changes in resident goals and preference. The facility Foot Care Skin Integrity policy dated 4/2025, identified the residents receive proper treatment and care to maintain mobility and good foot health. The risk assessment will include a comprehensive assessment to identify additional risk factors or conditions that increase risk for impaired foot skin integrity. Medical conditions will be managed and interventions implemented in accordance with professional standards of practice to prevent complications of medical conditions. The attending physician will be notified of the presence, progression towards healing, or lack of healing of any foot ulcers, or any changes in a residents medical condition.

Based on interview and document review, the facility failed to comprehensively assess and monitor for change in condition following computer tomography with contrast dye to ensure appropriate and prompt treatment for 1 of 1 residents (R1) who was at risk for acute renal failure. Additionally based on observation, interview, and record review the facility failed to comprehensively assess, monitor, and treat wounds for 1 of 1 residents (R2) reviewed for non-pressure skin concerns. Findings include: R1's quarterly minimum data set (MDS) dated [DATE], indicated R1 had intact cognition and was dependent on staff for all dressing, toileting, personal hygiene, transfers, and mobility with wheelchair. Further identified R1 had diagnoses that included hemiplegia following a cerebral vascular accident (CVA), heart failure, renal (kidney) failure, diabetes mellitus (inability to regulate blood sugars), dementia, and morbid obesity. The MDS also identified R1 was at risk for pressure ulcers. R1's care plan dated [DATE], identified R1 had a provider order for life sustaining treatment (POLST) which include a do not resuscitate (DNR) and do not intubate (DNI) but did accept intravenous, oral, and intramuscular antibiotics. R1's care plan identified R1 was at risk for infections; had a self-care deficit requiring staff assistance; was resistive to care at times; had behavior problems toward staff; was at risk for falls; at risk for constipation; high risk for respiratory infections; on antidepressant medications; on anticoagulant (blood thinning) therapy; potential nutritional problem; an ulcer between 3rd and 4th toes; at risk for pain; high risk for skin breakdown; bladder incontinence; and at risk for potential abuse and neglect. R1's care plan did not identify management and/or risk of congestive heart failure or renal failure A physician order dated [DATE], identified R1 to drink 5 six to eight ounce glasses of water daily in preparation for a dye study to protect the kidneys. R1's Medication Administration Record (MAR) for [DATE] indicated on [DATE] an order was entered to encourage resident to drink at least ,d+[DATE] eight-ounce glasses of water daily in preparation for a dye study to protect his kidneys. The MAR did not contain any monitoring of oral fluid intake. The MAR also noted, and order started on [DATE] and discontinued on [DATE], to monitor VS two times a day; if O2 sat not maintained above 90% or fever develops patient needs to be seen. The MAR also identified an order entered on [DATE] to monitor for vitals two times a day for infection. This order entry identified R1 had an elevated temperature of 99.3 degrees (F). R1's record did not identify a physician was notified of an elevated temperature. R1's physician order dated [DATE], included weight one time daily for congestive hear failure. The order did not identify parameters in which the physician was to be notified for weight gain/weight loss. R1's daily weight log indicated R1 weighted 325 pounds on [DATE] and 334.5 pounds on [DATE] which was an increase of 9.5 pounds in a month with no documentation of physician notification of the increased weight and no evidence of further assessment of the weight gain to identify if the gain was related to fluid or nutritional related. R1's progress notes identified the following: [DATE] and [DATE], indicated R1 was out for appointments and returned with diagnoses of recurrent renal cell carcinoma with level two tumor thrombus (tumor extension into a vessel). [DATE] at 12:15 p.m., sent a physician request form to provider to request Mucinex and (as needed) prn neb [nebulizer]. [R1] present cough with mucus and complains of chest pain. COVID was negative. [DATE] at 2:03 p.m., family member (FM)-A would like [R1] watched closely to see if he needs an antibiotic. Mucus clear and does not have a fever. [DATE] at 3:10 p.m., received orders for DuoNebs (inhaler) and Mucinex (loosens congestion) prn and monitor VS (vital signs) and needs to be seen if fever or [oxygen] sats (saturations) below 90%. [DATE] at 5:30 a.m., temp. (temperature) 100.1 [degrees F]; oxygen sats 90% when lying down and 95% when sitting up on room air. Cough very loose. 7:39 a.m., called daughter and she wanted provider contacted. R1 was swabbed for RSV (respiratory syncytial virus) and FLU (influenza). 7:16 p.m., R1 tested negative for RSV, FLU, and COVID. [DATE] at 11:19 p.m., updated provider and received order for Zpak (used to treat bacterial infections). [DATE] at 11:45 a.m., R1 does not have as frequent of a cough and cough is not as moist and congested, afebrile (no fever). [DATE] at 8:11 a.m., writer reported to the nurse that she thought resident was full of fluid and needed to go to the hospital. [DATE] 11:31 a.m., resident awake since 4am [4:00 a.m.]; at 7 am R1 asked to lie down in bed and indicated not feeling well; temperature 99.3 [F], did not want breakfast, had chills, lungs [sounds] slightly diminished in bases. Documentation did not indicate provider was notified of change in condition and no further progress notes on [DATE]. [DATE] at 5:38 a.m. R1 awake at 1a.m., taken CPAP (continuous positive airway pressure machine to treat sleep apnea) off and refused to allow it back on, oxygen sats 93% on room air. [DATE] at 10:35 a.m., [R1] assessed as he seems to be worse; audible wheezing and wet non-productive cough. O2 (oxygen) sats ,d+[DATE]% on room air. R1 stated he feels like shit and just might die. R1 had been eating and drinking minimally. Family in agreement to sent to ED. [DATE] at 7:14 p.m. R1 going to ICU (intensive care unit). R1's kidneys are shutting down and there is acid in his blood. R1's hospital Admission Note dated [DATE] at 11:23 p.m., identified R1 transferred to higher level of care hospital due to severe Acute Kidney Injury (AKI) and concern for need of urgent dialysis (filters waste and excess fluid from the blood). The Admission Note further indicated the etiology for R1's AKI differential includes mainly contrast [dye]-induced, and R1's cough and dyspnea are likely consequences of the fluid overload caused by the renal [kidney] failure. R1's death certificate indicated R1 died on [DATE], in the hospital due to acute and chronic kidney failure. During an interview on [DATE] at 5:00 p.m., FM-A identified R1 had at CT with dye contrast on both [DATE] and [DATE] and was told that R1 should have adequate fluid before and after the procedures to prevent kidney damage but, was not aware of the fluid order that was written on [DATE], and did not know if the facility was monitoring it. FM-A further identified R1 had a CT scan with dye on [DATE] and because of the findings, was asked to return for a second CT scan on [DATE] and R1 was already feeling sick by then. Reported R1 became really sick by the weekend (two days after the CT scan). FM-A asked RN-C to send him to the emergency department for evaluation but was told by RN-C that R1 did not have a fever, and they would not do anything for him until R1 developed one. FM-A stated during a visit on [DATE], a facility nurse (unsure which one) reported R1 was better and decided to wait one more day to have R1 seen by a provider. The next day, a different nurse called and stated R1 needed to be sent to the ED for evaluation and treatment. FM-A indicated she expected facility staff to be monitoring R1 more closely than they were. During an interview on [DATE] at 12:15 p.m., nursing assistant (NA)-A identified working with R1 the days prior to R1's hospitalization . On those days, R1 was wheezing a lot but was told R1 had a cold or something. NA-A was not aware R1 had any wounds or pressure areas for R1. During an interview on [DATE] at 9:30 a.m., NA-B identified R1 was more rude and disrespectful then normal for a couple of days before he went to the hospital. NA-B stated he was not feeling well, was more wheezy, appetite had decreased, not sleeping well, and was hard for us [staff] to get him to eat or drink anything. NA-B further identified she notified nursing staff and thinks they were checking on him more frequently but was not sure what the nurses were doing for R1. NA-B indicated staff were not monitoring R1's fluid intake or urine output. During an interview on [DATE] at 12:41 p.m., NA-C identified the nurses did not communicate to any of the staff about any need to increase R1's fluids and did not know that R1 should have had fluid intake monitored before and after the CT scan, and did not know that the CT scan could have put R1's health at risk further. R1 got sick with cold symptoms right after the CT scan. On [DATE], NA-C reported to RN-B that R1 was full of fluid, chest was full, stomach felt like rubber and was tight. RN-B told her the ED would not do anything for R1 because R1 was already on an antibiotic and nebulizer treatments. NA-C did not know whether RN-B further assessed R1 or not but in the morning of [DATE], R1 looked even worse and further described R1 was full of fluid, chest was rattling, having a hard time breathing, and appeared in a lot of pain. NA-C further reported that R1 told her that he had never felt that bad. NA-C then reported to RN-A and then RN-A assessed R1 and sent him to the ED. During an interview on [DATE] at 1:40 p.m., licensed practical nurse (LPN)-C indicated if a resident is on a physician ordered fluid intake or restriction, it should be on the MAR and would be measured and monitored but did not know of any resident's that the facility had been monitoring for fluid intake or restriction within the past few months. If there is a change in condition, the nurse should immediately assess and document in the progress notes that the nurse notified the family and provider of the change. LPN-C denied working with R1 during the days prior to his hospitalization so was not sure of R1's condition. During an interview on [DATE] at 9:40 a.m., LPN-B identified being familiar with R1's cares but did not know he was to be monitored for fluid intake and did not know anything about R1 having CT scans done. LPN-B further identified R1's cough did not get any better so notified family and they requested antibiotics, the physician was notified and ordered antibiotics and did infection monitoring on R1 every shift (included monitoring temperature, pulse, respirations, pain, and oxygen level) but although R1's vital signs were stable, R1 did not get any better and one of the RN's from the office sent R1 to the ED, R1 was hospitalized , and died . During an interview on [DATE] at 11:32 a.m., social service designee (SSD) indicated [nurse] charting could be better so everyone could know what is happening with the residents. During an interview on [DATE] at 3:05 p.m., registered nurse (RN)-A indicated not seeing R1 for a week prior to [DATE] and was asked to assess R1 for change of condition. RN-A noted R1 to have respiratory wheezing that was audible immediately entering the doorway and was dusky in color, with R1 stating he felt like he was going to die. RN-A notified family and arranged for ED transfer. RN-A also indicated an order was entered into the computer as encourage to drink instead of drink and no documentation was entered for tracking how much fluid R1 had consumed prior to or after the CT scans. During an interview on [DATE] at 3:45 p.m., the director of nursing (DON) indicated she received and transcribed R1's order for on [DATE] but instead of drink five ,d+[DATE] ounce glasses of water a day prior to the CT scan, transcribed the order as encourage five ,d+[DATE] ounce glasses of water a day and verified there was a difference in the interpretation of drink and encourage. The DON also stated she should have transcribed the order exactly as written, monitored the amount of fluids R1 had consumed, and communicated that amount to the provider that ordered the CT scan. The protocol for recognizing a change in condition is the nursing assistants (NA)'s inform the nurse and then nurse is to do an assessment of vital signs, oxygen level, lung sounds for respiratory, overall condition. If needed, the nurse would call the family to see if the resident should go in [clinic or ED] to be evaluated. If not, we would call or fax the doctor. The DON indicated R1 had a big change in condition on [DATE]-[DATE], when R1 developed a fever and lung sounds slightly diminished. We [facility nurse] got an order for nebulizer and Mucinex and he should have been monitored daily. The DON indicated vital signs were put in R1's MAR but lung sounds, or edema is not routinely checked unless the nurse felt it was something that needed to be done. The DON further identified R1 asked to go to the ED on [DATE] but R1 seemed to be the same as the day before so did not send him. The DON confirmed there was no documentation about R1's condition change until the next day ([DATE]) when R1 transferred to the ED. The DON stated she would have expected to see more [progress] notes than there were. R2 R2's face sheet dated [DATE], identified diagnoses of presence of right artificial hip joint (replacement of artificial parts for bone), and infection and inflammatory reaction due to internal right hip prosthesis (infection and inflammatory reaction that occurs around a joint replacement implant). R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had some cognition issues, no behaviors, independent with activities of daily living, and used a walker for mobility. R2's care plan dated [DATE], identified potential for skin breakdown. Interventions included weekly treatment documentation to include measurement of each area of skin breakdowns width, length, depth, type of tissue and exudate and any other notable changes or observations. R2's care plan did not identify any specific areas of skin concern. R2's physician notification form with approved order dated [DATE], identified R2 had an open wound on back of right hip that measured 2.0 cm x 1.0 cm. looked like a pressure sore from hip being pressed on side of recliner. Orders to clean and cover with mepilex (name brand of a foam absorbent dressing) until resolved. R2's progress note dated [DATE], identified R2 took off mepilex and noted drainage coming from gluteal fold. Serosanguineous drainage, wound edges intact, wound bed is reddish surrounding yellow/whitish in the middle of the wound. Measurements are 1.5 cm x 1.0 cm x upper part of the wound 0.8 cm depth and lower part is 0.5 cm depth. Cleansed, applied mepilex with hydrogel. R2 had no pain with the only complaint being itchiness. At 10:42 a.m., R2 stated he did not want a big dressing on his wound. Informed R2 he had more drainage at night and the bigger foam should help. Refused hot pack prior to dressing change. R2's skin observation tool dated [DATE], identified a skin abnormality to right gluteal fold, type of wound was pressure stage III with measurements of 1.5 cm x 1.0 cm x depth of 0.5 cm and 0.8 cm. Applied hydrogel and mepilex after cleansing. R2's progress note dated [DATE] at 8:30 a.m., identified there are no wounds on buttocks or gluteal fold. Only wounds are on right hip area. The lower wound is located at the top of an old hip surgery incision, area is a hole which the wound bed is located at the base of the hole and the skin up the edges of the hole and top of the hole are normal color, intact skin with no maceration. Wound bed which only covers the base of the hole measured 1.0 cm x 1.5 cm and 0.1 cm depth. 85% red beefy tissue and 15% yellow slough. The other wound which is located about 1XXX,d+[DATE].5 inches above the other wound is 0.5 cm x 1.0 cm and 0.2 cm depth with yellow/pink wound bed. R2 did not have the wounds covered and stated he took it off because it bothers him and makes him itch. Noted an area of serous drainage on pants about the size of an orange. Will fax MD-A for change in treatment as there is too much drainage for silver hydrogel to be effective. At 11:14 a.m., order obtained to change treatment to calcium alginate to wound bed, after cleansing with wound cleanser apply skin protectant to surrounding skin and cover with mepilex daily. R2's physician notification form with approved order dated [DATE], identified R2 continues to have a large amount of drainage to wound on right outer buttock. May we change to calcium alginate after cleansing with wound cleanser and skin protectant to surrounding skin and cover with mepilex. Response was ok to wound treatment changes. R2's skin observation tool dated [DATE], identified open area on right buttocks still has small pinpoint opening below skin bubble that sticks out. Dressing was saturated with sanguineous (blood mixed with yellow liquid) fluid. No redness or signs of infection. No measurements provided. R2's record did not identify weekly skin evaluations with measurements on [DATE]. R2's skin observation tool dated [DATE], identified wound care being done to right hip region. No measurements, type of wound or drainage provided. R2's progress note dated [DATE] at 9:40 p.m., identified changed dressing to ulcer on buttocks. Continues to be the same, not healing but not worse. R2's skin observation tool dated [DATE], identified pinpoint open area that drains serous fluid on right hip has 0.4 cm high skin growth next to open area. No measurements or type of wound provided. R2's progress note dated [DATE], identified dressing change to right hip area after a warm pack for 15 minutes. Small amount of drainage with no odor. R2's skin observation tool dated [DATE], identified pinpoint area that drains serous fluid on right hip has 0.4 cm high skin growth next to open area. No measurements or type of wound provided. R2's record did not identify weekly skin evaluations with measurements on [DATE], and [DATE]. R2's progress note dated [DATE] at 11:36 a.m., identified wound on right hip is no longer open, is fully covered with normal color skin and no drainage. R2's progress note dated [DATE] at 12:15 p.m., identified area on right hip that was resolved is now open again and measured 0.2 cm x 0.3 cm x 0.3 cm water blister noted below open area. Moderate amount of serous drainage from area. Will inquire with family if they would like to take R2 to wound clinic as this was closed and now is open again and took a long time to heal. Family requested to continue treatment at facility. At 2:32 p.m., upon inspection of wound again noted that wound is 2.5 cm depth and about the size of the wooden end of a Q-Tip. R2's weekly skin observation dated [DATE], identified location was healed surgical scar on right hip/buttock with unknown etiology. Impression was worsening. Slough tissue and unable to visualize wound base due to minimal opening at top layer of skin. Moderate amount of yellow, tacky drainage with no odor. Depth measured 5.2 cm. Scar tissue around wound macerated and irregular. No suspected infection or inflammation present. Orders for CT of hip. Cover with absorbent dressing. MD-A does not feel packing the wound is needed currently. R2's progress note dated [DATE] at 10:15 a.m., identified wound is directly on the healed surgical scar from right hip revision. No peri wound redness, no pain or discomfort. Wound has very small opening at surface of epidermal layer. Able to probe Q-Tip into wound 5.2 cm depth but may be deeper. Unable to determine if wound tracts or undermines and unable to measure length and width due to small opening. Drainage is yellow and tacky. Packed with one fourth inch packing strip and covered with absorbent bordered dressing. Notified family and they are willing to get treatment and be seen at a wound clinic. Will contact MD-A for wound dressing change and wound clinic referral. At 12:25 p.m., spoke with MD-A to get referral for dressing order and wound clinic appointment. MD-A felt that this may involve the right hip prosthesis, and the first step should be a right hip CT. if there is prosthesis involvement, dressings are irrelevant at this time. Family aware. R2's progress note dated [DATE] at 11:01 a.m., identified area on buttocks still open 0.25 cm round with serosanguineous drainage, dressing changed. R2's progress note dated [DATE] at 11:05 a.m., identified MD-A examined wound on right hip by palpation and movement and discussed getting the CT scan. The physician visit note dated [DATE], identified the biggest concern was R2's hip wound and concern for an underlying infected hip replacement. R2 denied pain in that area interestingly. Area over the right hip shows a depressed area that is red, somewhat irritated, with an open area in the center that medical director (MD)-A was unable to express any purulent (thick, milky discharge that typically indicates an infection) material out of but does appear as though it has been draining. Possibly a draining sinus. Ordered at computed tomography (CT) scan of pelvis and hip to observe how deep the area of infection over the right hip was. Nursing staff stated it has been draining and this is a concern given R2's history of infected prosthetic. Certainly, prudent to look at a referral to orthopedic department for their thoughts. If R2 does have an infected right hip replacement that is not going to heal without removal, spacer, antibiotics, etc. this would likely result ultimately in R2 not really doing well at all. R2's CT with IV contrast dated [DATE], identified diagnoses of septic arthritis (painful infection in a joint), arthritis pyogenic hip (serious painful infection of joint often caused by bacteria). A small quantity of fluid is seen along the lateral incision within the proximal superficial subcutaneous tissue (layer of skin) of right thigh measured approximately 5.4 cm x 3.2 cm x 4.4 cm in size. R2's progress note dated [DATE] at 5:04 p.m., identified MD-A reviewed CT results. Fluid collection increased in size and ordered Keflex and doxycycline. Also, arginaid ordered. At 5:53 p.m., changed dressing to right hip. Light tan colored drainage noted on old mepilex. No signs of infection noted to area. R2's physician notification form dated [DATE], identified MD-A reviewed the CT results per radiology and it appeared the fluid collection has increased in size some from previously. MD-A recommended these findings be reviewed by orthopedic team that worked on R2. In the interim, start R2 on an antibiotic. Keflex 500 mg three times per day for 10 days and doxycycline 100 mg twice daily for 14 days. R2's physician notification form dated [DATE], identified wound on right buttock/old surgical scar continues to close over and fill with yellow, tacky fluid. Depth almost at 6 cm. May we add one fourth packing strip to wound with current orders and wondering if R2 should be seen by orthopedics. Reply was ok for packing of wound and recommended being seen by orthopedics to determine need for additional imaging and intervention. R2's weekly skin observation dated [DATE], identified location as healed surgical scar right hip/buttock with unknown etiology. Unchanged. Slough tissue present, moist. Very small opening with deep tract. Unable to visualize base. Large amount of purulent drainage with no odor. 0.1 cm x 0.1 cm x 5.8 cm depth. Indurated, scar tissue on peri wound. No infection suspected and no inflammation present. Cover with absorbent dressing. Sent fax to MD-A about packing wound. No evidence of healing, continued to drain large amount of tacky, yellow fluid. R2's progress note dated [DATE] at 6:09 p.m., identified fax sent to MD-A for order to pack right buttock wound with one fourth inch packing, as it continues to close over the tiny opening and fill with thick, tacky yellow drainage. Wound measured 6+ cm depth. Also questioned if follow-up with orthopedics was needed. R2's care plan dated [DATE], identified potential for skin breakdown. Has an open area on right hip. Interventions included treatment to open area on right hip as ordered by doctor, pack with packing after cleansing and cover with dressing daily, use only a continuous strip and leave a tail of ,d+[DATE] inches on outer side of wound to prevent packing getting left in wound. R2's skin observation tool dated [DATE], identified skin abnormality to right trochanter (hip), type is listed as other. Measurement 1.0 cm x 0.5 cm x 5.0 cm depth. Currently just covering wound with dressing per provider, pending an updated wound care order. R2's progress note dated [DATE] at 12:48 p.m., identified an orthopedic appointment for right hip had been made. During an interview on [DATE] at 11:22 a.m., licensed practical nurse (LPN)-A stated the nurse would check every resident's skin when they had a bath. The nurse would assess skin issues, bruises, dressings that are in place. For new skin issues the doctor, director of nursing (DON), and family are notified. During an interview on [DATE] at 11:30 a.m., LPN-B stated she had measured the length and width of R2's wound but not the depth on [DATE] after he had a bath. R2 did not currently have a dressing in place on his right hip wound. Registered Nurse (RN)-A had been measuring the depth. They were waiting for new orders from the doctor for packing the wound. During an interview on [DATE] at 11:39 a.m., RN-A stated she had taken over wound management the week of [DATE]. During an observation on [DATE] at 12:50 p.m., LPN-B and RN-A applied enhanced barrier precautions (EBP) prior to entering R2's room. R2 had been seated on the edge of his bed and stood up with a walker upon LPN-B and RN-A entering the room. LPN-B placed a clean towel over R2's overbed table and moved the garbage close to the overbed table. LPN-B removed needed wound care supplies from R2's closet and placed on towel. RN-A described the process for packing the wound with a tail to LPN-B. RN-A stated R2 had a CT scan last week. The wound would close over with fluid. The packing is to keep the wound open and wick out the fluid. The wound opening is the size of a Q-tip and does not have pain with it. The wound has been an on-going issue since ,d+[DATE]. RN-A lifted up R2's skin as the wound site was not visible without lifting the skin up with a hand. RN-A pointed out that proud flesh dimpled skin was at the end of the right hip surgical scar and the opening to the wound was not really visible. RN-A took took the wooden end of a Q-tip and placed it inside the wound opening and moved the Q-tip around. RN-A stated the wound felt boggy against the Q-tip. Removed Q-tip and measured the Q-tip with red-tinged drainage on it at 4.8 cm depth. Red liquid dripped from the wound down R2's leg. RN-A used a new Q-tip, after measuring out packing for the wound, and began to insert packing in the wound bed. R2 made noises and winced during this process. RN-A stated it was very difficult to pack the wound as it was such a tiny opening. Packed the wound with a tail hanging out and placed a mepilex over the area. Both nurses removed EBP when care was complete. During an interview on [DATE] at 1:39 p.m., LPN-B stated she was unsure how long it would take a boil to heal. Pressure sores occur from not having blood circulate to an area from a point that has pressure on it and did not feel that R2's wound was from pressure. Wounds should be measured a minimum of once a week and if a wound is not healing or does not have any change to it, the doctor should address every one to two weeks. During a phone interview on [DATE] at 12:50 p.m., MD-A stated if he had been aware that the 'boil' area that was being treated was on the right hip surgical site he would have ordered a CT sooner and consulted with R2's surgeon. One of the reasons MD-A ordered the CT scan was because he was under the impression that this was a new wound that had popped up. During an interview on [DATE] at 9:05 a.m., RN-A stated she had first observed R2's hip wound on [DATE]. Prior to observing the wound, RN-A was under the impression that R2's wound was a boil. The charge nurses are in charge of the day-to-day wound treatments and RN-A would complete a weekly skin wound assessment that would include assessing for changes, notifying the doctor for wound treatments and updating with changes, notifying family as needed. RN-A had completed wound training with licensed nursing staff within the past year but did not include nursing assistants (NA)'s in the education. Medical doctor (MD)-A would have to be notified and requested to look at wounds during his monthly rounds if a wound needed to be looked at. RN-A had addressed with MD-A the extent of R2's wound on [DATE] and that is when the CT was ordered. MD-A was not aware that R2 still had a wound on his right hip. Moving forward MD-A and family will be informed when wounds heal and the site will be monitored for a week afterwards. RN-A was completing the weekly wound assessments in the interim until the facility determined who would be in charge of them. During an interview on [DATE] at 10:36a.m., DON stated a wound resource binder is located at each nursing station. Wounds should have a weekly comprehensive assessment completed. DON was unable to articulate the amount of time a treatment should be completed before re-evaluation but if there was no change for a while would reach out to MD-A to request new treatment orders. There is no protocol for monitoring a healed wound and it would just be part of the nurses responsibility to assess weekly on bath days. The braden assessment is completed to determine a residents risk for pressure ulcers and pressure reducing mattresses and wheelchair cushions are interventions that would be put in place. MD-A would address wounds on residents whenever necessary. DON would go with on rounds and have handwritten notes of items that needed to be addressed and tell MD-A while in the room with the residents. DON did not have any wound care audits or confirmatory training paperwork on specific wounds with nursing staff completed, any education was only verbal. DON could not recall if she had assessed R2's wound at the initial evaluation. DON did not feel that a boil would remain from September until April and had only assessed the wound when she was working as the floor nurse. There had not been any discussion or concern that the wound could be infected and/or have something to do with his right hip prosthesis even though R2 admitted to the facility with a diagnosis of infection and inflammatory reaction from the right hip prosthesis. Treatment for wounds are determined by review of the nurse resource manual, review from DON or RN-A and the request faxed to MD-A with what orders the facility would like for treatment. The expectation is that wounds are measured, documented, complete assessment and weekly review completed and addressed with MD-A on monthly rounds or as needed for wound worsening or healing and needing new treatment orders. The DON was in charge of completing and comprehensively reviewing weekly wounds but currently RN-A had begun completing them in the interim. The goal is to have the assistant director of nursing (ADON) complete them (after orientation) and DON would be the back-up. The facility Wound Treatment Management policy revised ,d+[DATE], identified to promote wound healing of various types of wounds, the facility would provide evidence-based treatments in accordance with current standards of practice and physician orders. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include lack of progression towards healing, changes in wound characteristics, and changes in resident goals and preference. The facility policy titled Change of Condition and Assessments Policy and Procedure last reviewed [DATE], indicated the policy establishes standardized procedures for registered nurses (RNs) to assess and manage changes in condition among residents. The goal is to ensure timely detection, documentation, and intervention for any significant alteration in a resident's baseline status, safeguarding resident health and well-being. The policy defines change in condition as major decline or improvement in[TRUNCATED]

Based on interview and document review, the facility failed to ensure provider ordered medications were administered timely for 1 of 1 resident (R1). Findings include: R1 was admitted [DATE]. R1's admission Minimum Data Set (MDS) dated [DATE], indicated diagnosis of fracture of left ulna (a long bone in the forearm), chronic kidney disease (CKD) stage 3A, diabetes, urinary tract infection, and atherosclerotic heart disease (when plaque builds up in the walls of your arteries). Review of a fax to the provider dated 11/3/24 at 9:19 p.m., indicated R1 had completed the antibiotic. R1 indicated he was feeling better. R1 continued to have symptoms of fever, chills, and confusion. Review of a fax to the provider dated 11/4/24 at 3:26 p.m., indicated R1 had an episode of low O2 sats the evening prior and was given oxygen. R1 had a temperature of 100.7 at that time and there was no temperature since then. R1 complained of chills and feeling cold in the morning of 11/4/24. R1's lung sounds were clear but diminished in the bilateral lower lobes. The provider response on 11/4/24 at 4:52 p.m., indicated to do labs and chest x-ray two view (front and side). The provider ordered Rocephin (is used to treat bacterial infections) one gram IM (intramuscular) every day for seven days and a Z-Pak (Azithromycin-oral antibiotic used to treat bacterial infections) to be started. An interview on 11/13/24 at 3:13 p.m., with registered nurse (RN)-A stated she had worked 11/4/24 from 2:00 p.m. to 4:00 a.m. RN-A stated she had not processed R1's order for Rocephin and the Z-Pak that was faxed to the facility at 4:52 p.m. RN-A stated she knew the ordered Rocephin and Z-Pak were in the E-Kit in the facility. RN-A indicated the E-Kit list of medications hung on the nurse's station wall. RN-A stated she had not given the prescribed medications out of the E-Kit or processed the order for pharmacy. A review of the Emergency Medication Kit (E-Kit) Reorder list on 11/13/24 at 3:15 p.m., revealed Azithromycin (Z-Pak) 250 milligram (mg) tablets and Rocephin 1 gram injection were listed as contents of the E-Kit. An interview on 11/13/24 at 3:00 p.m., with director of nursing (DON) stated she had come to work on 11/5/24 at 4:00 a.m., The DON had talked to RN-A about having the provider ordered medications in the E-Kit and about checking the fax periodically for any received faxes. The DON stated she had processed the orders for pharmacy. The DON revealed she had not given the Rocephin and Z-Pak as prescribed by the physician to R1 while she was on the floor. An interview on 11/13/24 at 4:00 p.m., with Physician A stated the Rocephin and Z-Pak were in the facility's E Kit that was why Physician A ordered those medications. Physician A stated the Rocephin and Z-Pak should have been given timely after the fax was sent back to the facility 4:52 p.m. The facility policy Medication Orders dated 4/2024, revealed medications should be administered only upon the signed orders of a person lawfully authorized to prescribe. Documentation of medication orders: a. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). b. Clarify the order. c. Enter the order on the medication order and receipt record. d. If using electronic medication records, input the medication order according to the electronic health record (EHR) instructions and facility policy. e. Call or fax the medication order to the provider pharmacy. f. Transcribe newly prescribed medications on the MAR or treatment record or ensure the order is in the electronic MAR. g. When new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing Dc'd and the date, or discontinue the order as per the electronic software instructions and retype the new order. h. Enter the new order on the MAR or ensure the new order is in the electronic MAR.

Based on observation, interview, and document review the facility failed to follow the appropriate food preparation safety requirements for thawing frozen meat to reduce and/or prevent the risk of food borne illness. This had the potential to affected 25 of 25 residents who obtained their meals from the kitchen. Findings include: During observation on 7/31/24 at 11:31 a.m., oven roasted turkey breast and a pork product were individually vacuum sealed in a plastic wrap being thawed together in the middle section of a three section sink for the next day meal. While the meat was being thawed in a water bath, no continuous running cold water observed to minimize/prevent food borne illness. During interview on 7/31/24 12:04 p.m., Dietary aide-A stated staff training was completed at the facility and dietary aide-A was taught that a cold-water bath was an appropriate technique to thaw frozen meat. This technique and facility training were confirmed with the dietary manager. U.S. Food and Drug Administration ' s (FDA) Food Code 2022 Chapter 3 indicates: 3-501.13 Thawing. TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 41 degrees F or less or (B) Completely submerged under running water: (1) At a water temperature of 70 degrees F or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 41 degrees F. (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 41 degrees F, for more than 4 hours including; (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking, or (b) The time it takes under refrigeration to lower the FOOD temperature to 41 degrees F.

Based on observation, interview and document review, the facility failed to perform hand hygiene during cares, clean lift equipment after use, ensure 1 of 1 staff were fit-tested with N95 masks prior to entering COVID positive resident room, and adhere to EBP (enhanced barrier precautions) for 1 of 1 residents (R2). This had the potential to impact 25 residents residing in the facility. Findings include: R2's quarterly MDS assessment dated [DATE], indicated R2 was cognitively intact, dependent on staff for transfers, dressing, hygiene, and toilet use, and had diagnoses of neurogenic bladder (loss of bladder control due to nerve damage), dementia, and heart failure. R2's care plan revised 4/8/24, indicated R2 was transferred with a mechanical lift for all transfers and was on EBP due to an indwelling urinary catheter. During an observation on 8/1/24 at 9:07 a.m., nursing assistant (NA)-B was exiting R2's room and entering R1's room. No hand hygiene was observed. At 9:11 a.m., NA-B was observed exiting R1's room and returning to R2's room. No hand hygiene was observed. On 8/1/24 at 9:11 a.m., NA-B was observed entering R2's room without putting on a gown or gloves. NA-B closed the door to R2's room. A sign on R2's door indicated the need for gown and gloves when assisting R2 with dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care (catheter), and wound care. On 8/1/24 at 9:25 a.m., NA-B exited R2's room. NA-B confirmed she assisted R2 with a bed bath and verified she did not wear a gown for the task. NA-B stated she was not familiar with R2 and this was her first day working at the facility. NA-B stated she saw the sign for EBP and the cart with supplies and personal protective equipment (PPE) outside the door but had not seen other staff using gowns or gloves, so did not think she needed to. NA-B verified she should have used PPE when assisting R2 and further stated she should have completed hand hygiene when going from R2's room to R1's room and back again. On 8/1/24 at 9:28 a.m., NA-B and NA-A entered R2's room with a mechanical lift. Neither NA-B or NA-A were observed putting on a gown or gloves prior to entering the room. A sign remained on the door to R2's room indicating the need for EBP and a cart with gowns, gloves, and hand sanitizer was outside R2's door. On 8/1/24 at 9:34 a.m., NA-A removed a mechanical lift from R2's room and pushed it to the nurse's station. NA-A was not observed sanitizing the mechanical lift. NA-A then left the area. No other observation of lift sanitation was observed. On 8/1/24 from 9:34 a.m. to 9:48 a.m., NA-A confirmed she had assisted NA-B with transferring R2 into her wheelchair. NA-A stated she did not wear a gown when assisting R2 and further stated we never gown up for that here. NA-A reviewed the sign on R2's door and confirmed she should have worn a gown and gloves when transferring R2. NA-B exited R2's room with a bag containing a soiled brief. NA-B confirmed she completed a brief change, hygiene, and transferred R2 into her wheelchair. NA-B verified she did not wear a gown when assisting R2 and again verified she saw the sign on the door and the cart outside the room and should have worn a gown. On 8/1/24 at 9:48 a.m., NA-B exited R2's room. NA-B confirmed the mechanical lift NA-A walked out with had not been sanitized in R2's room after use. NA-B then took the mechanical lift from the nurse's station for use with another unknown resident. NA-B was not observed sanitizing the lift. NA-B confirmed she thought the lift had been sanitized after use since it was at the nurse's station. NA-B stated lifts should be sanitized immediately after use to avoid spreading germs to other residents. On 8/1/24 at 9:54 a.m., licensed practical nurse (LPN)-A stated NA-B and NA-A should have used EBP when assisting R2 with bathing, hygiene, changing of brief, and transferring. LPN-A further stated she would expect hand hygiene when leaving a resident room and prior to entering a resident room. LPN-A also stated she would expect mechanical lifts to be sanitized immediately after use and leaving a mechanical lift at the nurse's station without sanitizing it could increase spread of infection. During an interview on 8/2/24 at 9:30 a.m., RN-A was informed of findings related to lack of PPE worn in EBP rooms. RN-A stated it was her expectation staff adhere to EBP as indicated on the signs posted on resident doors. RN-A stated NA-A had received training on EBP precautions in August 2023. NA-B who was agency staff, had just started at the facility and had not received formal orientation including EBP training. 42073 During observation on 7/30/24 at 8:52 a.m., TMA-A, entered R13's room and did not perform hand hygiene prior to entering. On 7/30/24 at 9:06 a.m., TMA-A exited R13's room and did not perform hand hygiene. At 9:07 a.m., TMA-A stated the facility policy was to perform hand hygiene on entrance and exit of resident rooms. TMA-A stated she should have performed hand hygiene prior to entering and exiting R13's room. During an observation on 7/31/24 at 7:51 a.m., NA-F was observed in R80's room who was in TBP for Covid, with a standing mechanical lift taking R80 to the bathroom. NA-F had on full PPE, including an N95 mask. NA-F who was agency staff stated he had not been fit-tested for the brand of N95 masks used at the facility. During a phone interview on 8/2/24 at 11:23 a.m., with the director of long-term care (DLTC) for the nursing staffing agency of which NA-F was employed, the administrator and RN-A, DLTC stated the agency did not do N95 fit training. 50761 During observation on 7/29/24 at 5:01 p.m., NA-D exited R2's room with a stand lift (mechanical device used for transferring), placed the stand back in the storage area near the east hallway nursing station without cleaning it and walked away. NA- D was asked if the lift was cleaned, NA-D confirmed the stand should have been cleaned right away after resident use because other staff would not know if it was cleaned. During continuous observation on 7/30/24 at 8:33 a.m. to 8:48 a.m., NA-C, exited R14's room with the stand, placed it at the end of the west hallway and did not clean it after use. Before entering R23's room on 7/30/24 at 8:48 a.m., TMA-A who was orientating NA-C stated the stand was cleaned . Although this was not observed during the observation . During an interview on 8/2/24 at 9:30 a.m., RN-A stated NA-A had training on cleaning lifts in August 2023. NA-B who was agency staff, had just started at the facility and had not received formal orientation including disinfecting lifts after use. During a telephone interview on 8/02/24 at 11:31 a.m., the director of nursing (DON) was informed of the infection prevention and control findings. The DON stated she expected all residents rooms to be thoroughly cleaned, including residents in TBP, and stated leadership would address whose responsibility it was to clean TBP rooms and provide appropriate training as needed. Further, the DON stated staff were expected to follow facility policies for hand hygiene, cleaning and disinfecting equipment, and wearing proper PPE for residents in EBP. The DON stated the facility would need to figure out how to onboard agency staff who needed fit-testing for N95 masks and would work with RN-A on that. Facility Handwashing/Hand Hygiene policy dated August 2015, indicated the facility considered hand hygiene the primary means to prevent the spread of infection. All personal were trained; all personnel follow handwashing/hand hygiene procedures and use alcohol-based hand rub for the following examples: before and after direct contact with residents, contact with skin, blood or body fluids, handling dressings, before and after entering isolation precaution settings. Facility Environmental Services/Housekeeping/Laundry policy dated 2019, indicated housekeeping surfaces required regular cleaning and removal of soil and dust. Disinfectant/detergents were used for environmental surface cleaning, but the actual physical removal of microorganisms and soil by wiping or scrubbing was probably as important. High touch surfaces included beds, bed rails, bedside table, call button, call button in bathroom, closet handles, light switch, TV remote and trash can. Facility Equipment and Supplies Used During Isolation policy with review date of 5/2024, indicated nursing would notify environmental services regarding equipment that needs sanitization after use in the care of an individual with isolation precautions. Environmental services and/or nursing would be responsible for cleaning and sanitizing equipment before it is return to designated storage areas. Facility Cleaning and Disinfection of Resident Care Items and Equipment policy dated July 2014, indicated resident-care equipment would be cleaned and disinfected according to CDC recommendations. Durable medical equipment would be cleaned and sanitized before reused by another resident. Facility Infection Prevention and Control Program policy with reviewed date of 5/24/24, indicated all staff receive training relevant to their specific roles and responsibilities, including policies and procedures related to their job function. Staff would demonstrate competence relevant to infection control practices.

Based on observation and interview and record review, the facility failed to clean resident rooms for (R80, R22, R24, R26, R18) who were on transmission-based precautions (TBP) timely and maintain an environment in good repair affecting 12 residents who used the west unit tub room. Findings include: During an interview on 7/30/24 at 8:59 a.m., housekeeper (H)-A stated housekeeping did not clean rooms of residents in TBP and stated nursing staff was supposed to clean those rooms. During an interview on 7/30/24 at 10:16 a.m., environmental services director (EVSD) stated neither housekeeping nor nursing cleaned the rooms of residents who were in TBP. EVSD stated nursing brought out the garbage and did a quick visual of the room, but did not clean toilets, floors, or high touch surfaces. If a room really needed cleaning, EVSD stated nursing would let housekeeping know and housekeeping would don PPE (personal protective equipment) and clean the room. During an observation on 7/31/24 at 7:29 a.m., R80 who was in TBP , shared an adjoining bathroom with another resident who was in TBP. In the bathroom, the toilet had a commode with arm rests positioned over the toilet. The white commode splash guard was splattered with a brown substance . During an interview and observation and on 7/31/24 at 7:51 a.m., nursing assistant (NA)-F assisted R80 to the bathroom using a standing lift device. During an observation on 7/31/24 at 8:51 a.m., R24 and R26's who were both in TBP shared a bathroom. The toilet had a commode with arm rests positioned over the toilet. The light gray commode splash guard was splattered with a brown substance and the back of the toilet seat was smudged with what looked like feces. The two over the bed tables used by R24 and R26 were soiled and dirty smeared and had greasy looking spots. During an interview on 7/31/24 at 8:49 a.m., nursing assistant (NA)-F stated housekeeping updated them that morning NA's were supposed to clean the rooms of residents in TBP. NA-F admitted he had not received training to properly clean a room of a resident in TBP, nor had he been informed of what cleaning supplies to use and where they were located. During an interview on 7/31/24 at 9:08 a.m., NA-A stated she cared for residents in TBP and stated NA's were supposed to take out the trash and clean the toilet. NA-A stated she had not been trained on how to properly clean a toilet, had no instructions to follow and did not know what cleaning products to use. During an interview on 7/31/24 at 11:05 a.m., the administrator was informed of the condition of soiled toilets in rooms of residents in TBP. The administrator stated it was not acceptable to have toilets in that condition. During an interview on 8/2/24 on 9:30 a.m. registered nurse (RN)-A infection preventionist wasn't sure who was responsible for cleaning TBP resident rooms RN-A acknowledged the rooms and the shared bathrooms needed regular cleaning and disinfecting. During an observation on 7/31/24 at 9:01 a.m., the flooring in the tub room on the west unit was noted to be in disrepair. The original flooring visible around the perimeter of the room was made up of small, square blue/gray tiles in various sizes. Some of the tiles at the foot end of the tub appear to have been removed and gray paint had been applied over the section of the flooring directly around the tub. At the foot end of the tub where a resident would enter and exit the tub and where their feet would rest, the flooring was wet due to residents having been bathed. The paint in this approximate 3 x 3-foot area, had chipped and/or had been scraped away, exposing the missing tile and concrete, leaving an unclean, uneven surface for resident's feet. During an interview on 7/31/24 at 1:17 p.m., the environmental services director (EVSD) was informed of the observation. EVSD stated he was aware of the condition of the flooring with missing paint and had not gotten around to re-painting it. EVSD acknowledged the condition, and may be difficult to properly clean the floor. During an interview on 7/31/24 at 1:23 p.m., housekeeper (H)-A stated she mopped the floor in the tub room and was aware the paint was flaking off. H-A could not recall if she had brought it to EVSD's attention. On 8/1/24 at 9:45 a.m., a policy on facility upkeep and maintenance was requested and EVSD stated they did not have one.

Based on observation, interview, and document review the facility failed to ensure actions were taken to protect 1 of 1 resident (R1) from sexual abuse when R1 voiced concerns with nursing assistant (NA)-A. Further the facility failed investigate this allegation, report timely to the state agency (SA), or take actions to protect other residents with a subsequent second accusation of sexual abuse involving (NA)-A. The facility implemented intervention, and the deficiency is being issued as past noncompliance. The immediate jeopardy began on [DATE], when the facility failed to report and investigate R1's report of rough handling of NA-A, and received an additional accusation of sexual abuse from R1 about NA-A on [DATE]. The Director of nursing (DON), registered nurse (RN)-A, and social services (SS) were notified of the immediate jeopardy on [DATE] at 6:45 p.m. The immediate jeopardy was removed and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore identified as Past Noncompliance. Findings include: R1's admission record dated [DATE], indicated R1 was admitted on [DATE], diagnoses included Alzheimer's disease, dementia, depression, and insomnia. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment, no acute change in mental status, no behaviors, required extensive assistance with bed mobility, transfer, locomotion, dressing, toileting, and personal hygiene. R1's care plan printed [DATE], indicated R1 had an ADL (activities of daily living) self-care performance deficit related to impaired mobility. Intervention included: bathing required one staff physical assist with whirlpool bath, bed mobility required one staff limited to extensive assistance to turn and reposition in bed, with use of ,d+[DATE] side rails is able to do per self with use of half side rails at times, required one staff physical assist to dress, personal hygiene able to wash hands and face when handed readied wash cloth, brush teeth when handed readied toothbrush, staff do peri care twice daily and as needed, toilet use one staff assist and EZ stand lift, staff change incontinence product and cleanse resident after each incontinent episode, transfer one staff assisted and EZ stand lift (mechanical device used to transfer). Progress note dated [DATE], at 2:18 p.m. documented by social services (SS)-A read: R1 indicated a man came into her room a couple of weeks ago climbed on top of her in bed and tried to put his penis in her, but he wasn't very good at it. R1 said he just wanted to satisfy himself. RN-A came in along with law enforcement officer (LE)-A. The administrator was informed immediately and a Vulnerable Adult was filed. Police were also notified immediately. Writer left a message for the Ombudsman to contact us in reference to this. Interviews of staff and residents are being done or are done. RN-A care conference note document dated [DATE], indicated the following were present on [DATE], during R1's care conference: law enforcement (LE)-A, registered nurse (RN)-A, R1, SS-A, family member (FM)-A, FM-B (via phone), and FM-C (via phone). R1 stated, I didn't tell anyone and she does not remember the exact date and apologizes for not telling anyone sooner. FM-A , indicated she had not reported the information to anyone until last evening in which she told her siblings. FM-A said the best guess of when R1 told her about the allegation was on approximately ,d+[DATE] to ,d+[DATE]. FM-A stated that after the first time R1 told her about it, R1 brought it up 2 or three times afterwards. R1 stated that a person came into my room in the evening, and we hadn't had the last small meal or whatever. It was getting dark and I was in bed. She says she had her pajamas on and was covered up. He was a small person compared to some that work here, not very tall. He was a little bigger than me but not a great deal. He got into bed, on top of me and I told him he couldn't do that but he wasn't going to leave. Later in interview she again stated that he laid on top of me and tried to insert his penis but he didn't do a very good job of it. She laughed and said, I have 4 kids, I know. He wasn't mean in the process but I didn't resist. He didn't stay very long. He came back in a second time and gave me my meds, my bedtime medications. He didn't want to hurt me, he just wanted to satisfy himself'. R1 stated that she is aware of ,d+[DATE] males working here at this time. I don't care if men help me. They are stronger and can lift both my legs into bed at the same time. I had men take care of me at the other place. FM-A commented there was an aide helping R1 with her hearing aides and she told the NA that she was uncomfortable with him, FM-A wasn't sure the name of who she was referring to. FM-B stated that he called one evening and overheard a conversation with R1 and a female staff say that they would only have ladies help her. The care conference notes further indicated: staff interviews completed and was given immediately to the DON and SS. SS stated that she was aware that R1 did not want men helping her. RN-B and RN-C stated they were aware that R1 didn't want NA-A assisting her. NA-B stated she was in R1's room one evening and NA-A came to R1's door requesting assistance from NA-B and R1 said Do not let him in my room. Law enforcement notes dated [DATE], indicated on [DATE], at approximately 11:00 a.m. law enforcement (LE)-A was dispatched to the facility to take a sexual assault report and present in the conference room were RN-A, SS-A, R1, FM-A, and on the phone FM-B and FM-C. R1 explained she was getting ready for bed and a male was in the room and got into bed with her, laid on top of her and tried to insert his penis into her, but he did not do a very good job of it. R1 told the male to get out, and she was going to report what happened, and the male left. R1 stated she felt the male wasn't trying to hurt her, but more so wanted to satisfy himself. R1 also stated she normally doesn't have an issue with male caregivers, this is the only time she has had an issue. R1 described the male as, not very tall, not aggressive, it didn't scare her, but it bothered her to the point she finally confided in FM-A around [DATE]-12, 2023. R1 was asked if the male has been in her room since the incident happened and she said one time but he didn't do anything and was only in the room briefly, thinks he was there with her bedtime medication. R1 had mentioned to staff that she was uncomfortable with him and that she was sorry for not saying anything right away. Staff mentioned to the family that R1 could be sent in for a sexual assault exam and family didn't think it was necessary since so much time has passed. According to FM-A, R1 mentioned the incident two other times since it was first mentioned and every time the details are consistent. Staff at the facility fit the description were: NA-A and LPN-A Record review indicated, the facility started an investigation on [DATE], staff were interviewed, law enforcement was contacted, NA-A was suspended and staffing contract terminated on [DATE]. The administrator was informed immediately and a VA was filed. Police were notified immediately, Ombudsman was contacted, interviews of staff and residents were completed. Review of an incident submitted to state agency on [DATE], indicated R3 (different resident) reported an allegation of sexual abuse. The alleged perpetrator was identified as NA-A. On [DATE], at 9:15 a.m. during an interview the DON and RN-A indicated on [DATE], they became aware of R1's concerns of NA-A's care not gentle and not allowing NA-A in R1's room. The SS-A interviewed R1 on [DATE], when SS-A was notified R1 did not want males in her room. The DON indicated R1 did not want the one [specific physical characteristic] man in her room as he was not gentle. The DON confirmed the incident from [DATE], was not investigated by the facility to determine what occurred, and verified NA-A continued to work with residents at the facility. There was no indication the facility completed an investigation to identify what occurred with R1's even though the facility was aware NA-A had a history of sexual abuse allegations from R3. On [DATE], at 11:09 a.m. during an interview R1 indicated about two weeks ago a NA described as [specific physical characteristic] young man, attempted to get into her bed during the night time or early evening. R1 indicated the individual tried to get under the covers of her bed with her, and his clothes were on. R1 indicated the person no longer worked at the facility, and further indicated she told staff about it during her care conference on [DATE]. On [DATE], at 11:39 a.m. during an interview the SS indicated R1 was interviewed after staff stated R1 did not allow NA-A into her room. The SS indicated on [DATE], R1 gave a verbal statement she did not want the one man in her room as he was not gentle. SS indicated no further questions were asked about the comment not gentle and did not report the concerns to the state agency, and did not further investigate R1's concerns. SS verified the concerns were expected to be reported and investigated to protect the residents at the facility. Although the facility was aware of previous allegation of abuse with NA-A, they had not investigated the [DATE] concern from R1 about NA-A. On [DATE], at 11:40 a.m. during a follow up interview The DON indicated on [DATE], she discussed and educated NA-A that he was not allowed in R1's room, and NA-A indicated he already knew that because R1 had told him that and did not allow him in her room. NA-A continued to work in the facility from [DATE]-[DATE] and provided care to other residents. On [DATE], at 11:45 a.m. during a phone interview FM-A indicated during a face to face visit at the facility during the week of [DATE], R1 indicated a man got too intimate with her, FM-A indicated she questioned that, with what do you mean, was it different then when staff help you get into bed and R1 indicated it was when she was already in bed. FM-A indicated she did not ask any more questions at that date, and further indicated R1 had some dementia. FM-A indicated the next week during a face to face visits R1 brought up the incident again, and indicated R1 told her the same thing, and tried to get a description and R1 indicated the incident was at night, lights were off could not describe how tall he was. FM-A indicated on [DATE], R1 indicated the male tried to get fresh with her and tried to have intercourse with her, and R1 stated she didn't want to be a tattle tale, and wanted to bring it to authorities in the proper way. FM-A confirmed she did communicate to staff at the facility regarding the incident, wanted to respect R1. FM-A indicated they were at R1's care conference on [DATE], and R1 indicated to staff a male pulled the covers off when she was in bed, and stated she yelled forcefully to get out of here, and nobody heard her to say anything, and he left. FM-A further indicated LE-A interviewed R1. FM-A stated R1 had no concerns with other males providing her care. On [DATE], at 1:06 p.m. during a phone interview RN-B indicated on an unknown date about two weeks prior, R1's door was shut and further indicated that was unusual for R1. RN-B indicated R1 stated I don't like that [specific physical characteristic] boy. RN-B indicated the only staff member that fit the description who was working at the facility at the time R1 described was NA-A, who was observed in the hallway. RN-A further stated she discussed R1's concerns about NA-A with the DON, to make the DON aware of R1's concerns with NA-A. On [DATE], at 1:11 p.m. during a phone interview NA-B indicated on [DATE], R1 was overhead and indicated she did not want NA-A in her room. NA-A indicated R1's comment was reported to RN-A, RN-B, and the DON. R1's medical record failed to include NA-A was not allowed to care for resident, after R1's concerns regarding NA-A. Review of facility nursing work schedule revealed that NA-A worked on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. NA-A was not on the schedule after [DATE]. Facility policy titled Abuse, Neglect, and Exploitation, dated ,d+[DATE], indicated: Immediate investigation was warranted when suspicion of abuse occurred. The facility would ensure all residents were protected from physical and psychosocial harm during and after the investigation. The facility would report all alleged violations to the administrator, or designee, state agency, and any other required agencies within specified timeframe's: immediately, but not later than two hours after the allegation is made. An investigation would be conducted, including identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; and to provide complete and thorough documentation of the investigation. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions: Facility investigation dated [DATE], identified NA-A was immediately suspended on [DATE], and terminated agency contract/employment. LPN-A was not scheduled to work until [DATE], when the facility had completed the investigation, law enforcement contacted, VA report filed with SA, staff interviews, and resident interviews conducted. Facility developed training plan on [DATE], which included abuse, neglect, and exploitation policy, abuse/neglect/exploitation definition, abuse reporting, review of abuse policy, Clinical care module: Understanding Abuse and Neglect, and competency test that staff had to complete. The training was implemented on [DATE] with continuation for all staff to complete prior to the start of their next shift. During staff interviews on [DATE], between 10:00 a.m. and 5:15 p.m. identified RN-A, RN-B, RN-C, RN-D, DON, SS, LPN-A, NA-B, NA-C, and NA-D, were able to articulate what constituted abuse and the facility's abuse reporting policy and procedure.

Based on interview and document review, the facility failed to ensure the administration of antianxiety and antipsychotic medications were warrented for one of two (R1) residents with a [DIAGNOSES REDACTED]. The resident also exhibited increased agitation and fear, and required an inpatient hospital admission for the escalated behaviors. The findings include: Resident's #1's (R1) record was reviewed and revealed R1was admitted to the facility following a fall at home and sustained a fractured right wrist. The resident also had a [DIAGNOSES REDACTED]. Within 24 hours of admission to the facility, the resident received physician orders [REDACTED]. R1, [AGE] years old, was admitted to the facility on [DATE]. The hospital history and physical dated May 27, 2014, identified the resident lived at home with family and came into the hospital to have the right wrist recasted. During the hospitalization , concerns regarding the resident's safety were expressed and nursing home placement was initiated. The information in the hospital history and physical identified the resident had memory problems, and had poor ambulatory skills with a history of falls. The information also indicated the resident was awake and alert. The resident had no history of prescription medications, nor was there any indication the resident had exhibited behaviors prior to admission to the nursing home. The admission Pain Management assessment completed on June 2, 2014, identified the resident had severely impaired cognitive skills, objective symptoms included agitation, combativeness, bracing, guarding, confusion, distress, and crying. The information also identified the resident had a recent fall with fracture, and that the resident had a high probability of pain. The information also identified the resident's current physician orders [REDACTED]. The admission progress notes dated May 28, 2014, at 4:16 p.m., identified the resident's family member voiced concern regarding the resident's poor sleep the night before admission to the nursing home. The documentation indicated the resident's physician would be notified if need be. On May 29, 2014, at 3:14 a.m., a licensed practical nurse (LPN) documented in the resident progress notes that the resident was extremely confused, agitated and angry. The documentation also indicated the resident yelled out loudly. Later that same day at 10:07 p.m., an LPN documented the resident was "extremely agitated" all shift and that PRN [MEDICATION NAME] (antianxiety) 0.5 mg was given twice as well as scheduled [MEDICATION NAME] 0.5 mg with no effect. The documentation identified the resident's physician was notified and additional orders were received to administer [MEDICATION NAME] (antipsychotic) 1 mg two times daily. On review of the physician orders, it was noted on May 29, 2014, the following orders were received: 1. [MEDICATION NAME] (antianxiety) 0.5 milligrams (mg) 1 tablet two times daily as needed (PRN) for restlessness and anxiety related to a [DIAGNOSES REDACTED]. 2. [MEDICATION NAME] 0.5 mg 1 tablet two times daily at 7:00 a.m. and 8:00 p.m. for restlessness and anxiety related to a [DIAGNOSES REDACTED]. 3. [MEDICATION NAME] (antipsychotic) 1 mg two times daily for anxiety state. On May 31, 2014, at 11:00 a.m., the progress notes identified the resident's family member voiced concern that the resident appeared "over medicated". The notes identified the family member stated the resident was slow to respond, speech was slow, and did not want to smile. At 9:54 p.m., the progress notes indicated the resident refused hour of sleep medications and yelled at staff to get out of the room. Chair and bed alarms had been placed on admission and the documentation identified "alarms constantly ringing". The notes indicted the on call physician was contacted and an order was received for [MEDICATION NAME] 1 mg intramuscularly (IM) every 4 -6 hours PRN for severe agitation. On June 1, 2014, at 1:07 p.m., the progress notes continued to identify the resident was "increasingly agitated". That the resident expressed the need for toileting and not wanting staff to assist. The notes identified that two staff were needed to give the resident PRN [MEDICATION NAME] IM. The resident's physician was called as well as the resident's family. The progress notes indicated the resident's physician gave an additional order for [MEDICATION NAME] (antipsychotic) 2 mg IM every 4 hours PRN for agitation/aggression. Later that same day, the progress notes identified the family reiterated their concern regarding the resident being so sleepy. On June 2, 2014, at 3:35 p.m., the resident's family member informed staff the resident was "afraid of the dark and will scream out". The documented note also identified the resident's family informed facility staff the resident had a history of [REDACTED]. On June 3, 2014, at 12:00 p.m., the progress notes identified the family voiced concern regarding the resident's medication regimen. The family stated "I've never seen him/her so drowsy", the family member was heard talking to the resident and saying, "I can hardly talk to you; you're so drugged up, you used to talk to me." The licensed nurse documented the resident was drowsy, non-verbal and did not participate in conversations. The documentation on this same day, identified the family member was observed to hug, rub and kiss the resident with no verbal or facial change returned from the resident. The review of the progress notes from June 6 through June 18, 2014, continued to identify the resident with behaviors of yelling out, and resisting cares. The documentation also reflected the administration of the antianxiety and antipsychotic medications. On June 18, 2014, the resident returned to the clinic and was re-evaluated for the fractured right wrist. The clinic physician documented the resident was overly medicated and that the resident slept through the entire visit. The clinic physician discontinued the [MEDICATION NAME] and recommended a reduction in medication doses due to sleepiness. New [DIAGNOSES REDACTED]. Sedational Somnolence. A closed reduction for the right wrist fracture was scheduled for June 20, 2014. On June 20, 2014, at 11:00 a.m., the resident progress notes indicated the resident returned from the right wrist procedure with a cast applied to the right wrist. On June 20, 2014, at 2:25 p.m., the DON documented she informed the resident's primary physician that the resident's [MEDICATION NAME] had been discontinued by the clinic physician. The DON documented the resident's primary physician was upset that this took place and reordered the [MEDICATION NAME] 0.5 mg three times a day PRN for anxiety state. The resident's record also revealed that on June 23, 2014, the resident's primary physician reordered [MEDICATION NAME] 1 mg IM every 4-6 hours PRN for severe agitation, and on July 1, 2014, the physician ordered [MEDICATION NAME] 0.5 mg 1/2 tablet two times a day.On interview with the resident's family member (FM-1), on August 1, 2014, concern was expressed regarding the status of the resident. FM-1 stated that within days of admission to the facility the resident was in "La La Land", and drooling out the side of the mouth to the point the resident's shirt had a wet spot and that he had to keep wiping the drool from her mouth. FM-1 stated prior to admission, the resident would maybe shed a tear when talking about the past. and gave an example how the resident shed a tear that she couldn't see like she used to. FM-1 stated the resident would sometimes wake up from a nap and be disoriented to where she was, but once awake would get her bearings. FM-1 stated when the resident lived at home, he visited almost daily, took the resident into the community for errands and business and that the resident would always ask about the farming. In addition; FM-1 stated the resident was "in good shape" and did not take any prescription medications prior to admission to the nursing home. FM-1 voiced concern regarding how sedated the resident was. On interview with the resident's guardian on July 30, 2014, concern was voiced regarding the sedation of the resident. The guardian stated when facility staff were questioned she was informed that if the care prescribed by the physician was not approved she could take the resident elsewhere. The guardian stated the resident was alert, talkative, and although confused and unable to carry on a lengthy conversation on one topic, the resident answered simple questions appropriately. The guardian stated the resident was cooperative with the hospital personnel and care of the fractured wrist prior to admission to the nursing home. The guardian was not aware of the resident exhibiting agitated or aggressive behaviors prior to admission to the facility. The guardian stated the resident was walking some prior to admission, and was also continent of bowel and bladder functions, and that very quickly the resident was not walking at all, and was incontinent of bowel and bladder function. The progress notes for the month of July 2014 revealed behaviors of yelling, resistance of cares, crying and exhibition of paranoid behaviors. The resident's record lacked evidence of documentation that the interdisciplinary team evaluated the resident for treatable medical, physical, emotional, psychiatric, psychological, functional, social, and environmental factors that may have contributed to the resident's behaviors. In addition; the resident's record lacked evidence of documentation the resident's pain was re-evaluated after the closed reduction of the right wrist fracture. On July 17, 2014, the progress notes identified the resident "does not chew well and at times will pocket foods." The documentation identified the resident had a speech evaluation and a pureed diet was suggested. The resident refused to eat the pureed diet and "would cry at the table." The resident's admission weight on May 29, 2014 was 109 pounds and the resident's weight on July 15, 2014 was 105.6 pounds. The progress note identified nutritional supplements were ordered for the resident. On July 22, 2014, the resident was transferred to the hospital. On July 31, 2014, interview with the registered nurse (RN-C) at 2:30 p.m., no further information was provided regarding the assessment or treatment for [REDACTED]. LSW-D stated shortly after admission the resident's sleep schedule was off, that the resident had hallucinations, made comments that didn't make sense, and sometimes had a wild look in his/her eyes. LSW-D stated he/she had no involvement in the use of the psychoactive medications. On August 5, 2014, at 1:15 p.m., on interview with the director of the hospital's behavior unit that the resident was admitted to on July 22, 2014, verified the resident was very agitated and very distressed upon admission to the unit. The director also stated the resident expressed extreme fear of the dark and paranoia of people trying to kill him/her. The director stated that although the resident's behaviors had improved, the resident continued to express fear of the dark. The hospital admission psychiatric evaluation and plan of treatment dated July 24, 2014. included discontinuing the PRN [MEDICATION NAME] and [MEDICATION NAME], and tapering the scheduled [MEDICATION NAME] to discontinue. The resident's [MEDICATION NAME] was changed from 2 mg daily to 0.25 mg four times a day with a low dose 0.5 mg every 4 hours PRN agitation/paranoia for a max of 3 PRN doses within 24 hours. The hospital notes also identified the Black-Box warnings involving the use of antipsychotic and mood stabilizing medications in the elderly were discussed with family members.