Every finding on record at Patriot Health and Rehabilitation Center

Based on policy review, observation, record review, and interview the facility failed to ensure residents received the necessary treatment and services consistent with professional standards of practice to promote healing for 9 of 9 (Residents #1, #2, #5, #11, #14, #15, #16, #18, and #19) reviewed for pressure ulcers. The facility's failure to perform wound care treatments and weekly wound assessments in accordance with facility policy contributed to the deterioration of pressure ulcers/injury for Resident #14 and #18, resulting in Harm. The findings include: 1. Review of the facility policy titled, Pressure Injury Prevention and Management, dated 2/14/2023, revealed . provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .Licensed nurses will conduct a full body assessment on all residents upon admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse and documented. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS [Minimum Data Set] . The RN [Registered Nurse] Unit Manager . will review all relevant documentation regarding skin assessments, pressure injury risks, program towards healing, and compliance at least weekly, and document a summary of findings in the medical record . Review of the undated facility policy titled, Documentation of Wound Treatments, revealed The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition and changes in treatment .Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. The following elements are documented as part of a complete wound assessment: Type of wound (pressure injury, surgical .) and anatomical location. Stage of the wound, if pressure injury (stage 1, 2, 3, 4, deep tissue injury, unstageable pressure injury) or the degree of skin loss if non-pressure (partial or full thickness) Measurements: height, width, depth, undermining, tunneling .Description of wound characteristics: Color of the wound bed, type of tissue in the wound bed (granulation, slough, eschar, epithelium), Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated), Presence, amount, and characteristic of wound drainage/exudate, Presence of odor, Presence of pain .Wound treatments are documented at the time of each treatment . Review of facility policy titled, Consulting Physician/Practitioner Orders, dated 12/1/2024, revealed Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician .For consulting physician/practitioner orders received .the nurse will .Follow facility procedures for verbal or telephone orders . 2. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including, Chronic Obstructive Pulmonary Disease, Schizophrenia, Anxiety, and Diabetes. Review of the quarterly MDS assessment dated [DATE], revealed a Brief Interview for BIMS score of 3 which indicated Resident #14 was severely cognitively impaired and was at risk for developing pressure ulcers. Review of Physician Order dated 12/6/2024, for wound care to the right and left buttock included, .cleanse .with normal saline .cover with honey alginate and cover with a foam dressing .one time a day . Review of the TAR dated 12/2024, revealed the wound care was not documented as being provided as ordered for the left and right buttock on 12/7/2024,12/8/2024 and 12/9/2024. Review of Physician Order dated 12/30/2024 for wound care to the left and right buttock included .Cleanse . with wound cleanser or normal saline .cover with calcium alginate . with super absorbent dressing .one time a day . Review of the Resident #14's Wound Assessment Report dated 12/30/2024, revealed resident had an unstageable right buttock pressure ulcer that measured 8.0 cm long x 5.5 cm wide x 0.1 cm deep with 50% slough and large serosanguineous (a thin, pink drainage that comes from an open wound) drainage. Review of the Resident #14's Wound Assessment Report dated 12/30/2024, revealed resident had a stage 3 left buttock pressure ulcer that measured 2.0 cm long x 2.0 cm wide x 0.1 cm deep and had large serosanguineous) drainage. There was no documentation the weekly wound assessment was performed the weeks of 1/6/2025 and 1/13/2025. Review of the TAR dated 1/2025, revealed the wound care was not documented as being provided to the left and right buttock as ordered on 1/9/2025, 1/11/2025, 1/13/2025, 1/14/2025, 1/15/2025 and 1/16/2025. Review of Resident #14's Wound Assessment Report dated 1/21/2025, revealed resident had an unstageable right buttock pressure ulcer that measured 8.0 cm long x 5.0 cm wide x 2.0 cm depth with 15% slough [dead tissue] 75% eschar [dead, dry black tissue] and 2 centimeters of undermining and moderate serosanguineous drainage. During observation and interview on 1/21/2025 at 11:18 AM, LPN D performed wound assessment with measurement and staging and reported foul odor noted, necrotic tissue noted to the right buttock (coccyx) wound bed. LPN D reported slough 25%, 50% necrotic, 25% granulation LPN reported measurements as 8.0 cm long x 5.0 cm wide x 2.0 cm deep with 2.5 cm undermining. LPN D reports wound was staged as Unstageable due to slough. LPN D confirmed Resident #14 currently has 1 visual wound and was unsure when the wound to left buttock closed. The right buttock wound deteriorated from 1/13/2025 to 1/21/2025 with an increase in depth, developed eschar and undermining with an odor. The facility's failure to perform weekly wound assessments and provide wound treatments as ordered resulted in a decline in the wound, resulting in a harm for Resident #14. 3. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including, Parkinson's Disease, Malnutrition, Heart Failure, Schizophrenia, and Depression. Review of the Physician Order dated 12/4/2024 revealed, .Cleanse open area to sacrum with normal saline, pack with calcium alginate, apply super absorbent dressing and cover with foam .one time a day . Review of the Physician Order dated 12/30/2024 revealed, .Cleanse sacral area with wound cleaner or normal saline .apply calcium alginate .cover with super absorbent foam dressing .one time a day . Review of the TAR dated 12/2024, revealed the wound care was not documented as being provided on the sacrum as ordered on 12/7/2024 and 12/8/2024. Review of the Resident #18's Wound Assessment Report dated 12/30/2024, revealed resident had a stage 4 pressure ulcer on her sacrum that measured 7.0 cm long x 8.0 cm wide x 1.5 cm deep. The wound had undermining and large serosanguineous drainage. Review of the Physician Order dated 12/30/2024 revealed, .Cleanse sacral area with wound cleaner or normal saline .apply calcium alginate .cover with super absorbent foam dressing .one time a day . Review of the TAR dated 1/2025, revealed the wound care was not documented as being provided on the sacrum as ordered on 1/5/2025, 1/8/2025, 1/9/2025, 1/10/2025, 1/11/2025, 1/12/2025, 1/13/2025, 1/14/2025, 1/15/2025, 1/16/2025 and 1/18/2025. There was no documentation the weekly wound assessment was completed for the week of 1/6/2025 and 1/13/2025. Review of Resident #18's Wound Assessment Report dated 1/21/2025, revealed resident had a stage 4 pressure ulcer on her sacrum that measured 7.0 cm long x 10.0 cm wide x 1.0 cm deep with 75 % granulation tissue, 5% slough, 20% eschar and 1 cm] undermining and had moderate serosanguineous drainage. There was no documentation the Weekly Wound Assessment Report was completed the week of 1/6/2024 and 1/13/2024. The wound deteriorated from 1/13/2024 to 1/21/2025 with an increase in width, now has slough and eschar. The facility's failure to perform weekly wound assessments and provide wound treatments as ordered resulted in a decline in the wound, resulting in a harm for Resident #18. 4. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Coronary Artery Disease, Hypertension, Pneumonia, Diabetes, and Malnutrition. Review of the initial Wound Assessment Report dated 8/9/2024, revealed there were no wound measurements documented in accordance with the facility's policy for the following wounds: a. Stage 2 pressure injury to middle lower back b. Deep Tissue Injury to left heel c. Deep Tissue Injury to right heel d. Deep Tissue Injury to right foot 1st digit Review of the admission MDS assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Resident required maximum assistance of staff to perform Activities of Daily Living (ADLs). Resident was assessed for the following pressure injuries: one stage 2, one stage 3, and three deep tissue injuries (damage to the soft tissue beneath the skin caused by pressure or shear forces). 5. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Anxiety, and Depression. Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #2 was severely cognitively impaired. Two Stage 3 pressure ulcers were documented that were not present on admission. Review of Physician's Order dated 12/4/2024 revealed, .Cleanse area to left buttock with wound cleanser, apply oil emulsion to wound bed, apply calcium alginate, and cover with foam dressing one time a day every other day for pressure injury AND as needed . Review of Physician's Order dated 12/4/2024, revealed .Cleanse area to right buttock with wound cleanser, apply oil emulsion to wound bed, apply calcium alginate, and cover with foam dressing. one time a day every other day for pressure injury Review of the Treatment Administration Report (TAR) dated 12/2024, revealed the wound care was not documented as being provided as ordered on 12/7/2024 and 12/15/2024. Review of the Weekly Wound Assessments dated 12/23/2024 and 12/30/2024, revealed Resident #2's Left buttock wound stage was changed from a Stage 4 on 12/23/2024 to a Stage 3 on 12/30/2024 with the same following measurements: a. 12/23/2024 - 6.0 cm long (centimeters) x 3.0 cm wide x 0.1cm deep Stage 4 b. 12/30/2024 - 6.0 cm long x 3.0 cm wide x 0.1cm deep Stage 3 Review of Resident #2's Weekly Wound Assessments revealed wound assessments were not conducted on 12/23/2024 on the right buttock wound, and 1/7/2025 on the right and left buttock wounds, in accordance with the facility policy. Observation on 1/16/2025 at 1:31 PM in Resident #2's room, Licensed Practical Nurse (LPN) C and Certified Nursing Assistant (CNA) E entered the resident's room to perform wound care. LPN C removed the soiled bandage and reported left upper buttock wound was a Stage 2 with minimal greenish drainage and reported right buttock wound was a Stage 2 with blood-tinged greenish drainage. LPN C cleansed right buttock with Normal Saline moistened gauze, cleansed left buttock with Normal Saline moistened gauze, patted dry with gauze, and applied oil emulsion to right buttock. LPN C obtained scissors from her scrub pocket, cut and applied the calcium alginate to the right buttock . LPN C removed gloves and donned gloves without performing hand hygiene, applied oil emulsion, calcium alginate to left buttock, and covered wounds with bordered foam dressing. LPN C failed to follow physician's order for cleansing the wounds with wound cleanser. During an interview on 1/21/2025 at 8:45 AM, the Assistant Director of Nursing (ADON) B was asked regarding Resident #2's wound staging documentation. The ADON B confirmed the 12/23/2024 wound assessment for resident's left buttock documented a Stage 4 and on 12/30/2024 documented a Stage 3. The ADON B confirmed the wound care nurse should not change the staging from Stage 4 to Stage 3. ADON B was asked regarding the blanks on the resident's TAR for wound care. The ADON B confirmed that there should not be blanks on the TAR and cannot confirm if the wound care was provided. The ADON B confirmed that weekly wound assessments should be performed of all wounds with measurements included. 6. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including, Adult Failure to Thrive, Dysphagia, Depression, and Polyneuropathy. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated resident was cognitively intact. Resident #5 admitted to the facility with 3 unstageable pressure wounds. Review of the Physician's Order dated 12/6/2024 revealed, .Cleanse coccyx [base of spine/tailbone] area . left hip area .[and] right hip with normal saline .apply honey alginate .cover with border gauze .one time a day . Review of the TAR dated 12/2024, revealed the wound care was not documented as being provided to the right hip, coccyx and left hip as ordered on 12/11/2024 and 12/22/2024. Review of the Physician Order dated 12/25/2024 for wound care to the coccyx, and the left and right hip included, .Cleanse .with wound cleanser or normal saline .apply honey alginate .cover with bordered gauze .one time a day . Review of Resident #5's Wound Assessment Report dated 12/30/2024, revealed an unstageable pressure ulcer on the left iliac crest (curved, bony ridge at the top of the hip bone) that measured 2.5 cm long x 1.5 cm wide x 0.1 cm deep with 25% granulation (new) tissue . 75% of eschar (dead tissue/debris) .and had moderate serosanguineous (pinkish/red) drainage. Review of the Resident #5's Wound Assessment Report dated 12/30/2024 revealed an unstageable pressure ulcer on the coccyx that measured 7.5 cm long x 6.0 cm wide x 0.1 cm deep with 25% granulation tissue . 75% of eschar and . moderate serosanguineous drainage. Review of the Resident #5's Wound Assessment Report dated 12/30/2024, revealed resident had an unstageable pressure ulcer on the right iliac crest that measured 2.5 cm long x 5.0 cm wide x 0.1cm deep with 25% granulation tissue, 75% slough and .moderate serosanguineous drainage. Review of the Weekly Wound Assessment report revealed there was no documentation the wound assessments were completed the weeks of 1/6/2025 and 1/13/2025. Review of the TAR dated 1/2025, revealed the wound care was not documented as being provided to the right hip, coccyx, left hip and right hip as ordered on 1/3/2025, 1/5/2025, 1/8/2025, 1/9/2025, 1/11/2025, 1/12/2025, 1/13/2025, 1/16/2025, and 1/17/2025. Review of Resident #5's Wound Assessment Report dated 1/21/2025, revealed an unstageable pressure ulcer on the coccyx that measured 8.0 cm long x 11.5 cm wide x 1.0 cm deep, 10% granulation tissue, 50% of slough and 40% of eschar and 0.5 cm undermining (a pocket or cavity forming underneath the skin) with large amount of serosanguinous drainage. Review of Resident #5's Wound Assessment Report dated 1/21/2025, revealed an unstageable pressure ulcer on the left hip measured 2.0 cm long x 1.5 wide x 0.4 cm deep with 25% granulation tissue, 50% of slough and 25% of eschar with moderate serosanguineous drainage. Review of Resident #5's Wound Assessment Report dated 1/21/2025, revealed an unstageable pressure ulcer on the right hip that measured 3.0 cm long x 6.0 cm wide x 3.0 cm deep with 25% granulation tissue, 50% of slough (build up of dead cells/tissue) and 25% of eschar and 3 cm undermining with large serosanguineous drainage. Review of Resident #5's Wound Assessment Report dated 1/21/2025, revealed an unstageable pressure ulcer on the left buttock that measured 5.0 cm long x 5.4 cm wide x 0.3 cm deep with 25% granulation tissue, 50% of slough and 25% of eschar and 0.5 cm undermining with large serosanguineous drainage. The facility failed to conduct weekly assessments and provide treatments as ordered. 7. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Anemia, Hypertension, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS was not assessed due to Resident #11 was severely cognitively impaired. Resident required maximum assistance of staff to perform ADLs. A Stage 2 pressure injury was documented in the assessment that was not present on admission. Review of Physician's Order dated 12/4/2024, revealed Cleanse area to right buttock with normal saline, pat dry, apply honey alginate [used to promote wound healing] to wound bed, and cover with foam dressing one time a day for pressure injury AND as needed . Review of Physician's Order dated 1/21/2025, revealed Cleanse open area to coccyx with NS [Normal Saline, used to cleanse wounds] /wound cleanser; pat dry; apply collagen [used to promote wound healing] and zinc [used to protect the skin as a barrier] to wound bed; cover with dry dressing daily and prn [as needed] one time a day for open area AND as needed for soiled or damaged Review of the TAR dated 12/2024, revealed the wound care was not documented as being provided to the right buttock as ordered on 12/8/2024. Review of Resident #11's Weekly Wound Assessments revealed there was no documentation a wound assessment was conducted the week of 1/7/2025. Observation and interview on 1/21/2025 at 9:48 AM, in Resident #11's room revealed LPN D and CNA G entered the resident's room to perform wound care. LPN D performed ordered wound care with moderate serous drainage reported. Resident did not have a dressing covering wound. LPN D reported wound as a Stage 3. LPN D measured the wound and initially stated the depth was 0.1 cm. LPN D was asked to re-measure the wound bed to the right buttock, as the depth of the wound appeared to be deeper than the first measurement. LPN D reported the measurements as 2.5 cm long x 2.0 cm wide x 0.2 cm deep with the depth measured at the center of the wound bed on the second attempt. LPN D reported wound bed tissue as 75% granulation and 25% slough. 8. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including, Anxiety, Benign Prostatic Hyperplasia, Hypertension, and Retention of Urine. Review of the quarterly MDS assessment dated [DATE], revealed Resident #15 had a BIMS score of 14, which indicated resident was cognitively intact and had 1 stage 3 pressure ulcer on admission. Review of the Resident #15's Wound Assessment Report dated 12/30/2024, revealed the resident had a stage 3 pressure ulcer on his pubis (one of the bones that make up the pelvis) that measured 2.0 cm long x 1 cm wide x 0.1 deep and had moderate serosanguineous drainage. There was no documentation the weekly wound assessment was completed for the weeks of 1/6/2025 and 1/13/2025. Review of the Physician's Order dated 12/31/2024 revealed, .Cleanse area on pubis with wound cleanser or normal saline .cover with calcium alginate silver and cover with a super absorbent dressing .one time a day . Review of the Resident #15's Wound Assessment Report dated 1/21/2025, revealed resident had a stage 3 pressure ulcer on his pubis that measured 1.0 cm long x 4.0 cm wide x 0.5 cm deep with moderate serosanguineous drainage. Review of the TAR dated 1/2025, revealed the wound care was not documented as being provided on the pubis as ordered on 1/5/2025, 1/8/2025, 1/9/2025, 1/10/2025, and 1/16/2025. 9. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Dementia, Dysphagia, Hypertension, and Psychotic Disturbance. Review of the Physician's Orders dated 12/4/2024 revealed, .apply xeroform gauze and cover with band-aid .to right foot plantar [facility acquired] . one time a day . Review of the Physician's Orders dated 12/13/2024 revealed, .Cleanse area on left buttock [facility acquired] with normal saline and apply hydrogel, apply honey alginate and cover with foam dressing .one time a day . Review of the TAR dated 12/2024, revealed the wound care was not documented as being provided on the left buttock as ordered on 12/22/2024 or on the right foot planter on 12/5/2024,12/7/2024 and 12/22/2025. Review of the Physician's Orders dated 12/25/2024 revealed, .Cleanse area on left buttock with wound cleanser or normal saline .apply hydrogel, apply calcium alginate .cover with foam dressing .one time a day .Cleanse area on left hip [facility acquired] with wound cleanser or normal saline .apply calcium alginate and cover with bordered gauze daily .Cleanse outside area on right foot with wound cleanser or normal saline .apply betadine .one time a day .Cleanse wound on inside plantar area on right foot with wound cleanser or normal saline .apply betadine .one time a day . Review of the Weekly Wound assessment dated [DATE] revealed resident had a facility acquired stage 2 pressure ulcer on right foot inside that measured 1.0 cm long x 0.75 cm wide x 0.1 cm deep with 100% granulation tissue. Review of the Weekly Wound assessment dated [DATE] revealed resident had a facility acquired unstageable right foot lateral that measured 1.0 cm long x 1.0 cm wide and 0.1 cm depth, with 100% eschar and scant serosanguineous drainage. Review of the Resident #16's Wound Assessment Report dated 12/30/2024, revealed resident had a facility acquired stage 3 pressure ulcer on the left iliac crest that measured 3.0 cm long x 2.0 cm wide x 0.1 cm deep with 100% of eschar and scant serous drainage. Review of Resident #16's Wound Assessment Report dated 12/30/2024, revealed a facility acquired stage 4 pressure ulcer on the left buttock that measured 2.0 cm long x 2.0 cm wide x 2.25 cm deep, with 100% granulation tissue and had serosanguineous drainage. There was no documentation the weekly wound assessments were completed for the weeks of 1/6/2025 and 1/13/2025. Review of the TAR dated 1/2025, revealed the wound care was not documented as being provided on the left buttock, left hip, outside lateral right foot and inside planter right foot as ordered on 1/5/2025, 1/8/2025, 1/9/2025, 1/10/2025, 1/11/2025, 1/15/2025, and 1/16/2025. 10. Review of the medical record revealed Resident #19 was admitted on [DATE], with diagnoses including Stroke, Heart Failure, Neurogenic Bladder, Diabetes, and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed the facility was unable to perform a BIMS due to Resident #19 was severely cognitively impaired. Resident required max assistance of staff to perform ADLs and had one Deep Tissue Injury that was not present on admission. Review of Physician's Order dated 12/4/2024, revealed Cleanse left heel [facility acquired] with normal saline, apply oil emulsion [a secondary dressing to manage drainage] to wound bed, cover with ABD [Abdominal] pad, and wrap with rolled gauze. one time a day for pressure injury AND as needed for pressure injury. Review of Physician's Order dated 12/13/2024, revealed Cleanse area on left heel with normal saline then apply oil emulsion and calcium alginate [absorbent dressing used to treat moderate to heavily draining wounds] and cover with abd pad and rolled gauze one time a day AND as needed. Review of Physician's Order dated 12/31/2024, revealed Cleanse wound on left heel with wound cleanser or normal saline, pat dry, cover eschar [dead tissue in a wound] with xeroform [used as a non-adherent primary dressing] then apply calcium alginate and abd pad and cover with rolled gauze and secure with cohesive bandage daily. one time a day AND as needed. Review of the TAR dated 12/2024 and 1/2025, revealed the wound care was not documented as being provided on 12/7/2024, 12/8/2024, 12/22/2024, 1/2/2025, 1/17/2025. Review of Resident #19's Weekly Wound Assessments revealed a wound assessment was not conducted the week of 1/8/2025. 11. During an interview on 1/22/2025 at 9:47 AM, the Director of Nursing (DON) was asked should there be blanks on the TAR for wound care treatments. The DON stated, .it means they didn't do their job . and I can't prove that they did or not .because they did not document .as you can tell I haven't been able to monitor .if I had the meetings like I normally do for my weekly wound meeting .there is definitely some new structure coming in to place for this . The DON confirmed physician orders should be followed, and weekly wound assessments should be done. The DON confirmed the ADON should have picked up the weekly wound assessments. The DON stated, That's the way it was designed .there is failure in the system .we were working on the floor and not doing our job . During a telephone interview on 1/22/2025 at 5:49 PM, the Medical Director confirmed wound care should be provided as ordered by the physician and weekly wound assessments should be done. The Medical Director stated, .does that have anything to do with staffing issue, we have had several to quit . I work here in the hospital and see wounds everyday .and hope we are going to get back up to par from where we were .didn't seem to have as many problems . The Medical Director was asked if not providing treatment to the pressure wounds could contribute to wound decline. The Medical Director stated, Definitely, it's up to us to make sure we are doing everything so the wound will heal . During an interview on 1/22/2025 at 5:49 PM, the Administrator confirmed wound care should be provided as ordered by the physician, that the treatment nurse is responsible for completing wound assessments weekly and accurately, and the ADON is ultimately responsible for ensuring that weekly wound assessments are completed.

Based on medical record review, observation and interview the facility failed to provide its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to maintain adequate supplies for staff or services necessary to provide for the needs of residents. The findings include: 1. Review of the medical record revealed that Resident #3 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Hypertension, Diabetes, and Asthma. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated that Resident #3 was cognitively intact. During an interview on 9/15/2025 at 9:57 AM, Resident #3 was asked about the facility running out of supplies. Resident #3 stated the facility ran out of toilet paper and briefs 2 weeks ago and staff had to go to [named retail store]to purchase some. 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Coronary Artery Disease, Diabetes, Debility, and Renal Insufficiency. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 15, which indicated Resident #4 was cognitively intact. Observation and interview in the Resident's room on 1/15/2025 at 3:47 PM, when asked about the facility running out of supplies Resident #4 stated that the size briefs that he normally wears are larger than the pink briefs that the facility has recently been providing him. The Resident picked up a pink brief and stated that it is too tight. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Neurogenic Bladder, Traumatic Brain Injury, Anxiety, Bipolar Disorder, and Schizophrenia. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 15, which indicated Resident was cognitively intact. During an interview on 1/15/2025 at 2:42 PM, Resident #6 stated that the facility ran out of wipes, briefs, and pads. Resident #6 confirmed that her family had to purchase items and bring to the facility for her. The Resident stated that the facility has been out of tea for several weeks. 4. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Depression, Obesity, Anxiety and Diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #7 was cognitively intact. During an interview on 1/15/2025 at 1:09 PM, Resident #7 was asked how his meals were at the facility. Resident #7 stated, .breakfast is crappy, they got a new owner, it's gotten bad, eggs burnt .I asked for ketchup, but I haven't seen it .went 2 days didn't have coffee or tea .no explanation given just said we didn't have any . 5. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including, Diabetes, Atherosclerotic Heart Disease, and Fracture of Left Lower Leg. Review of the admission MDS assessment dated [DATE], revealed the resident had a BIMS score of 15, which indicated Resident #8 was cognitively intact. Observation and interview in Resident #8's room on 1/16/2025 at 1:00 PM, revealed the resident was dressed and sitting in her wheelchair. Resident #8 was asked how her meals were. Resident #8 stated, .this week I got coffee, a couple of days last week I didn't get it [coffee] .I like tea and last week got Kool-Aid .said they didn't have it [tea] . Resident #8 stated, .I have been buying all my wet wipes .said they didn't have any .they don't have briefs the right size .buying my own briefs . I had to wear those diapers, were cutting into me .was uncomfortable .it's just different from when I was here before . 6. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Diabetes, Anxiety, Hypothyroidism, and Hypertension. Review of the admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 13, which indicated Resident #12 was cognitively intact. During an observation and interview in Resident #12's room on 1/16/2025 at 8:55 AM, revealed the resident was neatly dressed and sitting in her wheelchair. Resident #12 was asked how her breakfast was. Resident #12 stated, .sometimes don't get coffee for 3 or 4 mornings .said they didn't have it [coffee] . During an interview on 1/15/2025 at 8:48 AM, the Kitchen Supervisor confirmed the food truck comes to the facility on e time a week. The Kitchen Supervisor stated, .transition has been rocky .budget downsized .usually would spend 6,000 to 6,500 a week .they [referring to the new company] wanted it cut back .we aren't able to get the same options as before [change of ownership] .they have sent different option guide .residents not used to it . During an interview on 1/15/2025 at 9:10 AM, the Dietary Manager was asked if the food budget had been cut. The Dietary Manager stated .we got new guidelines .we had a budget of 4,000 when we first transitioned .not enough at all .one day last week they updated the budget to 6,000 .when we were [Named the previous company] we ran 6,000 a week, but they [new ownership company] didn't know . During an interview on 1/15/2025 at 9:25 AM, Dietary Staff M confirmed that last week they ran out of syrup for French toast, Dietary Staff M stated, .just happened with the new company .with the transition, everything was out .tea .coffee .we would go to the store . During an interview on 1/15/2025 at 10:00 AM, Licensed Practical Nurse (LPN) C was asked if the facility had been running out of food. LPN C stated, .coffee, tea .making Kool-Aide .wrote on the cart [referring to meal cart] don't have syrup for waffles yesterday . During an interview on 1/15/2025 at 11:08 AM, Certified Nursing Assistant (CNA) H, who manages the facility's central supplies, confirmed that the facility ran out of briefs and pull ups. CNA H stated that she entered an order for some to be overnighted. CNA H confirmed that she went to [two named retail stores] to purchase various different sizes of briefs and pull ups. During a telephone interview on 1/15/2025 at 2:51 PM, LPN O stated, .I didn't have supplies I needed to treat the wounds .I'm not going to work somewhere that doesn't supply the needs of the patients .when the new company took over .allotted budget $2,000 for a week including the wound care supplies, the briefs .wipes .the lady that did the ordering prior to that was $2300 every week not including the wound care .it was just brief, wipes .everything for the patient that insurance didn't cover .she said she didn't know what to do, her hands were tied .I went to the DON [Director of Nursing] .I told her I was running out of everything to treat these wounds .she [ DON] said just do the best you can .beginning of December when I started running out [of wound supplies] she [DON] told me to make a list of everything I needed .gave me a credit card .had the DON's name on it .told me to go to [named retail store] .I went and got koban that I needed .there were many days didn't have wipes and wash clothes . LPN O stated, .before this company took over people would scarf the food down .I guess they cut the food budget .I would talk to the patients [residents] and one morning only had oatmeal, dried toast and eggs .didn't have any meat with their breakfast . During an interview on 1/15/2025 at 3:41 PM, Nurse Practitioner (NP) was asked if wound supplies were available. NP stated, Sometimes no .if I couldn't find it .I could change the order [referring to the wound care order] . NP confirmed the facility has had to buy briefs for residents. During a telephone interview on 1/15/2025 at 4:26 PM, Random Staff P stated, .been out of briefs .wipes .soap and I have had to clean a patient [resident] with a pillow case .yesterday I couldn't find wipes .I talked to the Staffing Coordinator .would say we were out of wipes .she said the truck hadn't come; they need those things .and we just don't have it . During an interview on 1/16/2025 at 10:35 AM, CNA J confirmed the facility had been out of coffee and stated, I have a lot of people that drink coffee . CNA J confirmed sometimes the facility runs out of the correct size briefs for the residents and staff will use the smaller briefs for the residents. During a telephone interview on 1/16/2025 at 3:04 PM, Random Staff Q stated, .it's definitely a lot different since the beginning of December .since the new company .lot more complaints .of food .don't have briefs .out of coffee and tea .said somebody from corporate had changed the order around and not given what we had ordered . During an interview on 1/16/2025 at 1:52 PM, CNA I confirmed that the facility had run out briefs, wet wipes, and soap (for bathing) CNA I stated that she had purchased a couple bottles of soap so that her residents could get baths during her shift. CNA I confirmed that the facility has been out of tea and coffee for the last 2 weeks and had an out of syrup sign on the food cart earlier in the week. CNA I stated there has been a shortage of wash cloths in laundry that she was only 3 wash cloths when going to laundry at 9:00 AM. During an interview on 1/16/2025 at 2:41 PM. The DON confirmed that the facility had run out wound care supplies and had been purchased at the [named retail store]. During an interview on 1/16/2025 at 3:56 PM, the Administrator was asked about the facility running out of supplies. The Administrator stated, .with the change over we had a change in vendors .getting our contracts moved to [Named the new company] .we were placing orders had to go through corporate .and the rep [For the new company] didn't realize our shipments comes through Nashville .they [the new food company] comes through Memphis and Memphis does not delivery through [NAME] .that put us behind .the snow put us behind .in one of our shipments .for paper towels, toilet paper .soap .I actually had to place the order and send it to corporate . The Administrator confirmed the food budget had been lowered and stated, .we did buy some toilet paper .we are just now barely 6 weeks in and just now getting a good grasp on what day to order and what day it's going to come in .we have purchased things and get reimburse .there was some confusing .it does make it harder if you delivery dates is 2 days later than it used to be . During an interview on 1/17/2025 at 8:14 AM, Housekeeping Supervisor confirmed that the facility had ran out of washcloths and stated, .we went and bought some washcloths about a week and half ago .ordered some washcloths in December don't know what happened to the order we didn't get them . During an interview on 1/17/2025 at 11:38 AM, Assistant Director of Nursing (ADON) A confirmed that residents didn't have coffee, briefs and the facility had gone and bought briefs for the residents. ADON A confirmed residents had complained about the breakfast being cold and stated, . the residents are used to the quality with [Named the previous company] .and now they aren't happy with a lot of those changes . During a telephone interview on 1/17/2025 at 3:57 PM, LPN L confirmed the facility had ran out of wipes, briefs, body wash, coffee and stated, I went and bought body wash and shampoo (beginning of last week) . LPN L was asked if staff was having to use the wrong size brief on residents. LPN L stated .I have seen it [referring to resident's briefs] .too small . During a telephone interview on 1/21/2025 at 6:50 PM, Random Staff R stated, .we didn't have coffee for a few days for about a week before you guys got here .2 residents .their waffles didn't have any syrup .family brings in briefs . Random Staff R confirmed the facility had been out of soap and stated, .problems started with transition . During a telephone interview on 1/22/2025 at 10:41 AM, Dietary Staff N confirmed the new company had cut their food budget in the beginning and the facility had run out of coffee, tea and syrup for waffles. Dietary Staff N confirmed the previous owners food budget was higher than the new owners and stated, .cut us back a lot .and the resident was coming back at us .I understand they pay so much money to be there . During a telephone interview on 1/22/2025 at 5:05 PM, the Medical Director stated, I think it's been quite a transition .changed ownership .heard had trouble of getting supplies .switched vendors . The Medical Director was asked is the new company cutting the facility back on supplies. The Medical Director stated, I just heard that this week .at the minimal should have syrup with waffles . The Medical Director confirmed the facility should provide what the residents need.

Based on policy review, medical record review, observation, and interview, the facility failed to serve palatable food at a safe and appetizing temperature for 3 of 6 (Resident #7, #8, and #12) sampled residents reviewed for appetizing and palatable meals. The findings include: 1. Review of the facility's policy titled, Food Safety Requirements. dated 12/1/2024 revealed, .It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state .Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Depression, Obesity, Anxiety and Diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #7 was cognitively intact. Observation and interview in Resident #7's room on 1/16/2025 at 9:04 AM, Resident #7 was asked how breakfast was on this morning. Resident #7 stated, .like it [breakfast] always is .eggs cold . Observation and interview in Resident #7's room on 1/17/2025 at 2:21 PM, Resident #7 stated, .eggs still cold .have to get adjusted to eating cold eggs . 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Diabetes, Atherosclerotic Heart Disease, and Fracture of Left Lower Leg. Review of the admission MDS assessment dated [DATE], revealed resident had a BIMS score of 15, which indicated Resident #8 was cognitively intact. Observation and interview in Resident #8's room on 1/16/2025 at 1:00 PM, Resident #8 was asked how her meals were. Resident #8 stated, .the food is not really great here .if I don't have someone to bring me something, I try to eat it .the eggs are always cold . 4. Review of the medical records revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Diabetes, Anxiety, Hypothyroidism, and Hypertension. Review of the admission MDS assessment dated [DATE], revealed resident a BIMS score of 13, which indicated Resident #12 was cognitively intact. Observation and interview in Resident #12's room on 1/16/2025 at 1:26, Resident #12 was asked how her breakfast was this morning. Resident #12 stated, .I ate the cereal .always cold eggs .sausage . 5. Observation in the Kitchen on 1/16/2025 at 7:30 AM, revealed the breakfast tray line began with a menu of scrambled eggs, sausage links, oatmeal, pureed pork, pureed eggs, mechanical sausage, and gravy. Observation on 1/16/2025 at 8:26 AM, revealed the last breakfast tray was served on the 200 Hall. Observation and interview in the Dining Room, on 1/16/2025 at 8:30 AM, with the Dietary Manager present, revealed the Test tray had scrambled eggs were 39.9 degrees in temperature, some of the eggs were brown in color and unpalatable and unappetizing, sausage links were 40.3 degrees in temperature and unpalatable and unappetizing, and the gravy was 31.1 degrees in temperature and unpalatable and unappetizing. The Dietary Manager took a bite of the sausage link, spit it out, and stated, .you can tell we have changed brands . The Dietary Manager was asked if she had any complaints about the food being cold. The Dietary Manager stated, .that's our number one complaint . During an interview on 1/17/2025 at 11:38 AM, Assistant Director of Nursing (ADON) A confirmed most of the complaints are about the breakfast being cold, and stated, . the residents are used to the [food] quality with [Named the previous company] .and now they aren't happy with a lot of those changes . During a telephone interview on 1/17/2025 at 2:47 PM, Licensed Practical Nurse (LPN) L was asked if she had any complaints related to resident's meals being cold. LPN L stated, Many times . During an interview on 1/22/2025 at 9:47 AM, the Director of Nursing (DON) confirmed she had complaints related to residents' food being cold, that meals are important, and residents should enjoy their food.

Based on policy review, medical record review, observation and interview, the facility failed to ensure the resident's right to be treated with dignity was maintained for 1 of 16 (Resident #7) residents sampled for dignity. The findings include: 1. Review of the facility policy titled, Resident Rights, dated 3/7/2023, revealed .The resident has the right to a dignified existence .The resident has a right to be treated with respect and dignity . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Depression, Obesity, Anxiety and Diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #7 was cognitively intact. Review of the Care Plan revised on 12/26/2024, revealed, .resident has an ADL [activities of daily living] self-care performance deficit .BATHING/SHOWERING .resident requires ext [extensive] assist by 1-2 staff with showering .requires extensive assist by 1 staff to a standing position . Review of the medical record dated 1/1/2025, revealed Resident #7 weighed 294 pounds. Observation and interview in Resident #7's room on 1/16/2025 at 9:04 AM, revealed the resident was dressed and lying in bed. Resident #7 stated, .had a shower yesterday .stuck me in a smaller shower chair .I couldn't get up, the chair stuck to me, think they [staff assisting] were laughing at me, it made me feel bad, big fat man stuck in the shower chair . Resident #7's eyes watered up and a tear ran down his face while talking about this. Observation and interview in Resident #7's room on 1/16/2025 at 1:29 PM, revealed the resident was dressed and lying in bed, Resident #7 stated, .the Administrator and Social Worker came and asked me where I wanted it [referring to the 3 CNAs (Certified Nursing Assistants) laughing in the shower room] to end .they were supportive and said they shouldn't have laughed .I didn't know what their [referring to the 3 CNA's] motive was .it made me feel bad . Resident #7 confirmed that was his first time being put in the smaller shower chair and stated, .I didn't know what was going on .nobody was talking . Observation and interview in Resident #7's room on 1/17/2025 at 2:21 AM, revealed staff assisted the resident from his large wheelchair to his bed and Resident #7 stated, .they have ordered 2 more large shower chairs . During an interview on 1/16/2025 at 10:09 AM, CNA K, confirmed when she went in the shower room, Resident #7 was in the smaller shower chair. CNA K stated, .we do have one that is bigger .when I came in the other 2 CNA's were already assisting him .they were both on each side of him and he suggested we used baby oil .he had a shirt on and shorts pulled up above his knee .put baby oil on the right side .I'm behind the shower chair .and when they went to transfer .he leaned to one side to make it easier to get him up .and I pulled the chair out .pulled his pants .and that's when I slid .and that's when we started laughing .and he was at the bar/rail in the shower room .holding on .I was behind him . CNA K confirmed Resident #7 couldn't see her or the other 2 CNAs and they were all 3 laughing. CNA K stated, .we didn't verbalize what happened about me almost fallen . CNA K was asked can you understand why he would think you all were laughing at him. CNA K stated, Absolutely. During an interview on 1/16/2025 at 10:35 AM, CNA J confirmed Resident #7 was a 2 persons assist to get up and one person assist to walk. CNA J was asked why she had used the smaller wheelchair on Resident #7 for his shower. CNA J stated, I have used it before on him .It [referring to the larger shower chair] wasn't in the shower room at the time .I didn't go to the 300 [referring to the shower room] to get it .CNA H helped me get him from the wheelchair to the shower chair . CNA J confirmed she wouldn't use the smaller chair anymore and stated, .stood him up and the shower chair was stuck to him .put baby oil on both his sides .he was laughing and joking about it as well .and I told her [referring to CNA H] to go get another CNA .when she [referring to CNA K] came in she slipped .he [referring to Resident #7] is still in the chair .his back is to her .we giggled .the floor stays wet and then with the baby oil .she catches herself from slipping and she comes over .she holds the back of the chair .and we go under each arm and he came on up .he had on a shirt .shorts about to his knees .I pulled his pants up and rolled the wheelchair under him . CNA J confirmed the resident couldn't see [Named CNA K] slip, he didn't know why they were laughing and it wasn't appropriate for them to laugh and stated, I totally get it . During an interview on 1/16/2025 at 11:11 AM, CNA H stated, .[named CNA J] had asked me to help stand him [referring to Resident #7] up so she could dry his bottom and put him back in the wheelchair .we tried to stand him up and we couldn't get him up . CNA H confirmed the shower chair was stuck on his right side and stated, I left .went to see if anyone was available and [named CNA K] was the first person I saw . CNA H confirmed that she and CNA K walked in the shower room at the same time and stated, .[named CNA J] put baby oil on his right side .I get back on the right side .and [Named CNA J] is on the left .we are facing the door and his back is towards the door .[named CNA K] was at the back of the wheelchair .we counted 1, 2, 3 and we go to stand him up while we are pulling him up .[named CNA K] is working on his hip .we get him up [named CNA K] slipped and that's why we were laughing .we are together all the time .we are goofy .it was a wrong situation at the wrong time . now he thinks we are laughing at him .we should have handled the situation better . During an interview on 1/16/2025 at 3:56 PM, the Administrator stated, .me and the Social Worker went down and talked to him [referring to Resident #7] .CNA assigned to him asked if he was ready for shower .didn't have the larger shower chair .used the smaller one .and that Resident #7 said, My butt is too big isn't this funny .this big fat man is stuck in a chair .I think we need to get another person .and suggested that we get baby oil to get me out of chair .the girl behind me or to the right .started laughing .I thought were they laughing at me or the situation .when I got back into my room .I got into my head and thought it was personal .he teared up with me as well and I asked would he like to talk to someone .he said he was seeing someone and he was already taking medication for his anxiety .going to set him up with a visit with our .psych NP .he was grateful for that .we did talk to the 3 CNAs .him being vulnerable .they just didn't think about it . During an interview on 1/21/2025 at 2:57 PM, Assistant Director of Nursing (ADON) A was asked about the incident with Resident #7's shower chair. ADON A stated, .we have a larger chair .apparently the shower chair was occupied and that's why he was stuck in it .they should have waited for the appropriate size chair . During a interview on 1/22/2025 at 9:47 AM, the Director of Nursing (DON) stated, .we do have wider shower chair .in hind site .should have found another shower chair and started again .when [Named Administrator] went to talk to him .it made him feel afterwards .like it was about him . The DON confirmed moving forward the staff will use the larger shower chair for Resident #7. During a telephone interview on 1/22/2025 at 5:05 PM, the Medical Director was asked should residents be treated with dignity. The Administrator stated, Everybody should.

Based on policy review, medical record review, observation, and interview, the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections when 1 of 2 Licensed Practical Nurses (LPN C) failed to perform hand hygiene during wound care and 5 of 5 (LPN C, LPN D, Certified Nursing Assistant (CNA) E, CNA F, and CNA G) staff failed to wear appropriate Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) during wound care. The findings include: 1. Review of the facility policy titled, Enhanced Barrier Precautions, dated 12/1/2024, revealed .to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds .and/or indwelling medical devices .Implementation of Enhanced Barrier Precautions: PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .High-contact activities include .Wound care: any skin opening requiring a dressing .Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the resolution of the wound or discontinuation of the indwelling medical device . Review of the facility policy titled, Hand Hygiene, dated 12/1/2024, revealed All staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors .If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . 2. Review of the medical record revealed that Resident #2 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Anxiety, and Depression. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #2 was severely cognitively impaired, and had two Stage 3 pressure ulcers that were not present on admission. Observation on 1/16/2025 at 1:31 PM, revealed LPN C and CNA E entered Resident #2's room without PPE or gown. LPN C performed wound care and CNA E positioned the resident without proper PPE. LPN C removed soiled dressing, removed gloves, performed hand hygiene, donned gloves, cleansed right buttock with Normal Saline moistened gauze, cleansed left buttock with Normal Saline moistened gauze, pat dry with gauze, applied oil emulsion to right buttock. LPN C obtained scissors from her scrub pocket and cut and applied the calcium alginate to the right buttock. LPN C removed the soiled gloves and donned gloves without performing hand hygiene, applied oil emulsion to left buttock, applied calcium alginate to left buttock and covered wounds with foam dressing. LPN C and CNA E failed to don PPE for enhanced barrier precautions. LPN C failed to perform hand hygiene that resulted in potential cross-contamination (the transfer of harmful bacteria from one object to another) during wound care to the left buttock. 3. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Anemia, Hypertension, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score was not assessed due to Resident #11 was severely cognitively impaired and had a Stage 2 pressure injury that was not present on admission. Review of a Physician's Order dated 1/21/2025, revealed Cleanse open area to coccyx [base of spine/tailbone] with NS [Normal Saline, used to cleanse wounds] /wound cleanser; pat dry; apply collagen [used to promote wound healing] and zinc [used to protect the skin as a barrier] to wound bed; cover with dry dressing daily and prn [as needed] one time a day for open area AND as needed for soiled or damaged Observation on 1/21/2025 at 9:48 AM, LPN D and CNA G entered Resident #11's room to perform wound care without PPE/gown for enhanced barrier precautions. 4. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including, Chronic Obstructive Pulmonary Disease, Schizophrenia, Anxiety, and Diabetes. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #14 was severely cognitively impaired and was at risk for developing pressure ulcers. Observation and interview on 1/21/2025 at 11:18 AM, prior to entering Resident #14's room, LPN D confirmed the Treatment Administration Record (TAR) showed 2 pressure wounds, 1 on the right buttocks and one on the left buttocks. LPN D and CNA E entered Resident's room to perform wound care without PPE or gown for enhanced barrier precautions. 5. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Malnutrition, Heart Failure, Schizophrenia, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #18 was cognitively impaired, and had 1 Stage 4 pressure ulcer that was present on admission. Observation on 1/21/2025 at 12:06 PM, LPN D and CNA F entered Resident #18's room without PPE or gown for Enhanced Barrier Precautions to perform wound care. LPN D performed ordered wound care and CNA F assisted with positioning the resident without proper PPE. During an interview on 1/21/2025 at 3:24 PM, the Assistant Director of Nursing (ADON) A confirmed that staff should wear gown and gloves as PPE while performing wound care with residents in Enhanced Barrier Precautions. During an interview on 1/22/2025 at 9:20 AM, the Director of Nursing (DON) confirmed that hand hygiene should be performed before donning gloves, immediately after removing gloves and during wound care. The DON confirmed that a gown should be worn as a part of PPE for EBP during wound care.

Based on policy review, medical record review, and interview the facility failed to develop a person-centered care plan for 1 of 19 (Resident # 11) residents reviewed for pressure ulcers. The findings include: 1. Review of the facility's policy titled, Comprehensive Care Plan, dated 12/1/2024, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 2. Review of the medical record revealed that Resident #2 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Anxiety, and Depression. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 3, which indicated Resident #2 was severely cognitively impaired, and had two Stage 3 pressure ulcers that were not present on admission. Review of the Weekly Wound assessment dated [DATE], revealed Resident #2 had a Stage 3 pressure ulcer to the left buttock with the initial date of treatment on 12/30/2023. The facility failed to care plan for pressure ulcer care and management. During an interview on 1/21/2025 at 11:53 AM, the MDS Coordinator confirmed that residents assessed for pressure ulcers should have a care plan for pressure ulcers. During an interview on 1/22/2025 at 9:20 AM, the Director of Nursing confirmed that a resident assessed for pressure ulcers should have interventions and goals on the resident's care plan to address the pressure ulcers.

Based on policy review, review of staff competency documentation, medical record review, observation and interview the facility failed to ensure licensed nurses had the skills and knowledge to detect changes in a resident's condition related to pressure ulcers for 9 of 9 (Residents #1, #2, #5, #11, #14, #15, #16, #18, #19) sampled residents. The findings include: 1. Review of the facility policy titled, Pressure Injury Prevention and Management, dated 2/14/2023, revealed .to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .Licensed nurses will conduct a full body assessment on all residents upon admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse and documented. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS [Minimum Data Set] .Training in the completion of the pressure injury risk assessment, full body assessment, and pressure injury assessment will be provided as needed .After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. The RN [Registered Nurse] Unit Manager .will review all relevant documentation regarding skin assessments, pressure injury risks, program towards healing, and compliance at least weekly, and document a summary of findings in the medical record. The attending physician will be notified of presence of new pressure injury upon identification, the progression towards healing or lack of healing of any pressure injuries weekly, any complications .Any changes in the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner . Review of the undated facility policy titled, Documentation of Wound Treatments, revealed The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition and changes in treatment .Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. The following elements are documented as part of a complete wound assessment: Type of wound (pressure injury, surgical .) and anatomical location. Stage of the wound, if pressure injury (stage 1, 2, 3, 4, deep tissue injury, unstageable pressure injury) or the degree of skin loss if non-pressure (partial or full thickness) Measurements: height, width, depth, undermining, tunneling .Description of wound characteristics: Color of the wound bed, type of tissue in the wound bed (granulation, slough, eschar, epithelium), Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated), Presence, amount, and characteristic of wound drainage/exudate, Presence of odor, Presence of pain .Wound treatments are documented at the time of each treatment . 2. The facility was unable to provide documentation of certification or training regarding assessment, staging, treatment, or evaluation of wounds for the Assistant Director of Nursing (ADON) who was responsible for the wound care and treatments in the facility. Review of the facility competency documentation for LPN D performing wound care, revealed no documentation of education or training related to wound assessment, staging, and treatment of pressure wounds prior to 1/21/2025. Review of the facility form AHC Dressing Change Competency, for LPN C dated 6/20/2024, failed to address wound assessment, staging, and treatment of pressure wounds. Review of the Wound Staging Competency and Wound Care Validation Checklist dated 1/21/2025, revealed LPN D signed and dated the checklist form for completion by third party company. 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Coronary Artery Disease, Hypertension, Pneumonia, Diabetes, and Malnutrition. Facility nursing staff failed to assess and measure the following wounds on 8/9/2024: Stage 2 pressure injury to middle lower back, Deep Tissue Injury to left heel, Deep Tissue Injury to right heel, Deep Tissue Injury to right foot 1st digit. 4. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Dementia, Anxiety, and Depression. Review of the Weekly Wound Assessments dated 12/23/2024 and 12/30/2024, revealed Resident #2's Left buttock wound changed from a Stage 4 to a Stage 3 with the following measurements: a. 12/23/2024 - 6.0 cm (centimeters) x 3.0 cm x 0.1cm Stage 4 b. 12/30/2024 - 6.0 cm x 3.0 cm x 0.1cm Stage 3 During an interview on 1/21/2025 at 8:45 AM, Assistant Director of Nursing (ADON) B was asked regarding Resident #2's wound staging documentation. ADON B confirmed that on the 12/23/2024 wound assessment Resident #2's left buttock was documented as a Stage 4 and on 12/30/2024 it was documented as a Stage 3. ADON B confirmed that the wound care nurse should not change the staging of the wound once it was a Stage 5. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Adult Failure to Thrive, Dysphagia, Depression, and Polyneuropathy. Review of the Physician's Order dated 12/6/2024 revealed wound care to the coccyx [base of spine/tailbone], left and right hip one time a day. Review of the Treatment Administration Record (TAR) dated 12/2024, revealed no documentation to show wound care was provided to?the coccyx, left hip and right hip as ordered on 12/11/2024 and 12/22/2024. Review of the (TAR) dated 1/2025, revealed no documentation to show wound care was provided to the coccyx, left hip and right hip as ordered on 1/3/2025, 1/5/2025, 1/8/2025, 1/9/2025, 1/11/2025, 1/12/2025, 1/13/2025, 1/16/2025, and 1/17/2025. Resident #5's unstageable pressure ulcers to the right hip, left hip, and coccyx (base of spine/tailbone) deteriorated. 6. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Anemia, Hypertension, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a Stage 2 pressure injury that was not present on admission. Review of Resident #11's Weekly Wound Assessments revealed there was no documentation to show a wound assessment was conducted the week of 1/7/2025. Observation and interview on 1/21/2025 at 9:48 AM, in Resident #11's room, LPN D reported wound as a Stage 3. 7. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including, Chronic Obstructive Pulmonary Disease, Schizophrenia, Anxiety, and Diabetes. Review of Physician Order dated 12/6/2024, revealed wound care to the right and left buttock one time a day. ?? Review of the TAR dated 12/2024, revealed no documentation to show wound care was provided as ordered for the left and right buttock on 12/7/2024,12/8/2024 and 12/9/2024. Review of Physician Order dated 12/30/2024 revealed wound care to the left and right buttock one time a day. There was no documentation the weekly wound assessments were performed the weeks of 1/6/2025 and 1/13/2025. ? Review of the TAR dated 1/2025, revealed no documentation to show wound care was provided as ordered to the left and right buttock on 1/9/2025, 1/11/2025, 1/13/2025, 1/14/2025, 1/15/2025 and 1/16/2025. Resident #14's wound deteriorated. 8. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including, Anxiety, Benign Prostatic Hyperplasia, Hypertension, and Retention of Urine. Review of the quarterly MDS assessment dated [DATE], revealed Resident #15 had 1 stage 3 pressure ulcer on admission. Review of the Resident #15's Wound Assessment Report dated 12/30/2024, revealed a stage 3 pressure ulcer on the pubis (one of the bones that make up the pelvis) that measured 2.0 cm long x 1 cm wide x 0.1 deep and had moderate serosanguineous drainage. Review of the Physician's Order dated 12/31/2024 revealed wound care to the pubis one time a day. There was no documentation the weekly wound assessments were completed for the weeks of 1/6/2025 and 1/13/2025. Review of the TAR dated 1/2025, revealed no documentation to show wound care was provided on the pubis as ordered on 1/5/2025, 1/8/2025, 1/9/2025, 1/10/2025, and 1/16/2025. Review of Resident #15's Wound Assessment Report dated 1/21/2025, revealed resident had a stage 3 pressure ulcer on his pubis that measured 1.0 cm long x 4.0 cm wide x 0.5 cm deep with moderate serosanguineous drainage. Resident #15's wound deteriorated. 9. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Dementia, Dysphagia, Hypertension, and Psychotic Disturbance. The facility failed to ensure Resident #16's weekly wound assessments were completed on 1/6/2025 and 1/13/2025. Review of the TAR dated 1/2025, revealed no documentation to show wound care was provided as ordered on 1/5/2025, 1/8/2025, 1/9/2025, 1/10/2025, 1/11/2025, 1/15/2025, and 1/16/2025 to the left buttock stage 4, the right outside lateral foot unstageable, right inside planter (sole) foot stage 2 and left iliac crest (curved part at top of hip) unstageable. 10. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Malnutrition, Heart Failure, Schizophrenia, and Depression. There was no documentation the weekly wound assessment was completed for the week of 1/6/2025 and 1/13/2025 Facility staff failed to properly assess and identify the wound stage due to insufficient training. Review of the TAR dated 1/2025, revealed no documentation wound care was provided as ordered on the sacrum on 1/5/2025, 1/8/2025, 1/9/2025, 1/10/2025, 1/11/2025, 1/12/2025, 1/13/2025, 1/14/2025, 1/15/2025, 1/16/2025 and 1/18/2025. Resident #18's Stage 4 wound deteriorated. 11. Review of the medical record revealed Resident #19 was admitted on [DATE], with diagnoses including Stroke, Heart Failure, Neurogenic Bladder, Diabetes, and Dementia. Review of the TAR dated 12/2024 and 1/2025, revealed no documentation wound care was provided as ordered on 12/7/2024, 12/8/2024, 12/22/2024, 1/2/2025, 1/17/2025. Review of Resident #19's Weekly Wound Assessments revealed a wound assessment was not conducted the week of 1/8/2025. Resident #19 developed a Deep Tissue Wound Injury that progressed to an unstageable pressure injury as a result of the facility's failure to perform weekly wound assessments and wound care as ordered. During an interview on 1/22/2024 at 9:20 AM, the Director of Nursing (DON) was asked regarding the deterioration of Resident #11's wound from a stage 2 to a stage 3 on 12/30/2024. The DON stated that the wound was staged incorrectly in the beginning. The DON confirmed that the treatment nurse is responsible for completing wound assessments weekly and accurately, and the ADON is ultimately responsible for ensuring that weekly wound assessments are completed.

Based on policy review, medical record review, and interview, the facility failed to ensure residents were free of accidents, when staff failed to properly use the Hoyer lift during a transfer and failed to report the incident timely for 1 of 3 (Resident #1) residents reviewed for falls. The findings include: 1. Review of the facility's policy titled, Safe Resident Handling and Transferring, dated 10/2022, revealed .It is the policy of this facility to provide safe handling and transferring for residents who need assistance . Review of the facility's policy titled, Accidents and Supervision, dated 10/21/2022, revealed .The resident environment remains free of accident hazards . Review of the facility's policy titled, Occurrence Reporting, dated 12/01/2022, revealed .Our facility shall .provide a safe environment .The following are examples .accidents/incidents .Falls .All observed, reported, or other acquired knowledge .shall be reported to the charge nurse .by the employee who finds or witnesses . Review of the undated Hoyer lift manufacturer's guidelines revealed, .step by step instructions for proper use of the lift .Transferring to a Wheelchair .The legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety . 2. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses of Severe Morbid Obesity, Osteoarthritis, Abnormalities of Gait and Mobility, and Restless Leg Syndrome. Review of the Care Plan dated 8/9/2022 revealed, .Self care deficit R/T [related to] ambulation .locomotion and transfers .Staff may use hoyer lift for transfers with 2 staff present . Review of the quarterly Minimum Data Set assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status of 15, which indicated he had intact cognition, and required 2 plus persons for physical assistance with transfers. Review of the undated Interdisciplinary Team Occurrence Investigation Worksheet, revealed .Physical Function problems that may have contributed to the fall .Muscle Weakness .The root cause of the occurrence .Hoyer transfer to chair .Intervention(s) put in place .Inservice on proper Hoyer Technique . Review of the NURSE'S EVENT NOTE dated 4/20/2023, revealed .4/18/2023 .Location Incident Occurred .Shower room .area of injury .Bar from hoyer hit forehead . Review of the Nursing Note dated 4/19/2023 at 12:04 PM, revealed .Resident is to be sent to the ER [emergency room ] for eval [evaluation] and treatment due to a previous incident that occurred in the shower room yesterday. Resident stated that he is having neck, back, and right leg pain at this time and his RP [responsible party] want him to be seen .Resident's friend .called .and stated that resident had the Hoyer lift fall on him yesterday. I spoke with the resident in his room, and he stated that Hoyer lift fell over while he is [was] in the sling yesterday. Resident stated the arm of the Hoyer lift hit his left forehead. Resident stated he was not hurting yesterday .felt pain .when he woke up this morning and nurse had given him some pain medication .requested resident to be sent to ER .NP [Nurse Practitioner] .gave order for resident to be sent to ER . Review of the Nursing Note dated 4/19/2023 at 5:37 PM, revealed .Resident returned back with no new orders, but to follow up with PCP [Primary Care Provider] . Review of the Resident Care Summary assessment dated [DATE] revealed, .Safety .Fall Risk .Transfer .Ax2 [Assist times 2] Hoyer Lift .Other Interventions .Inservice on proper Hoyer technique . During an interview on 6/20/2023 at 11:46 AM, Resident #1 was asked what happened when he fell in the shower room. Resident #1 stated .I was in the shower room, CNAs [Certified Nursing Assistants] were using a lift .had me up on the lift in an angle, the lift got off balance. I was hanging in the air .the lift went sideways. I was going down and the metal bar from the lift hit me in the head. I fell into the wheelchair .the whole lift was on its side on the floor .it took 2 or 3 people to get the lift off the floor. I was still connected to the lift pad and straps .I had to ask to get me checked out before they sent me to the ER, was not hospitalized , no injuries from the fall . During a telephone interview on 6/21/2023 at 5:14 PM, CNA #1 was asked what happened in the shower room with Resident #1. CNA #1 stated, .After giving [named Resident #1] a shower, I was using the Hoyer lift to transfer [named Resident #1] .there is a lever that opens and shuts the legs of the Hoyer lift, when I had the legs open, I think I hit the lever with my knee, and it closed the legs .[nursing] students were holding the lift to keep the lift straight, the Hoyer lift tilted to one side, the flat metal bar .tilted and hit his head .[named Resident #1] landed in the wheelchair .when [Named CNA #2] came in, the Hoyer lift was still tilted, she [CNA #2] pulled the emergency thing to let the bar down, to unhook the straps .the lift pad was still under [named Resident #1] in the chair . CNA #1 confirmed the incident was on 4/18/2023 and she did not report the incident until 4/19/2023. CNA #1 stated, .hate it happened should have been thinking more . During a telephone interview on 6/21/2023 at 5:52 PM, CNA #2 was asked about the incident in the shower room with Resident #1 and the Hoyer lift. CNA #2 stated, I heard a commotion. I peeped in the shower room and [named Resident #1] was in a wheelchair. There were student nurses around the back, the lift had tilted .on him .the lift's metal bar was too high to remove the straps I pulled the emergency lever to get it down enough to remove the straps .I got the bar down, I pulled the lift from under the wheelchair, the legs of the lift were not open . CNA #2 stated, .[named CNA #1] did not have the legs of the Hoyer in the right position . Review of the Work Summary Report sheet dated 4/18/2023, revealed CNA #1 worked that day. During an interview on 6/22/2023 at 2:57, the Staffing Coordinator confirmed an investigation was completed on 4/19/2023 related to the incident that occurred on 4/18/2023 involving Resident #1, a Hoyer lift and CNA #1. The Staffing Coordinator confirmed CNA #1 did not report Resident #1 had fallen into his wheelchair during a transfer using the Hoyer lift and that the metal bar of the Hoyer lift hit Resident #1's head. The Staffing Coordinator confirmed CNA #1 failed to safely handle and transfer Resident #1 while in the shower room on 4/18/2023. Review of the facility's Corrective Action Document dated 4/19/2023 and related to CNA #1, revealed .Unsatisfactory job performance .Failure to report a resident event to charge nurse or any other administrative personnel .Employee suspended pending further investigation .discussed via phone . Review of the facility's Employee Notification of Termination dated 4/21/2023, revealed CNA #1's termination date was 4/21/2023. During an interview on 6/22/2023 at 4:33 PM, the Director of Nursing (DON) was asked when and to whom should a CNA or any staff member report an accident or incident involving a resident. The DON stated .immediately to the charge nurse . The DON was asked is it correct to say CNA #1 did not immediately report the incident with the Hoyer lift and Resident #1. The DON stated, .yes and the disciplinary action was to let her go because none of the nurses or management knew it until the next day .

Based on facility employee file review, policy review, Licensed Practical Nurse (LPN) Job Description, and interview, the facility failed to ensure staff State of Tennessee (TN) nursing license were current and up to date for 1 of 3 (LPN #1) staff members reviewed for licensure. The findings include: Review of .nursys .QuickConfirm License Verification Report, dated 11/9/2021 revealed LPN #1 had an unencumbered, compact, multistate license issued in Arizona on 8/25/2009, with an expiration date of 4/1/2023. Review of the facility's Job Description .LPN, dated 12/28/2020, and signed by LPN #1 on 11/14/2021 revealed, .The Licensed Practical Nurse .To perform this job .REQUIRED QUALIFICATIONS .Current State of Tennessee Licensed Practical Nurse . Review of the facility's policy titled, Nursing Services and Competent Staff, dated 10/24/2022, revealed, .It is the policy of this facility to provide sufficient nursing staff with appropriate competencies .to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .The facility shall supply services .of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans .Except when waived, licensed nurses .The facility must ensure that licensed nurses .have the specific competencies and skill sets necessary to care for resident's needs . Review of the facility's Work Summary Report, dated 5/1/2022 through 5/21/2022, revealed LPN #1 worked 5/16/2022, 5/17/2022, 5/20/2022, and 5/21/2022 without a multi-state or TN Nursing License. Review of the Timesheet Report, dated 5/22/2022 through 2/4/2023, revealed LPN #1 Worked the following days without a multi-state or TN Nursing License: On 5/22/2022, 5/25/2022, 5/26/2022, 5/30/2022, and 5/31/2022. On 6/3/2022, 6/4/2022, 6/5/2022, 6/8/2022, 6/9/2022, 6/12/2022, 6/13/2022, 6/14/2022, 6/17/2022, 6/18/2022, 6/19/2022, 6/21/2022, 6/22/2022, 6/23/2022, 6/26/2022, 6/27/2022, and 6/28/2022. On 7/1/2022, 7/2/2022, 7/3/2022, 7/5/2022, 7/6/2022, 7/7/2022, 7/8/2022, 7/10/2022, 7/11/2022, 7/12/2022, 7/15/2022, 7/16/2022, 7/17/2022, 7/20/2022, 7/21/2022, 7/24/2022, 7/26/2022, 7/29/2022, 7/30/2022, and 7/31/2022. On 8/2/2022, 8/3/2022, 8/4/2022, 8/7/2022, 8/8/2022, 8/17/2022, 8/18/2022, 8/22/2022, 8/23/2022, 8/26/2022, 8/27/2022, 8/28/2022, and 8/31/2022. On 9/1/2022, 9/5/2022, 9/6/2022, 9/8/2022, 9/9/2022, 9/10/2022, 9/11/2022, 9/28/2022, 9/29/2022, and 9/30/2022. On 10/3/2022, 10/4/2022, 10/5/2022, 10/6/2022, 10/7/2022, 10/8/2022, 10/9/2022, 10/12/2022, 10/13/2022, 10/16/2022, 10/17/2022, 10/18/2022, 10/21/2022, 10/22/2022, 10/23/2022, 10/24/2022, 10/26/2022, 10/27/2022, 10/28/2022, and 10/31/2022. On 11/1/2022, 11/4/2022, 11/5/2022, 11/6/2022, 11/7/2022, 11/9/2022, 11/10/2022, 11/14/2022, 11/15/2022, 11/18/2022, 11/19/2022, 11/20/2022, 11/23/2022, 11/24/2022, 11/28/2022, and 11/29/2022. On 12/2/2022, 12/3/2022, 12/4/2022, 12/7/2022, 12/8/2022, 12/12/2022, 12/13/2022, 12/14/2022, 12/16/2022, 12/17/2022, 12/18/2022, 12/20/2022, 12/21/2022, 12/22/2022, 12/26/2022, 12/27/2022, 12/30/2022, and 12/31/2022. On 1/1/2023, 1/4/2023, 1/5/2023, 1/9/2023, 1/10/2023, 1/13/2023, 1/14/2023, 1/18/2023, 1/19/2023, 1/23/2023, 1/24/2023, 1/27/2023, 1/28/2023, 1/29/2023, and 1/30/2023. On 2/1/2023, 2/2/2023, and 2/4/2023. Review of the Work Summary Report, dated 2/5/2023 through 2/23/2023, revealed LPN #1 worked 2/6/2023, 2/7/2023, 2/8/2023, 2/10/2023, 2/11/2023, 2/12/2023, 2/15/2023, 2/16/2023, 2/20/2023, and 2/21/2023 without a multi-state or TN Nursing License. Review of the STATE OF TENNESSEE DEPARTMENT OF HEALTH .LICENSURE AND REGULATION DIVISION OF HEALTH RELATED BOARDS .verification of licensure in the State of Tennessee .Licensed Practical Nurse .[name LPN #1] .ISSUE DATE .2/27/2023 . LPN did not receive her multi-state TN Nursing License until 2/27/2023. Review of the Employee Summary from LPN #1's employee file dated 6/22/2023, revealed LPN #1's date of hire was 11/18/2021. During an interview on 6/21/2023 at 5:45 PM, LPN #1 confirmed her date of hire was November 2021 and at that time she had a multi-state compact nursing license issued in Arizona (AZ). LPN #1 was asked when she notified the AZ Board of Nursing that her state of residency had changed to Tennessee (TN). LPN #1 stated, I don't know exactly. LPN #1 was asked did the AZ Board of Nursing notify her that her nursing license changed from a multi-state compact license to a single state license when she changed her state of residency to TN. LPN #1 stated, No .to my knowledge they never told me it was single state. LPN #1 stated, .my understanding it was a multi-state license and I never thought to look again [on the AZ Board of Nursing portal] .the facility gave me a form to declare my residency [to TN]. LPN #1 confirmed she was not aware that she had worked from 5/13/2023 until 2/27/2023 without a valid multi-state or TN Nursing License. LPN #1 stated, That was not to my knowledge .I don't know at what point and why [nursing license changed from a multistate license to a single state license]. During an interview on 6/22/2023 at 1:30 PM, the Regional Nurse Consultant (RNC) stated, .TN Board of Nursing issued [LPN #1] a TN state [nursing] license in February of 23 [2023] with no restrictions .[I] reached out to AZ .there is a nursing portal they can log in to and she [LPN #1] logged in [to the portal] in May [2022] and changed her address in the portal on 5/13/2022 .when she did that it automatically changed her residency to Tennessee and you can't have a multistate license in 2 different states and you also can't have a multi-state license in a different state than your primary residency state .automatically converted that license to a single-state license. I asked them who was notified and how she was notified. They said at that time they did not notify anybody .they said that was part of the compact state rules .her responsibility [to know compact state rules] .I asked them did they notify the TN Board of Nursing, and they said no .asked TN [Board of Nursing] what triggers your license to transfer from a multi-state license to a single-state [license] and they told conviction of a felony, obtaining another multi-state compact license and being put on the abuse registry .I asked AZ the same thing and they said change in residency .They [AZ Board of Nursing] couldn't specifically say the date she changed her address [in the portal], but they did it [changed her to a single-state AZ Nursing License] on 5/13 [2022] . The RNC confirmed LPN #1 did not have a multi-state or TN Nursing License from 5/13/2022 until 2/27/2023, when her TN Nursing License was issued. The RNC stated, We didn't know it, or we wouldn't have let the girl work. The RNC was asked when LPN #1 applied for a Tennessee Nursing License. The RNC stated, November 16th [2022]. Review of the .nursys .QuickConfirm License Verification Report, dated 6/29/2023, revealed LPN #1's AZ license had been changed to a single-state license issued in AZ with an expiration date of 4/1/2023. The report did not list when LPN #1's nursing license were changed to a single-state AZ Nursing License.

Based on policy review, medical record review, and interview, the facility failed to ensure a resident with a knee immobilizer received services for the prevention of pressure ulcers for 1 of 3 sampled residents (Resident #7) reviewed for the use of an immobilization device. The facility's failure to provide preventative treatment resulted in Actual Harm when Resident #7 developed a Stage 3 Pressure Ulcer. The findings include: 1. Review of the facility's policy Pressure Injury Prevention and Non-Pressure Ulcer Management dated 9/28/2022 revealed, This facility is committed to the prevention of avoidable pressure injuries .It is the policy of this facility to implement evidence - based interventions for all residents who are assessed at risk .The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear .Avoidable means the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following .evaluate the resident's clinical condition and risk factors .define and implement interventions that are consistent with residents needs .A pressure ulcer is any lesion caused by intense and/or prolonged pressure that results in damage to the underlying tissue .Examples of risk factors include .Impaired / decreased mobility and decreased functional ability .Resident refusal of some aspects of care and treatment . 2. Review of the closed medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Fracture Right Pubis, Fracture Left Lower Femur, Encounter of Surgical Aftercare, Osteoarthritis, Pressure Ulcer Right Buttocks Unstageable, Pressure Ulcer Left Buttocks Unstageable, Pressure Ulcer Sacral Region Unstageable, and Difficulty Walking. Review of the Care Plan dated 11/12/2022 revealed, .fractures .self-care deficit .At risk for impaired skin integrity .friction noted to left distal leg 12/29/2022 .now stage 3 pressure ulcer .left lower leg friction 12/15/2022 .Stage 3 Pressure Ulcer Left Distal Leg .Observe for changes in lower extremity skin integrity . Review of the Hospital Physician's Order dated 11/19/2022 revealed, .Knee Immobilizer may be off in bed but on any time being mobilized . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition, and required extensive to total staff assistance Activities of Daily Living (ADLs). Review of the facility's Braden Scale for Predicting Pressure Injury Risk dated 11/29/22, 12/6/2022, and 12/13/2022 revealed Resident #7 was assessed with a score of 15, indicating Resident #7 was at risk for developing pressure ulcers. Review of the November 2022 Treatment Administration Record (TAR) revealed the knee immobilizer was applied nightly from 11/22/2022 to 11/30/2022. The facility was unable to provide documentation that the skin was assessed before or after the application of the knee immobilizer. Review of the facility's Wound assessment dated [DATE] revealed, .Facility acquired .Location of Wound .Lower Leg Left Lower/Distal .Wound Type . Friction .Partial Thickness .0.70 x [by] 0.50 x 0.1 [centimeters] .area due to brace that has rubbed skin . Review of the Wound assessment dated [DATE] revealed, .1.5 x 1.5 x 0.1 [centimeters] .area presently has 50% [percent] slough and will now be staged at 3. Resident continues to wear brace will [while] up and removed while in bed. Area is due to pressure from brace .Wound Progression .declined .Stage Increased .Yes . Review of the Orthopedic Physician's order dated 12/22/2022 revealed, .She is to have the brace off at rest .only on for ambulating . Review of the December 2022 TAR revealed the knee immobilizer was applied nightly from 12/1/2022 to 12/31/2022. The facility was unable to provide documentation that the skin was assessed before or after the application of the knee immobilizer. Review of Orthopedic Physician's order dated 1/5/2023 revealed, .Brace for ambulation only .otherwise off. Review of the January 2023 TAR revealed the knee immobilizer was applied nightly from 1/1/2023 to 1/9/2023. The facility was unable to provide documentation that the Left Lower Distal Leg was assessed underneath the immobilizer for the prevention of pressure ulcers and/or injuries. During an interview on 1/31/23 at 2:15 PM the Treatment Nurse confirmed she did the initial skin assessments after the nurses did the admission skin assessment or if a nurse found an area on a resident. The Treatment Nurse confirmed that she did not check any other areas on residents other than the areas that had wounds. The Treatment Nurse confirmed Resident #7 wore the immobilizer all the time. The Treatment Nurse confirmed the nurses checked skin weekly and not daily unless an area was found or reported to them, and then they assessed only the area of concern. During an interview on 2/2/23 at 2:36 PM, Licensed Practical Nurse (LPN) #7 confirmed she was informed by therapy staff that Resident #7 had a wound on her left lower leg. LPN #7 confirmed that nurses were supposed to check skin daily when residents wore any kind of brace or immobilizer. LPN #7 was asked if she ever had to apply or remove the immobilizer to Resident #7 left lower extremity. LPN #7 confirmed on the nights that she worked past 7:00 PM she applied the brace before she left because the resident was in the bed for the night at that time. LPN #7 was asked how often Resident #7 had the brace on. LPN #7 confirmed that Resident #7 wore the brace when she got up to go to therapy in the mornings and when she went back to bed. LPN #7 was asked if Resident #7 had a wound to her left lower leg. LPN #7 confirmed she was informed by therapy staff that there was a wound on her left lower leg. LPN #7 stated, .when it (wound) was found she [Resident #7] was wearing it (immobilizer) all the time . During an interview on 2/2/23 at 3:52 PM, LPN #8 confirmed Resident #7 was readmitted to the facility on [DATE] and had a knee immobilizer. LPN #8 confirmed that the immobilizer was to be applied at night while she was sleeping and when she was in the bed. LPN #8 confirmed she applied the immobilizer to Resident #7's left lower extremity every night she worked. During an interview on 2/2/23 at 4:37 PM, the Director of Nursing (DON) confirmed nursing failed to follow physician orders for the use of the immobilizer. The DON confirmed the nurses should be checking the skin underneath the immobilizer, and there should be a monitor to document the skin checks in the MAR or the TAR.

Based on CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) 3.0 Manual, medical record review, and interview, the facility failed to ensure the completion of a significant change Minimum Data Set (MDS) assessment within 14 days for the development of pressure ulcers at stage 2 or higher for 1 of 3 (Resident #1) residents reviewed for pressure ulcers. The findings include: Review of the CMS RAI Manual revealed, .Significant Change in Status Assessment (SCSA) .is a comprehensive assessment for a resident that must be completed .for either major improvement or decline .A 'significant change' is a major decline or improvement in a resident's status that .will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .impacts more than one area of the resident's health status .requires interdisciplinary review and/or revision of the care plan .the nursing home may take up to 14 days to determine whether the criteria are met .The resident's condition is not expected to return to baseline within two weeks .if the condition has not resolved within 2 weeks, staff should begin an SCSA .Emergence of unplanned weight loss problem (5% [percent] change in 30 days or 10% change in 180 days) .Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Systemic Lupus, Schizophrenia, Bipolar Disorder, Depression, Anxiety, and Dysphagia. Review of the quarterly MDS dated [DATE] revealed Resident #1 had a Stage 3 Pressure Ulcer and 3 Unstageable Pressure Injuries which presented as Deep Tissue Injuries. Review of the medical record revealed the following Pressure Ulcers for Resident #1: a. Left Upper Proximal Foot identified on 9/15/2022 as a Deep Tissue Injury and was present when the resident was discharged to the hospital on 1/10/2023 b. Left Medial Foot identified on 10/31/2022 as an Unstageable and was present when the resident was discharged to the hospital on 1/10/2023 c. Left Elbow identified on 12/5/2022 as an Unstageable with 100% eschar that remained present until the resident was discharged to the hospital on 1/10/2023 d. Right Buttocks Stage 3 Identified on 12/12/2022 that remained present until the resident was discharged to the hospital on 1/10/2023 e. Left Ischium (lower buttock folds) identified on 12/12/2022 as an Unstageable with 100% slough that remained present until the resident was discharged to the hospital on 1/10/2023 During an interview on 2/2/23 at 4:37 PM, the Director of Nursing (DON) was asked if a resident had a decline in status such as the development of a pressure ulcer that did not resolve in 2 weeks, should a significant change assessment be completed. The DON stated, Yes, anyone that has that type of change we want to do a significant change . The facility failed to complete a significant change MDS assessment to reflect the development of pressure ulcers with stages greater than Stage 2.

Based on policy review, medical record review, and interview, the facility failed to include a resident or family member in the Interdisciplinary Team (IDT) Care Plan meeting for 2 of 12 sampled residents (Resident #3 and #18) reviewed for Care Plan Meetings. The findings include: Review of the facility's policy titled, Care Planning-Resident Participation, dated 10/18/2021, revealed .This facility supports the resident's right to be informed of, and participate in his or her care planning and treatment .the facility will notify the resident and/or resident representative, in advance .to the plan of care .and assist the resident and/or .representative to participate in choosing care . Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Interdisciplinary Plan of Care Review dated 11/1/2021, revealed a family member participated in the IDT meeting via phone. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #3 was moderately impaired for cognitive skills for daily decision making. The facility was unable to provide documentation that the resident or representative had been invited to the IDT Care Plan meeting since 11/1/2021. During a phone interview on 5/16/2022 at 1:28 PM, Resident #3's family member was asked if she had been invited to/or participated in a Care Plan meeting. The family member stated, We have not been invited for 3 to 4 months now . Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Interdisciplinary Plan of Care Review dated 8/20/2021, revealed a family member participated in the IDT meeting via phone. Review of the significant change status MDS dated [DATE], revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The facility was unable to provide documentation that the resident or representative was invited to the IDT Care Plan meeting since 8/20/2021. During an interview on 5/17/2022 at 8:37 AM, Resident #18 was asked if she had been invited to/or participated in a Care Plan meeting. Resident #18 stated, .I know I haven't, and my brother hasn't told me about one either . During an interview on 5/17/2022 at 12:22 PM, the Administrator confirmed the IDT meetings are held quarterly and the resident and/or their representative had not been invited.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 5 of 9 sampled residents (Resident #18, #22, #56, #65, and #154) had alternative food and menu choices. The findings include: Review of the facility's policy titled, Dietary: Resident Dietary Needs, Allergies .Preferences and Substitutes, dated 11/30/2021, revealed .To ensure that facility staff support the nutritional well-being of the residents while respecting an individual's right to make choices about his or her diet .will ensure residents are offered meaningful choices in meals/diet that are nutritionally adequate and satisfying to the individual . Review of the facility's policy titled, Resident Rights ., dated 1/2022, revealed .The facility will inform the resident .of his or her rights .The right to .receive services in the facility with reasonable accommodation or resident needs and preferences .the right to make choices about aspects of his or her life .that are significant to the resident . Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of Chronic [CONDITION(S)], Hypertension, [CONDITION(S)], and Heart Failure. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. During an interview on 5/17/2022 at 8:38 AM, Resident #18 stated, .do not get menus, they place [menus] .outside dining room, if you're able you can see it .you wouldn't know what you're having in the bed [Resident #18 is confined to the bed] . Review of the medical record, revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Diabetes Mellitus, and Dysphagia. Review of the quarterly MDS dated [DATE], revealed Resident #22 had a BIMS score of 13, which indicated that she was cognitively intact. During an interview on 5/16/2022 at 2:24 PM, Resident #22 stated, no choices .no menus .you either eat what they bring or you go hungry . Review of medical record, revealed Resident #56 was admitted to the facility on [DATE] with diagnoses of Diabetes, Spinal Stenosis, Hypertension, and Chronic Kidney Disease. Review of the admission MDS dated [DATE], revealed Resident #56 had a BIMS score of 15, which indicated that she was cognitively intact. During an interview on 5/16/2022 at 11:34 AM, Resident #56 stated, .no choices with meals .never know what food is being delivered .no menus available .never know what food is coming before we get it . Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Diabetes, and Chronic Kidney Disease. Review of the annual MDS dated [DATE], revealed Resident #65 had a BIMS of 11, which indicated she had moderate cognitive impairment. During an interview on 5/18/2022 at 1:58 PM, Resident #65 was asked how she knew what was on the daily menu. Resident #65 stated, I don't .they used to bring something around a long time ago, but now we don't get nothing .they don't ask you any more . Review of the medical record, revealed Resident #154 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Depression, and Anxiety Disorder. Review of the admission MDS dated [DATE], revealed Resident #154 had a BIMS score of 15, which indicated that he was cognitively intact. During an interview on 5/18/2022 at 1:24 PM, Resident #154 confirmed that he never knew what the menu was for the day. Resident #147 stated, .I don't ever know .I haven't ever got [gotten] a menu . Observation and interview on the 100 and 300 Halls on 5/18/2022 at 1:25 PM, revealed there were no menus at the 100 and 300 Hall Nurses' Station, staff were asked at each nursing station about the menus, staff looked, and were unable to locate the dietary menus. During an interview on 5/18/2022 at 1:35 PM, the Registered Dietitian (RD) confirmed that the residents had no way to know what the meal would be prior to delivery of the meals and that residents confined to their rooms had no meal choice prior to their meal delivery. The RD stated, .My plan from now on for each resident is to have their own menus in their rooms .

Based on medical record review, review of the meal tray card, observation, and interview, the facility failed to provide the appropriate equipment necessary to maintain the ability to drink independently for 1 of 5 sampled residents (Resident #22) reviewed for dining. The findings include: Review of the medical record, revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Diabetes Mellitus, and Dysphagia. Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status score of 13, which indicated Resident #22 was cognitively intact and was able to feed herself after tray set-up. Review of Resident #22's meal tray card revealed, .lids on all cups . for breakfast, lunch and supper meals. Observation in resident's room 5/16/2022, 5/17/2022, 5/18/2022 and 5/19/2022, revealed Resident #22 had a constant shake/tremor in her bilateral arms and hands except while sleeping. Observation of the resident's room 5/18/2022 at 8:25 AM and 5/19/2022 at 8:38 AM, revealed Resident #22's orange juice was in a cup without a lid. During an interview on 5/18/2022 at 8:25 AM and 5/19/2022 at 8:38 AM, Resident #22 confirmed she was unable to drink her orange juice at breakfast due to her constant shaking and without a lid she would spill it all over her self. During an interview on 5/19/2022 at 8:31 AM, Licensed Practical Nurse (LPN) #1 confirmed Resident #22 did not have a lid on the orange juice on her breakfast tray and would not be able to drink it due to her arms shaking. During an interview on 5/19/2022 at 8:38 AM, the Certified Dietary Manager confirmed Resident #22 should have lids on all cups delivered to her room in order for her to drink fluids independently.

Based on medical record review, observation, and interview, the facility failed to care for a resident in a manner that maintained or enhanced their dignity for 1 of 3 sampled residents (Resident #214) reviewed with indwelling urinary catheters. The findings include: Review of facility's policy titled, Promoting/Maintaining Resident Dignity, revised 11/2017, showed that all staff members should promote and maintain resident dignity and respect. Review of the medical record, showed Resident #214 had a [DIAGNOSES REDACTED]. Observation in the resident's room on 2/24/2020 at 12:11 PM, 12:42 PM, 3:43 PM and 2/25/2020 at 4:44 PM, showed Resident #214 was seated in her wheel chair with the nephrostomy leg bag hanging on the right side of her wheel chair, uncovered and not in a dignity bag. During an interview conducted on 2/25/2020 at 4:47 PM, Licensed Practical Nurse (LPN) #1 confirmed that the nephrostomy leg bag should be covered. During an interview conducted on 2/26/2020 at 9:20 AM, the Director of Nursing (DON) confirmed that the nephrostomy leg bag should be covered.

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete and transmit a MDS assessment within 14 days for 1 of 24 sampled residents (Resident #1) reviewed for Resident Assessment and transmission. The findings include: Review of the MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR), page 664, showed, .Assessment Transmission .MDS assessments must be submitted within 14 days of the MDS Completion Date . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and expired on [DATE], with [DIAGNOSES REDACTED]. Review of the facility's MDS transmission log, showed that the death in the facility MDS was completed and transmitted on [DATE]. The facility failed to complete and transmit the assessment timely. During an interview conducted on [DATE] at 1:54 PM, MDS Coordinator #1 confirmed Resident #1 expired on [DATE] and there should have been a Death in Facility MDS completed and transmitted within 14 days.

Based on medical record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for pressure ulcers for 1 of 24 sampled residents (Resident #22) reviewed. The findings include: Review of the medical record, showed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the WOUND AND PRESSURE INJURY INFORMATION dated 11/17/2019, showed Resident #22 had a stage 2 facility acquired pressure ulcer to the coccyx. Review of the quarterly MDS assessment dated [DATE], showed Resident #22 had a pressure ulcer on admission. During an interview conducted on 2/26/2020 at 8:45 AM, MDS Coordinator #2 confirmed Resident #22 developed the pressure ulcer after admission to the facility and the MDS was coded incorrectly.

Based on policy review, medical record review, and interview, the facility failed to develop and implement Care Plans related to antidepressants, diuretics, suprapubic catheter, nephrostomy tube site, and isolation precautions for 3 of 24 sampled residents (Resident #58, #67, and #214) reviewed. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 12/2020, showed that the facility will develop and implement a comprehensive person-centered care plan. 1. Review of the medical record, showed Resident #58 had [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the medical record, showed a Care Plan was not developed for antidepressant use. During an interview conducted on 2/26/2020 at 4:10 PM, Minimum Data Set Coordinator (MDS) #1 confirmed that a comprehensive Care Plan should have been developed for antidepressant use. The facility failed to develop a comprehensive Care Plan for the use of an antidepressant. 2. Review of the medical record, showed Resident #67 had [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the Physician order [REDACTED].>Review of medical record, showed a Care Plan was not developed for diuretic use. During an interview conducted on 2/25/2020 at 3:38 PM, MDS Coordinator #1 confirmed that a comprehensive Care Plan should have been developed for diuretic use. The facility failed to develop a comprehensive Care Plan for the use of a diuretic. 3. Review of medical record, showed Resident #214 had a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the Physician order [REDACTED]. Review of the Physician order [REDACTED].>Review of medical record, showed a Care Plan was not developed for suprapubic catheter care, nephrostomy tube site, and isolation precautions. During an interview conducted on 2/26/2020 at 8:32 AM, MDS Coordinator #2 confirmed that a comprehensive Care Plan should have been developed for suprapubic catheter care, nephrostomy tube site monitoring, and isolation precautions. The facility failed to develop a comprehensive Care Plan for suprapubic catheter care, nephrostomy tube site monitoring, and isolation precautions.

Based on policy review, medical record review, observation, and interview, the facility failed to document treatments for 1 of 3 sampled residents (Resident #22) reviewed with pressure ulcers. The findings include: Review of the facility's policy titled, Pressure Injury Prevention and Non-Pressure Ulcer Management, dated 11/2019, showed, .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, starting with prompt assessment and treatment Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure ulcer . Review of the medical record, showed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#22 had orders to .Cleanse areas on right and left buttocks with NS (normal saline) or wound cleanser. Apply [MEDICATION NAME] (antibiotic) ointment calcium alginate (absorbent) dressing and a super absorbent dressing. Affix with tape. Change daily and as needed .DISCONTINUED (12/5/2019) . Review of the (MONTH) 2019 Treatment Administration Record (TAR), showed no documentation that the treatment on 11/19/2019 was performed as ordered. Review of the (MONTH) 2019 TAR, showed no documentation the treatment on 12/2/2019 was performed as ordered. Review of the Physician order [REDACTED].Cleanse areas on buttocks with NS or wound cleanser, apply [MEDICATION NAME] to wound bed followed by dry collagen and a silver calcium alginate 4X4 (4 inches by 4 inches) dressing. Cover with a dry dressing and change qd (every day) and prn (as needed) . DISCONTINUED (2/5/2020) . Review of the (MONTH) 2020 TAR, showed no documentation the treatments on 1/1/2020 and 1/20/2020 were performed as ordered. Review of the Physician order [REDACTED].CLEANSE AREA TO LEFT UPPER BUTT[NAME]K WITH WOUND CLEANSER OR NS; PAT DRY; APPLY SANTYL (an enzymatic [MEDICATION NAME] ointment) TO WOUND BED; APPLY CALCIUM ALGINATE OVER SANTYL; COVER AREA WITH DRY DRESSING DAILY AND PRN . Review of the (MONTH) 2020 TAR, showed no documentation the treatments on 2/12/2020, 2/13/2020, and 2/23/2020 were performed as ordered. Observation in the resident's room during wound care on 2/25/2020 beginning at 4:44 PM, showed the Wound Care Nurse removed the dressing from Resident #22's pressure injury. The wound had a dark pink wound bed, clean red beefy edges, showing an appearance of a healing pressure injury. During an interview conducted on 2/26/2019 at 2:34 PM, the Director of Nursing confirmed the treatments to sacrum were not documented on 11/19/2019, 12/2/2019, 1/1/2020, 1/20/2020, 2/12/2020, 2/13/2020, and 2/23/2020.

Based on policy review, medical record review, and interview, the facility failed to monitor the left nephrostomy site for 1 of 3 sampled residents (Resident #214) reviewed with urinary conditions. The findings include: Review of the medical record, showed Resident #214 had [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the (MONTH) 2020 Medication Administration Record [REDACTED]. During an interview conducted on 2/26/2020 at 9:23 AM, the Director of Nursing (DON) confirmed that there was no documentation that Resident #214's left nephrostomy tube site was monitored each shift. The facility failed to monitor Resident #214's left nephrostomy tube site 2 times a day.

Based on policy review, National Weather Service Records, review of a police report, medical record review, observation, and interview, the facility failed to ensure adequate supervision to prevent elopement (unsupervised wandering off of the grounds of the facility) for 2 of 6 (Resident #1 and #2) cognitively impaired, vulnerable, residents reviewed for wandering/exit seeking behaviors. The failure of the facility to supervise and monitor residents with exit-seeking behaviors placed Resident #1 and #2 in Immediate Jeopardy when these residents eloped from the facility and were found in the turning lane of a heavily traveled street. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Regional Nurse Consultant were notified of the Immediate Jeopardy on 9/4/19 at 3:22 PM, in the Conference Room. F-689 was cited at a scope and severity of [NAME] F-689 J is Substandard Quality of Care. A partial extended survey was conducted on 9/4/19-9/6/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 9/5/19 at 12:05 PM, and the A[NAME] was validated onsite by the surveyor on 9/5/19 and 9/6/19 through review of assessments, policies related to active exit seeking behaviors, staff interviews, and in-service training records. The IJ was effective from 8/11/19 to 9/5/19. The findings include: 1. The facility's Elopements and Wandering Patients policy with a revision date of 11/2017 documented, .The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff .Adequate supervision will be provided to help prevent accidents or elopements . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a ELOPEMENT RISK assessment dated [DATE] revealed Resident #1 was a low risk for elopement. Medical record review of a Nursing Clinical Note dated 7/30/19 documented, .up in wheelchair wandering hallways at this time . Medical record review of a Nursing Clinical Note for Resident #1 dated 8/2/19 documented, .observed pt. (patient) wandering in and out of other rooms . Medical record review revealed there was no risk assessment completed when Resident #1 displayed these wandering behaviors prior to the elopement. Medical record review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. Resident #1 needed extensive assistance with transferring and walking and used an assistive device for mobility. A Police Report dated 8/11/19 documented, .WELFARE CHECK .CALL INFORMATION DISPATCHED DATE/TIME 08-11-2019 16:04 (4:04 PM) .ELDERLY FEMALE IS PUSHING AN ELDERLY MALE SUBJECT IN A WHEELCHAIR IN THE MIDDLE OF THE STREET .08-11-2019 16:18 (4:18 PM) .THE STAFF FROM (Named Nursing Home) HAS THESE SUBJS (subjects, Resident #1 and #2) . Medical record review of a ELOPEMENT RISK assessment dated [DATE] revealed Resident #1 was a high risk for elopement and interventions of Wanderguard bracelet initiated Care plan initiated/updated to reflect elopement risk and interventions implemented . Medical record review of the Care Plan Report revised on 8/11/19 documented, .At risk for elopement from facility due to wandering Actual attempt was successful to exit building 8/11/19 .Resident will not exit building without proper supervision .Offer diversional activities as needed .All visits with wife in her room and common areas .Monitor resident's location and presence of wanderguard .Assess potential physical causes for wandering (need of toilet, water, food, pain relief) .Provide diversional activities (folding, rummaging box, packing/unpacking . Medical record review of a Nursing Clinical Note dated 8/12/19 documented, .At approximately 16:10 (4:10 PM on 8/11/19) a police officer called to notify us (facility staff) there was a man (Resident #1) in a wheel chair stating he lived at our facility in the road .staff escorted both (Resident #1 and #2) back into the building . Medical record review of a Nursing Clinical Note for Resident #1 dated 8/14/19 documented, .wanderguard intact to right ankle, resident continues to wander off and nurse has pulled resident out of 2 different residents room so far this shift. Resident also keeps attempting to stand up with very unsteady balance . Observation and interview in Resident #1's room on 9/5/19 at 3:20 PM, revealed Resident #1 wanted to know where his wife (Resident #2) was at the time. He could not remember his wife was residing in another area of the facility. He could not remember the location of the Secure Unit. Staff assisted Resident #1 to visit with his wife in the Secure Unit. 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nursing Clinical Note dated 8/3/19 documented, .confused tonight. She (Resident #2) wanders in and out of other residents rooms and has asked this nurse to help find (her husband, Named Resident #1) . Medical record review of a Nursing Clinical Note for Resident #2 dated 8/4/19 documented, .overheard pt (patient) telling her husband (Resident #1) 'they are letting us go, and we have to go' then proceeded to help him (Resident #1) out of bed. Aide notified nurse that pt (Resident #2) was telling husband (Resident #1) they need to escape . Medical record review of a Nursing Clinical Note dated 8/5/19 documented, .wonderguard (wanderguard) placed to lt (left) ankle for wondering (wandering) behavior moving in and out of rooms searching for husband .redirected numerous times and continued searching through rooms . Medical record review of a ELOPEMENT RISK assessment dated [DATE] revealed Resident #2 was a high risk for elopement and interventions of Wanderguard bracelet initiated . Medical record review of a Nursing Clinical Note for Resident #2 dated 8/7/19 documented, .earlier this am (before midday) pushing husband in w/c (wheelchair) down hallway . Medical record review of the admission MDS dated [DATE] revealed Resident #2 was assessed to have a BIMS score of 3, which indicated severe cognitive impairment. Resident #2 did not require any assistive devices and walked independently with supervision. Resident #2 exhibited wandering behavior daily. Review of the Care Plan Report revised 8/11/19 documented, .Problems .(Named Resident #2) has exhibited Wandering Behavior .Assess potential physical causes for wandering (need for toilet, water, food, pain relief) .Provide diversional activities (folding, rummaging box, packing/unpacking) .Redirect (Named Resident #2) behavior/activity when wandering (8/11/19) Place in Special Care Unit. Ensure all door alarms/locks are armed to reduce the risk of (Named Resident #2) leaving secure area .Elopement 8/11/19: Placed on one on one observation, then placed in secure unit . Medical record review of a ELOPEMENT RISK assessment dated [DATE] revealed Resident #2 was a high risk for elopement and interventions of Wanderguard bracelet initiated . Medical record review of a ELOPEMENT RISK assessment dated [DATE] revealed Resident #2 was a high risk for elopement and interventions of Care plan initiated/updated to reflect elopement risk and interventions implemented . The National Weather Service records revealed the recorded high temperature for the facility area on 8/11/19 (the day of the elopement from the facility) was 93 degrees Fahrenheit. Review of the facility's security video monitor footage date and time stamped 8/11/19 at 16:09 (4:09 PM) revealed Resident #2 propelling Resident #1 in his wheelchair across the front parking lot and into the turning lane of the street, headed North. The couple was unsupervised and traffic was constant in both side lanes of the street. Review of Licensed Practical Nurse (LPN) #1's written statement dated 8/11/19 and verified by LPN #1 documented, .At around 4:10 (PM) the phone rang and an officer stated that he (Officer) had a gentleman in a w/c (wheelchair) at the (Named Elementary School) parking lot stating he (Resident #1) was from here (Nursing Home) but could not give a name . Review of LPN #2's written statement dated 8/11/19 documented, .Nurse took the phone call stating a resident (Resident #1) in a wheelchair was in the road between the facility & (and) Elementary School . Medical record review of a Social Services Clinical Note for Resident #2 dated 8/13/19 documented, .Resident does wander on secure unit and will go to doors . Observations in Resident #2's room on the Secure Unit on 9/3/19 at 1:15 PM, revealed Resident #2 was walking around in her room. She ambulated independently with good balance. Resident #2's husband (Resident #1) was visiting in her room. Resident #2 would follow Resident #1's directions for pushing him (Resident #1) in his wheelchair to go out into the hallway and to the dining area Interview with the Administrator on 9/3/19 at 2:50 PM, in the Conference Room, the Administrator was asked how Resident #1 and #2 exited the building. The Administrator stated, .went out exit door at end of service hall by the Secure Unit. Only door with alarm is front door. We (Administrative staff) reviewed the camera recording that evening. Two staff from dietary were on break outside and 1 of the staff punched in the code to open the door .They (dietary staff) helped them (Resident #1 and #2) out the door. They (dietary staff) came back in to work . Interview with Licensed Practical Nurse (LPN) #2 on 9/3/19 at 4:00 PM in the Conference Room, LPN #2 was asked if Resident #2 had displayed wandering behavior on 8/11/19. LPN #2 stated, .Wife (Resident #2) pushed him (Resident #1) in wheelchair down 300 cubby (short end of hall) and back up .It was routine for her to push him around .She would push him on all halls. They would look out doors some . Telephone interview with Dietary Aide #1 on 9/3/19 at 4:32 PM, Dietary Aide #1 was asked if he knew how Resident #1 and #2 had exited the building on 8/11/19. Dietary Aide #1 stated, .on my way in toward the dietary door, I noticed a lady and gentleman (Resident #1 and #2) at the door tapping on the glass. I went ahead and put the code in .I told them (Resident #1 and #2) they could go around to the front and sit under the awning. She (Resident #2) said okay and started pushing him (Resident #1) in the wheelchair toward the front. I knew he (Resident #1) was a resident, but I thought she (Resident #2) was a visitor . Interview with LPN #1 on 9/4/19 at 2:09 PM in the Dogwood Lane Hall, LPN #1 was asked what she would do to monitor and supervise residents at risk of wandering with exit seeking behaviors. LPN #1 stated, We did 15 minute checks on residents with wanderguards. We don't do that anymore. Nothing really. Interview with the Administrator and the Director of Nursing (DON) on 9/4/19 at 2:50 PM in the Administrator Office, they were asked what facility action was taken to ensure supervision was adequate for cognitively impaired residents with wandering/exit seeking behaviors. The Administrator stated, .changed the door codes. We did 15 minute checks for 72 hours on all residents with wanderguards. Nurse Managers did a risk assessment on all residents . The Administrator and the DON confirmed there were no new interventions currently in place for staff supervision of residents after the elopement of Resident #1 and #2 and the Care Plans of Resident #1 and #2 were updated on 8/11/19 with no new care plan interventions in place for supervision. The facility is located across the street from a small lake, near several businesses and an Elementary School. The street is a heavily traveled by traffic. The surveyor validated the A[NAME] by: 1. All entry/exit door codes were changed on 8/11/19. On 8/12/19 the Director of Nursing ensured signage was placed at each entry/exit door on red paper stating Attention Family, Staff and Residents: You must check in with the nurse of the resident before you can let someone leave the facility or go outside. Family, residents, and visitors must enter/exit through front door. The surveyor viewed the signage on each entry/exit door. 2. The Maintenance Director checked all entry/exit doors for proper functioning on 8/11/19 and 8/12/19, and weekly checks were ongoing. The surveyor reviewed the door check logs. 3. Residents wearing wanderguard bracelets will be checked every shift by a nurse to ensure placement of the wanderguard bracelet is maintained beginning on 8/11/19. Wanderguard transmitter functionality will be verified each day per Nursing Staff. The surveyor reviewed the documented check logs and interviewed staff on each shift. 4. All wanderguard transmitters were checked on 8/11/19, then daily by the nursing staff. The surveyor made observations and reviewed the daily wanderguard transmitter check logs. 5. A Wanderguard Identification Book was verified for accuracy on 8/11/19 by Nurse Managers. A Wanderguard Identification Book was placed in Dietary, Laundry, Receptionist Office, Activity Department, and Therapy Department on 8/12/19. The book will be updated as needed by the Social Worker. The surveyor reviewed the Wanderguard Book in each department for accuracy and placement. 6. Elopement risk assessments on all residents were completed on 8/12/19. The surveyor reviewed each assessment. 7. The Quality Assurance and Performance Improvement (QAPI) committee met on 8/12/19 to review and discuss specifics of plan of correction to prevent elopement and ensure resident safety. The QAPI committee completed a Community Risk Assessment and Evaluation on Elopement Prevention and Response on 8/12/19. The surveyor reviewed the assessment and the minutes of the QAPI meeting. 8. Facility Staff education was provided by the Administrator and Nurse Managers on facility elopement and wandering patients policy to all staff which began 8/11/19 and was completed 8/16/19. The surveyor reviewed the education sign-in forms and verified each staff member participation. The surveyor interviewed staff on each shift. 9. Elopement drills on all 3 shifts were conducted and completed by Maintenance Staff by 8/15/19 and will be ongoing weekly for one month for 2 months, then twice a year and as needed by Maintenance Staff. Discussions of drills will be ongoing during monthly staff meetings. The surveyor reviewed the elopement drills. 10. All staff were provided education for supervision of cognitively impaired residents with exit seeking behavior to prevent accidents and outcomes with serious injury. The education began 9/4/19 for on-duty staff and all off-duty staff to be educated before returning to work. The surveyor reviewed the education and sign-in forms and interviewed staff on each shift. 11. Nurses will implement interventions based on the elopement risk assessment. Cognitively impaired residents with exit seeking behavior not residing in the Secure Unit will have every 15 minute visual checks for 72 hours and other interventions implemented as appropriate may include but not limited to: placement on the Secure Unit, redirection, wanderguard bracelet, diversional activities, and referrals to other disciplines/departments. The surveyor observed interventions implemented and interviewed staff on each shift. 12. Beginning 9/5/19, the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinators, and Medical Records Nurse will audit staff education and supervision of cognitively impaired residents with exit seeking behavior every shift for one week, daily for one week, weekly for four weeks, monthly for two months, then quarterly ongoing. The surveyor reviewed the education audits and interviewed staff on each shift. 13. Results of the findings from the audits of staff education and supervision of cognitively impaired residents with exit seeking behaviors will be reported to the QA Committee. Noncompliance of F-689 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention quick reference guide, medical record review, observation and interview, it was determined the facility failed to identify the development of a pressure ulcer for 1 of 4 (Resident #14) sampled residents with pressure ulcers. The failure to identify skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #14. The findings included: Review of the NPUAP Pressure Ulcer Prevention quick reference guide documented, "p. (page) 12... Skin Assessment... 3. Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration... Ongoing assessment of the skin is necessary to detect early signs of pressure damage... p. 13... 7. Document all skin assessments... Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals..." Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "Weekly Wound Progress Note" dated 2/10/11 documented, "...L (left) buttocks... Type of Ulcer: Pressure... Size: (in cm (centimeters)) L (length) 2.8 W (width) 2 D (depth) UTD (unable to determine)... Tissue Type... Slough (never on St. (stage) I or II)... Periwound: red... Other description / comments: wound bed 60% (percent) yellow 40% red..." Review of the "PRESSURE ULCER RISK ASSESSMENT" dated 2/10/11 and 2/17/11 documented, "...TOTAL SCORE 16... 14- (to) 18 = (assessed as) Mod. (moderate) Risk." The facility failed to include "Current or History of Pressure Ulcers" on the health conditions section which would have increased the score for the pressure ulcer risk assessment. Review of the "Weekly Wound Progress Note" dated 2/20/11 documented, "Location: Coccyx... Date of Onset 2/20/11... Type of Ulcer: Stage UNS (unstageable)... Size (in cm) L 0.9 W 2.2 D UTD... Tissue Type... Slough (never on St. I or II)... Periwound: scar tissue... Other description/comments: 95% yellow 5% red..." Review of the treatment administration record (TAR) dated February 2011 documented, "...UNS L buttocks cleanse c (with) w/c (wound cleanser) apply santyl, col (collagen) alg (alginate) & (and) drsg (dressing) QD (daily) ...2/10/11..." Review of the TAR dated February 2011 documented, "...Coccyx Uns - decub (decubitus) - cleanse c w/c, apply Santyl, coll alg & drsg QD... 2/20/11..." The treatment to the unstageable pressure ulcer on the left buttock was performed daily and was in close proximity to the area where the second unstageable pressure ulcer developed on 2/20/11. Observations in Resident #14's room on 6/27/11 at 9:05 AM, revealed Resident #14 had an open area with a red wound bed and edges well approximated. The area surrounding the opening was slightly reddened. During an interview in the conference room on 6/29/11 at 6:00 PM, Nurse #12 was asked about Resident #14's unstageable pressure ulcer which was first documented on 2/20/11. Nurse #12 stated, "...I did the dressing change on the 19th. It may have developed a day or two before that... I have no reason as to why we didn't see it. I have no explanation for it..." During an interview in the conference room on 6/29/11 at 7:20 PM, the Director of Nursing confirmed there was no documentation of Resident #14's skin condition from his admission on 2/10/11 to the appearance of the unstageable pressure ulcer on 2/20/11. During an interview in the conference room on 6/29/11 at 8:30 PM, Nurse #1 was asked if there was any documentation of Resident #14's skin condition prior to the appearance of the unstageable pressure ulcer on 2/20/11. Nurse #1 stated, "...obviously, there's not..." The failure to identify skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #14.