Every finding on record at Pleasant Acres Care Center

Based on observations, staff interviews, and facility policy review the facility failed to ensure proper sanitary conditions in the kitchen area, where staff prepared food. The facility identified a census of 37 residents.Findings included: During the initial kitchen walkthrough on 12/16/26 at 10:35 AM, the following observations were made:Refrigerator units contained various scattered food debrisFreezer units with ice build upThe following foods not labeled: ranch dressingfrozen meatfrozen pizza During the initial tour, the Dietary Manager (DM) reported the facility had recently lost two kitchen staff, which resulted in some duties not being consistently completed. The DM reported the bottoms of the refrigerator units required cleaning, freezers needed defrosting, and all food required proper labeling. On 12/18/26 at 12:42 PM tour of the ice machine room showed:Ice machine with lime build up on outside of the machineSnack cart with loose debride build up on top of the cart and within the drawersWater cart with debride and dry liquid build upThe DM reported that dietary staff were not responsible for cleaning the ice machine, snack cart, or water cart. The DM stated that all of these items required cleaning, including the tray on top of the ice machine. The Sanitation Inspection policy dated 2025 identified it is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. Policy Explanation and Compliance Guidelines:All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. The department shall establish a sanitation program for food services based on applicable state and federal requirements.The sanitation program will provide for inspections to be conducted of the food service areas.Sanitation inspections will be conducted in the following manner:Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations.Inspections will be conducted but not limited to the following areas: Dry storageFreezerRefrigeratorDish roomPot washMain production areaFood preparation areaGeneral dietary observationsThe dietary manager shall develop and provide food service personnel with standard operating procedures for sanitation and daily inspections. Managers may familiarize staff with these procedures through various means such as monthly meetings, posted memorandums, training sessions and orientation of new personnel. Inspection Score (from Sanitation Inspection Report): The dietary manager, as part of the department's QAPI program, will perfon an in-depth analysis of the data obtained during the inspection utilizing the following: Numerator (The number of positives) divided by Denominator (the number of total opportunities) - Inspection Score Inspection score will be formulated on [NAME] area being evaluated. Scores will then be compared to department. Goals. Feedback will be reported to the food service staff and the QAPI Committee.

Based on observations, staff interviews, and facility policy review, the facility failed to provide safe transfers of residents with transfers 1 of 3 residents reviewed (Resident #11). The facility reported a total census of 37 residents. Findings include: Staff D, Certified Nursing Assistant (CNA) applied gait belt around Resident #11. Staff B, Registered Nurse (RN) and Staff E, CNA with their arms under Resident #11's armpits assisted Resident #11 to a standing position. Staff B and Staff E did not use the gait belt when assisting resident to standing position. After Resident #11 was finished with the toilet, Staff B and Staff E and with their arms under Resident #11's armpits assisted Resident #11 to a standing position. Staff D performed perineal care while Staff B and Staff E continued to assisted Resident #11 with standing position. Staff B and Staff E did not use the gait belt and assisted the resident back into his wheelchair. Once Resident #11 was back in the wheelchair. Staff D removed the gait belt. Review of the facility provided policy titled Use of Gait Belt dated 2025 revealed it is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Interview on 02/18/2026 at 2:42 p.m., with the Director of Nursing revealed the staff should not have been lifting under the residents arms and should have used the gait belt the resident had on.

Based on observation, medical record review, facility policy review and staff interview the facility failed to ensure resident self administering medications was safe to do and failed to watch resident not assessed to self administer medications took their medications for 1 of 1 resident observed (Resident #26). The facility reported a census of 37. Findings include: Observation on 02/18/2026 at 8:31 a.m. of Resident #26 sitting at the table in the activity room with 2 medication cups in front of her. One was noted to be full of applesauce and have a spoon in and the other was noted to have a variety of tablets in the cup. Resident #26 dumped the tablets onto the table and lined them up and took them with the applesauce. Observation revealed there was no facility staff in or around the area while resident took the tablets. Review of Resident #26's medical chart lacked documentation of assessment to self administer medications and lacked orders for self administration of medications. Review of facility provided policy titled Medication Administration dated 2025 revealed under policy explanation and compliance guidelines to observe resident consumption of medications. Interview on 02/18/2026 at 10:17 a.m., with the Director of Nursing revealed resident should have had someone watching her take her medications as she cannot take her pills without supervision.

Based on observation, clinical record review, and interviews with residents and staff, the facility failed to maintain resident dignity and privacy during incontinence care and to communicate about residents in a respectful manner for 2 of 12 residents reviewed (Residents #8 and #30). The facility reported a census of 37 residents.The findings include: 1. The Minimum Data Set (MDS) for Resident #30 dated 1/24/26 documented diagnoses of muscle weakness, anxiety disorder and respiratory failure. The MDS showed short-term memory and long-term memory coded as OK. Observation on 2/18/26 at 10:25 AM during incontinence care showed Staff B, Certified Nursing Assistant (CNA), used a walkie-talkie to request additional wet wipes for Resident #30. Upon arrival of the requested supplies, Staff A, Registered Nurse (RN), placed a brief over the resident's perineal area. When staff opened the door to deliver the wipes, Resident #30 lay on the bed with pants at her ankles and a brief covering her perineal area. Staff failed to place a blanket over the resident or pull the privacy curtain to ensure visual privacy. Staff left the room with the door open under the same conditions after placing the wipes on the bedside table. When staff resumed incontinence care, Resident #30 stated, I need to pee. Staff B responded, Go ahead and go, you still have your brief on. The resident paused and then stated, Never mind, I don't have to go. The Promoting/Maintaining Resident Dignity policy dated 2025 identified it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. When interacting with a resident, pay attention to the resident as an individual. Respond to requests for assistance in a timely manner. Speak respectfully to residents; avoid discussions about residents that may be overheard. Maintain resident privacy. In an interview on 2/19/26 at 9:41 AM, the Director of Nursing (DON) stated staff must cover residents with a blanket or pull the privacy curtain when opening the door to ensure privacy. The DON further stated staff should have offered Resident #30 a bedpan to maintain dignity after the resident expressed the need to urinate. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 documented diagnoses of quadriplegia, anemia (low red blood cells) and hyperlipidemia (high cholesterol). The MDS showed the Brief Interview for Mental Status (BIMS) was a 15 indicating no memory impairment. Interview on 02/18/2026 at 8:57 a.m., with Resident #8 revealed he had concerns on how the staff were talking to him. Resident #8 stated the staff was in the hallway outside of his room and he could hear the staff talking about him. The resident was upset and stated the nurse talks badly about other residents in the facility. The resident stated he opened his door and confronted her about it and when he did she became upset and short with him for the rest of her shift that night. He further stated this is not the first time this has happened he overhears the staff talking about him and other residents in the facility. Resident #8 stated it was frustrating to him that he gets labeled crabby or causing issues when this is his home and he is only sticking up for himself and other residents. During interview on 02/19/2026 at 8:46 a.m. the Administrator stated the staff should not be discussing residents in the hallways.

Based on observation, policy review, and staff interviews, the facility failed to perform blood sugar testing and administer insulin in a manner that protected the resident from bloodborne pathogens for 1 of 1 residents reviewed (Resident #7). The facility reported a census of 37 residents.Findings included: Observation on 2/19/26 at 7:29 AM showed Staff C, Registered Nurse (RN), opened the medication cart, removed the storage container for Resident #7's glucometer and testing supplies, locked the cart, and entered the resident's room. The nurse placed a barrier on the bedside table, set the glucometer and supplies on the barrier, and donned gloves without performing hand hygiene. Staff C completed the glucose check and discarded the used disposable supplies. Staff C exited the room wearing soiled gloves while holding the glucometer, returned to the medication cart, removed one glove, failed to perform hand hygiene, reached into her scrub pocket to retrieve the medication cart keys, and unlocked the cart. Staff A then opened the cart drawer, retrieved the storage container, returned the glucometer without proper cleansing, closed the container and drawer, removed the remaining glove, and performed hand hygiene. After reviewing the computer, Staff A opened the medication cart, retrieved insulin pens, needles, and supplies, donned gloves and entered the resident's room. Following insulin administration, Staff C exited the room wearing soiled gloves, removed one glove, failed to perform hand hygiene, reached into her scrub pocket to retrieve the medication cart keys, unlocked the cart, and opened a drawer. Staff C placed insulin pens in the drawer without properly disinfecting the pens, closed the drawer, removed the remaining glove, and performed hand hygiene. The Glucometer Disinfection policy dated 2025 indicated the purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees.Definitions: Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. Policy Explanation and Compliance Guidelines:Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use.Procedure:Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes.Wash hands.Explain the procedure to the resident.Provide privacy.Put on gloves.Obtain capillary blood glucose sampling according to facility policy. Remove and discard gloves, perform hand hygiene prior to exiting room.Reapply gloves if there is visible contamination of the device or if the resident is HIV or Hepatitis B or C positive.Retrieve (2) disinfectant wipes from container.Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer.After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry.Discard disinfectant wipes in waste receptacle.Perform hand hygiene.The Hand Hygiene policy dated 2025 identified All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines:Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom.6. Additional considerations:The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. In an interview on 2/19/26 at 10:57 PM, the Director of Nursing (DON) reported staff were required to disinfect glucometers using disinfecting wipes and to clean insulin pens as needed. The DON further indicated staff should perform hand hygiene before donning gloves and immediately after doffing gloves.

Based on clinical record review, staff interviews and facility policy review the facility failed to complete neurological checks after a resident fell for 1 of 1 residents reviewed (Resident #11). The facility reported a census of 37 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 documented disorientation, delirium due to known psychosocial condition, muscle weakness and history of falling. The MDS showed the Brief Interview for Mental Status (BIMS) score was not assessed. Review of report titled Incidents by Incident Type dated 2/18/26 revealed falls on the following dates:1/21/261/25/261/27/262/13/26 Review of the clinical record revealed the following:1/21/26- neurological checks 6:35 p.m., refused sleeping in wheelchair6:50 p.m., refused sleeping in wheelchair7:30 p.m., sleeping7:50 p.m., refused sleeping in wheelchair9:50 p.m., sleeping in wheelchair, refused11:50 p.m., refused sleeping in wheelchair 1/22/26 at 3:50 a.m., refused sleeping in wheelchair7:50 a.m., refused, sleeping in wheelchair1/25/26- the clinical record lacked documentation of neurological checks1/27/26- the clinical record lacked documentation of neurological checks2/13/26- neurological checks10:30 p.m., refused, sleeping 11:00 p.m., refused, sleeping 11:30 p.m., line drawn through 2/14/26 at 12:00 a.m., refused, awake behaviors1:00 a.m., refused, behaviors2:00 a.m., refused, behaviors Review of facility provided policy titled Head Injury dated 2025 revealed the following:Assess resident following a known, suspected, or verbalized head injury. The assessment shall include, at a minimum:Neurological evaluation for changes in:Physical functioningBehaviorCognitionLevel of consciousnessDizzinessNauseaIrritability Slurred speech or slow to answer question Perform neurological checks as indicated or as specified by the physician Interview on 02/18/2026 at 10:19 a.m., with the Director of Nursing revealed the neurological assessment should be completed when the resident is sleeping.

Based on observations, record review, interviews, and policy review, the facility failed to implement and practice appropriate infection control measures for use of a Bilevel Positive Airway Pressure (BiPAP) machine by not establishing or following a routine cleaning schedule for 1 of 12 residents reviewed (Resident #7). The facility reported a census of 37 residents. Findings include:The Minimum Data Set assessment dated [DATE] for Resident #7 documented diagnoses of obstructive sleep apnea, respiratory failure and obesity. The MDS indicated Resident #7 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment.Observation on 2/17/26 at 9:25 AM revealed a BiPAP machine on Resident #7's bedside table. When asked whether staff regularly cleaned the BiPAP oxygen tubing or facemask, Resident #7 stated, They have never cleaned it. When asked how long he had the BiPAP, the resident reported, For about a year and a half.The Clinical Physician Orders dated 10/23/24 for Resident #7 showed an order for BiPAP to be used at night. The Care Plan for Resident #7 indicated BiPAP therapy initiated on 10/28/24 and contained no instructions regarding cleaning or maintenance of the BiPAP equipment.The February 2026 Treatment Administration Treatment Record for Resident #7 contained no instructions regarding cleaning or maintenance of the BiPAP equipment.The CPAP/BiPAP Cleaning policy dated 2025 identified it is the policy of this facility to clean CAP/BiPAP equipment in accordance with current CDC guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection.Definitions: CAP, or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth.BiPAP, or bi-level positive airway pressure, is a similar respiratory therapy intervention that delivers an inhale pressure and an exhale pressure to provide a patent airway. It requires a machine that generates the separate pressures through a tube into a mask that fits over the nose or mouth. Policy Explanation and Compliance Guidelines:CAP/BiPAP equipment may vary by manufacturer. Common equipment includes the machine, tubing. mask, headgear/straps, disposable/non-disposable filters, and humidifier chamber.Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections.Staff shall perform hand hygiene and wear gloves whenever touching the CAP/BiPAP equipment.Dust the machine when needed, and wipe clean with a damp cloth and detergent.If humidification is required, distilled or sterile water will be used to fill the humidifier chamber. Empty the chamber completely after each use and wipe dry.Clean mask frame daily after use with CAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use.Weekly cleaning activities (specify day of week):a. Wash headgear/straps in warm, soapy water and air dry.b. Wash tubing with warm, soapy water and air dry.8. Follow manufacturer instructions for the frequency of cleaning/replacing filters and servicing the machine. Only the supplier may service the machine.9. Replace equipment immediately when it is broken or malfunctions, or if visible soiling remains after cleaning.10. Replace equipment routinely in accordance with manufacturer recommendations. General guidelines:Face mask and tubing - once every three monthsHeadgear, non-disposable filters, and humidifier chamber - once every six monthsDisposable filters - twice monthly11. For facility rental equipment, follow supplier's instructions related to cleaning before returning to the supplier. Consider which supplies are for single person use only (discard after use), and which supplies/equipment parts are reusable.In an interview on 2/18/26 at 1:06 PM, the Director of Nursing (DON) stated the facility failed to initiate a cleaning schedule for Resident #7's BiPAP equipment. When asked whether CPAP and BiPAP equipment should have a regular cleaning schedule, the DON confirmed that it should and indicated she would follow up on the matter.In a follow-up interview on 2/19/26 at 10:57 PM, the Director of Nursing (DON) stated the facility had not initiated a cleaning schedule for Resident #7's BiPAP equipment. The DON explained, It got missed. We will have to look at how it happened.

Based on observation, document review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs. The facility reported a census of 27 residents. Findings include: On 12/11/24 at 12:45 PM Staff D, [NAME] stated that she used one bag of diced chicken for the lunch meal. Staff D stated she followed the recipe for 36 servings of Chicken [NAME] Alfredo. Staff D acknowledged the menu required 9 lbs of chicken. Staff D acknowledged that she used 1 bag of diced chicken from the box that contained 2 bags of diced chicken. Staff D stated she did not know how many pounds of chicken were in the bag but she could look at the box to find out. On 12/11/24 at 1:00 PM an observation of the box of diced chicken used for lunch 12/11/24 revealed two 5lbs bags in each box. Review of a document titled, Chicken [NAME] Recipe #8723 documented the recipe required 9lbs of chicken for 36 servings. Review of document titled, Week 2 Wednesday documented Chicken [NAME] for noon meal. On 12/11/24 at 1:10 PM Staff D stated she used one bag of chicken for the recipe because she was told by the trainer when she started that one bag was the appropriate amount for the recipe. On 12/11/24 at 12:50 PM Staff C, Dietary Manager acknowledged two 5 lbs bags of diced chicken in each box. Staff C acknowledged one 5lbs bag was utilized for the recipe for 36 servings. Staff C stated 1.75 bags of diced chicken should have been used for the 36 serving recipe. Staff C acknowledged Staff D did not use the appropriate amount of chicken for the recipe. Review of undated policy titled, Portion Control documented foods will be served according to standard portion sizes to ensure adequate servings of food and to provide portions that are equal in size for those residents that do not require specialized dietary modifications. Standard portion sizes according to food groups include Meat Group 2-3 oz each at lunch & supper. On 12/12/24 at 9:28 AM the Administrator stated the facility's expectation was the recipe was followed. The Administrator stated if the recipe required 9 lbs of chicken that 9 lbs of chicken was used. The Administrator stated they did not have a policy related to following a recipe to provide the appropriate amount of each ingredient, but the facility followed professional standards and the regulations.

Based on clinical record review and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 2 of 2 residents reviewed who transferred to the hospital (Resident #4 and #15). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of heart failure, anemia and peripheral vascular disease. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #4's Progress Notes revealed the following information: On 2/5/24 at 11:06 p.m., Resident leaves facility via nonemergent transport. On 2/6/24 at 1:46 a.m., staff placed a phone call to the local hospital and the resident will be admitted to the local hospital. On 2/19/24 at 12:58 p.m., the local hospital called to give the facility report. Review of Resident #4's Census tab revealed the following: On 2/5/24- hospital paid leave. On 2/19/24- active. Review of MDS listing revealed the following: On 2/5/24- discharge return anticipated On 2/19/24- Entry Review of the facility document titled Notice of Transfer Form to Long Term Care Ombudsman dated February 2024 lacked Resident #4's name. 2. The MDS assessment dated [DATE] for Resident #15 documented diagnoses of atrial fibrillation, heart failure and Chronic Obstructive Pulmonary Disease (COPD). The MDS showed the BIMS score of 15, indicating no cognitive impairment. Review of Resident #15's Progress Notes revealed the following information: On 5/25/24 at 3:37 p.m., transported to emergency room . On 5/25/24 at 10:22 p.m., resident is admitted to the local hospital. On 6/3/24 at 12:15 p.m., resident returns from hospital stay. Review of Resident #15's Census tab revealed the following: On 5/25/24- hospital paid leave. On 6/3/24- active. Review of MDS listing revealed the following: On 5/25/24- discharge return anticipated On 6/3/24- Entry Review of the facility document titled Notice of Transfer Form to Long Term Care Ombudsman dated May 2024 lacked Resident #15's name. Interview on 12/10/24 at 12:54 p.m., with the Administrator revealed Resident #4 and Resident #15 were not submitted on the Ombudsman notification due to the report that was run did not include those resident's names. The 2 residents should have been on the notification. Interview on 12/11/24 at 12:24 p.m., with the Administrator revealed the facility does not have a policy on notification to the Ombudsman. The facility submits the report every month.

Based on electronic health record review, policy review, resident interviews, family interviews, and staff interviews the facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team composed of each resident and resident representative to allow developing the care plan and making decisions about his or her care to 2 of 12 residents reviewed (Resident #14 and #19). The facility reported a census of 27 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #14 was rarely / never understood and a Brief Interview for Mental Status (BIMS) was not completed indicating severe cognitive impairment. On 12/09/24 02:36 PM Resident #14's brother / POA stated there were no care conferences and would like them. Resident #14's brother / POA stated he was not ever told by the facility that he could be a part of the care conference. Review of EHR revealed no documentation of completion of care conference with family or resident present. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #19 had a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. On 12/09/24 at 12:48 PM Resident #19 stated he was not invited to care conferences since he has been at the facility. On 12/11/24 at 10:45 AM Staff B, Registered Nurse (RN) / Infection infection preventionist (IP) stated she had been in the position since 12/2/24 and since then been in charge of care conferences. Staff B acknowledged the residents had been telling her that the care conferences had not been completed with them. Staff B stated the administration team had discussed that care conferences had been missed and would need to get back on track with them. Staff B acknowledged care plan conferences had not been completed with Resident #14 or Resident #19 or their families. On 12/11/24 at 2:08 PM the Administrator acknowledged the facility had identified that care plan conferences had not been completed per the regulation. The Administrator stated the facility had been catching up to get back into compliance with the care plan conferences. Review of policy titled Care Planning - Interdisciplinary Team revised 9/13 documented The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.

Based on record review, resident and staff interviews and facility policy review the facility failed to provide physician ordered medications and failed to notify the physician of missed medications for 1 of 1 residents reviewed (Resident #4). The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of heart failure, anemia and peripheral vascular disease. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of the facility provided document titled Order Summary Report signed by the physician 11/20/24 revealed the following orders: Coumadin tablet, Bupropion tablet, and Calcitriol capsule. Review of Resident #4's Progress Notes revealed the following: On 11/14/24 at 5:16 p.m., Coumadin tablet, medication not available, attempted to remove medication from med bank-med bank states med bank unable to connect to drawers unable to take out medication. On 11/15/24 at 4:27 p.m., Coumadin tablet, on order. On 11/16/24 at 4:41 p.m., Coumadin tablet, on order. On 11/20/24 at 6:58 a.m., Calcitriol capsule, on order. On 11/23/24 at 7:54 p.m., Bupropion tablet, not available, on order. On 11/23/24 at 4:00 p.m., Coumadin tablet, not administered, on order. On 11/24/24 at 7:39 a.m., Bupropion tablet, not available, on order from pharmacy. On 11/25/24 at 5:14 p.m., Coumadin tablet, not available, on order. Review of Resident #4's Electronic Health Records (EHR) failed to indicate physician notification for missed medications on 11/14/24, 11/15/24, 11/16/24, 11/20/24, 11/23/24, 11/24/24 and 11/25/24. Review of facility provided policy titled Adverse Consequences and Medication Errors Revised February 2023 revealed promptly notify the provider of any significant error or adverse consequence. Interview on 12/11/24 at 12:22 p.m., with the Director of Nursing (DON) revealed there are times where the medications do not come on time to the facility. If a medication is missed or not given it should be documented in the progress notes and the nurse should be notifying the physician and documenting that in the progress notes as well.

Based on interview, record review, and policy review, the facility failed to ensure call lights responded to in a timely manner for 2 out of 4 residents reviewed (Resident #4 and #23). The facility reported a census of 27 residents. Findings include: 1. Interview on 12/09/24 at 1:14 p.m., with Resident #4 revealed call lights can take awhile. Resident #4 revealed he has waited over 15 minutes several times. Review of facility provided document titled Alarm Event Report dated 12/4/24-12/11/24 revealed the following: On 12/4/24 the call light turned on at 8:12 a.m. and was on for 29 minutes. On 12/4/24 the call light turned on at 8:59 a.m. and was on for 28 minutes. On 12/4/24 the call light turned on at 12:19 p.m. and was on for 48 minutes. On 12/5/24 the call light turned on at 8:46 a.m. and was on for 16 minutes. On 12/6/24 the call light turned on at 12:15 p.m. and was on for 37 minutes. On 12/7/24 the call light turned on at 11:05 a.m. and was on for 20 minutes. On 12/8/24 the call light turned on at 12:02 p.m. and was on for 1 hour and 7 minutes. On 12/9/24 the call light turned on at 6:19 a.m. and was on for 51 minutes. On 12/9/24 the call light turned on at 8:28 a.m. and was on for 21 minutes. On 12/9/24 the call light turned on at 4:57 p.m. and was on for 35 minutes. On 12/9/24 the call light turned on at 6:22 p.m. and was on for 24 minutes. On 12/10/24 the call light turned on at 2:41 p.m. and was on for 17 minutes. On 12/11/24 the call light turned on at 8:09 a.m. and was on for 21 minutes. 2. Interview on 12/09/24 at 1:52 p.m., with Resident #23's family revealed the facility takes a while to answer his call light and there are times it has been over 15 min especially on the weekends. Review of facility provided document titled Alarm Event Report dated 12/4/24-12/11/24 revealed the following: On 12/7/24 the call light turned on at 6:43 a.m. and was on for 55 minutes. On 12/8/24 the call light turned on at 5:35 p.m. and was on for 26 minutes. Interview on 12/11/24 at 2:47 p.m., with the Administrator revealed all call lights should be answered in under 15 minutes.

Based on observation, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a suprapubic catheter, that was on Enhanced Barrier Precautions (EBP) for 1 of 1 reviewed (Resident #21). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #21 was rarely / never understood and a Brief Interview for Mental Status (BIMS) was not completed indicating severe cognitive impairment. On 12/11/24 at 9:11 AM an observation revealed Staff A, Certified Medication Assistant (CMA) knocked on Resident #21's door, entered the room, completed hand hygiene, applied gloves, applied mask, applied a gown, placed a barrier on the ground, sat a graduate on the barrier, emptied urine from the catheter bag, alcohol wipe utilized to clean the catheter tip, and catheter tip reapplied to bag, 450mL of urine removed from the catheter bag. Urine emptied from the graduate into the toilet. Staff A removed the gown, removed gloves, removed the mask, and completed hand hygiene. Staff A applied gloves, obtained a washcloth, obtained barrier, and placed the barrier on the counter, pulled Resident #21's pants and brief down, removed gloves, completed hand hygiene, applied gloves, cleansed suprapubic area with no rinse cleanser, cleansed catheter tubing down about 6 inches, suprapubic area dried, brief pulled up, pants pulled up, gloves removed, and hand hygiene completed. No gown worn during catheter care. On 12/11/24 at 9:32 AM Staff A, CMA stated all Personal Protective Equipment (PPE) had been available the entire time she had worked at the facility. Staff A stated PPE is kept right outside of the residents room in drawers. Staff A stated PPE must be worn gown, gloves, and mask when possible contact with residents with EBP. Staff A stated she knew to wear a gown because it was explained that recently there was a change that required a gown, mask and gloves should be worn when catheters are emptied. On 12/11/24 at 3:23 PM Staff B, Registered Nurse (RN)/Infection infection preventionist (IP) stated she was not sure if a gown was required during supra pubic catheter cares. Stated she would need to speak to the DON. On 12/12/24 at 8:20 AM the DON stated there were no signs for EBP but there are drawers in the room and EBP was discussed with new hires as well as agency employees as well. The DON stated she would expect that a gown and appropriate PPE would have been worn with catheter care. The DON stated the facility's expectation was a gown would be worn with all catheter cares. Review of policy dated 3/25/24 titled Enhanced Barrier Precautions documented Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs). EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied before performing high-contact resident care activities (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of a gown and gloves include indwelling device care or use (Central lines, Urinary catheters, feeding tubes, tracheotomy/ventilator etc.). Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 7/11/24 and updated 7/12/22 revealed recent changes included, additional rationale for the use of Enhanced Barrier Precautions (EBP) in nursing homes, including the high prevalence of multidrug-resistant organism (MDRO) colonization among residents in this setting. Expanded residents for whom EBP applies to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status). Expanded MDROs for which EBP applies. Clarified that, in the majority of situations, EBP are to be continued for the duration of a resident's admission. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care.

Within 30 days of a resident's admission to a healthcare facility receiving reimbursement through the medical assistance program under Iowa Code chapter 249 A, the facility shall ask the resident or the residents personal representative whether the resident is a veteran and shall document the response. If the facility determines that the resident is a veteran, the facility shall report the resident's name along with the names of the resident's spouse and any dependent children, as well as the name of the contact person for this information, to the Iowa department of veteran's affairs. Where appropriate, the facility first shall seek reimbursement from the identified payer source before seeking reimbursement from the medical assistance program established under Iowa Code chapter 249A. Based on facility record review and interviews the facility failed to verify veteran ' s eligibility for all residents admitted from 7/1/22 to 10/16/23 reviewed to the Iowa Department of Veteran Affairs (VA) Department. The facility reported a census of 26 residents. Review of the facility's provided admission report dated 7/1/22 to 10/16/23 revealed 32 admissions since the facility's last survey. Interview on 10/18/23 at 3:00 PM with the Administrator revealed the facility has not been completing the VA eligibility.

Based on facility schedule reviews and staff interview, the facility failed to assure a Registered Nurse (RN) on duty for 8 hours daily, 7 days per week. The facility reported a census of 26 residents. Findings include: Review of the facility's nursing staff schedule dated 4/1/23 through 10/16/23 revealed there was no RN on duty for 8 hours on the following dates: 4/2/23, 4/8/23, 4/9/23, 4/16/23, 5/7/23, 5/29/23, 6/3/23, 6/17/23, 6/18/23, 6/24/23, 9/2/23, 9/3/23, 9/9/23, 9/10/23, 9/16/23, 9/17/23, 9/23/23, 9/24/23 and 10/1/23. The facility does not have a policy for RN coverage and follows the federal guidelines. Interview on 10/17/23 at 5:01 p.m., with the Director of Nursing (DON) revealed there should have been an RN for 8 hours everyday. Interview on 10/18/23 at 3:30 p.m., with the Administrator revealed there should have been RN coverage 8 hours everyday.

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 26 residents. Findings include: 1. An initial kitchen tour conducted on 10/16/23 at 11:10 AM, revealed the following observation, brown raised debris to the ceiling surrounding the air vents in the back corner. Observation on 10/18/23 at 11:30 AM Staff A, cook, applied gloves without performing hand hygiene. Staff A with gloved hands prepared and served the meal, touching the utensils, pans, and sprayer on the sink while washing out the robo coupe and while preparing a puree meal for Resident #1. Staff A then removed gloves and washed his hands and applied new gloves. Staff A with gloved hands picked up the plates, tongs, opened the cupboard and grabbed a bag of hotdog buns. With soiled gloves reached into the bag and removed a hotdog bun and with soiled gloves still on used the tongs to put the brat in the bun. Staff A with soiled gloves on placed the bag of hotdog buns on top of Resident #16 divided plastic plate. Staff A, with soiled gloves still on touched Resident #16 brat to cut it up and served the meal to Resident #16, Staff A, then removed his gloves and applied new gloves without performing hand hygiene. Per Hand Hygiene Policy reviewed 3/2022 hand hygiene is the number one way to prevent facility acquired infections by reducing the spread of harmful germs that can cause serious illness or death to residents. The facility requires healthcare providers to perform hand hygiene per CDC recommendations. Interview on 10/18/23 at 2:30 PM with the Administrator and the Dietary District Manager revealed expectation would be for all staff to wash their hands before applying gloves and after removing soiled gloves.

Based on record review, interview, and facility policy the facility failed to provide resident or resident representative quarterly statements for 3 out of 3 residents reviewed (Resident #9, #12 and #20) . The facility reported a census of 26. Findings include: 1. Interview on 10/16/23 at 1:10 p.m., with Resident #9 ' s financial power of attorney revealed he has never seen a statement for Resident #9 ' s trust account and does not know how much money he currently has. The facility revealed Resident #9 was given trust account statements and not provided to Resident #9 ' s financial power of attorney for Quarter Ending 3/2023, Quarter Ending 6/2023 and Quarter Ending 9/2023. Facility revealed Resident #9 was not provided with a trust account statement for Quarter Ending 9/2022 and for Quarter Ending 12/2022. 2. The facility revealed Resident #12 was given trust account statements and not provided to Resident #12 ' s financial power of attorney for Quarter Ending 3/2023, Quarter Ending 6/2023 and Quarter Ending 9/2023. Facility revealed Resident #12 was not provided with a trust account statement for Quarter Ending 9/2022 and for Quarter Ending 12/2022. 3. The facility revealed Resident #20 was given trust account statements and not provided to Resident #20 ' s financial power of attorney for Quarter Ending 3/2023, Quarter Ending 6/2023 and Quarter Ending 9/2023. Facility revealed Resident #20 was not provided with a trust account statement for Quarter Ending 9/2022 and for Quarter Ending 12/2022. Review of the facility provided policy titled Accounts Receivable Department with a revision date of 1/3/23 revealed statements- quarterly, upon discharge, as requested revealed quarterly statements to be printed by facility from RFMS and should be mailed or given to the Resident and or Responsible Party no less than quarterly. Interview on 10/18/23 at 12:00 p.m., with the Administrator revealed the trust account statements should have been done quarterly and should have been sent to the financial power of attorney instead of the resident.

Based on clinical record review and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 4 of 4 residents reviewed who transferred to the hospital (Resident #9, #15, #19 and #25). The facility reported a census of 26 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 documented diagnoses of hypertension, diabetes mellitus, and osteoporosis. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Review of Resident #9 ' s Progress Notes revealed the following information: a. 3/2/23 at 2:00 p.m., revealed nurse received call to send resident back to local hospital to be admitted . b. 7/21/23 at 9:10 p.m., revealed Resident #9 was admitted to hospital at 3:00 p.m c. 7/27/23 at 10:13 a.m., revealed Resident #9 back at facility. Review of Resident #9 ' s Census tab revealed the following: a. 3/2/23 unpaid hospital leave b. 3/14/23 active c. 7/21/23 stop billing d. 7/27/23 active Review of the facility documentation revealed the facility did not submit information to the LTC Ombudsman for March and July 2023. 2. The MDS assessment dated [DATE] for Resident #19 documented diagnoses of tibia fracture, hypertension and anemia . The MDS showed the BIMS score of 15 indicating no cognitive impairment. Review of Resident #19 ' s Progress Notes revealed the following information: a. 9/13/23 at 10:58 a.m., verbal order to direct admit resident to local hospital. b. 9/16/23 at 2:26 p.m., resident arrived back at the facility from the local hospital via ambulance. Review of Resident #19 ' s Census tab revealed the following: a. 9/13/23 hospital unpaid leave b. 9/16/23 active Review of the facility documentation revealed the facility did not submit information to the LTC Ombudsman for September 2023. 26527 3. According to the MDS assessment dated [DATE] Resident #15 scored 9 on the BIMS indicating moderate cognitive impairment. The resident required extensive assistance for bed mobility, dressing and toilet use. The resident had diagnoses including non Alzheimer's dementia, seizure disorder and psoriasis. The Progress Notes dated 2/3/23 at 5:25 p.m. documented at 3:30 p.m. the resident had a change in condition and at 4 p.m. the nurse called 911 and the resident transferred to the emergency room . On 10/18/23 at 2:48 p.m. the Administrator replied by email, they did not have Ombudsman notification for residents who were out of the facility in February 2023. 4. According to the MDS assessment dated [DATE] Resident #25 scored 15 on the BIMS indicating no cognitive impairment. The resident required limited assistance for bed mobility, transfer, and toilet use. The resident had diagnoses including diabetes, arthritis, and a wedge compression fracture of the 3rd lumbar vertebrae. The Progress Notes dated 9/6/23 at 11 a.m. documented the resident transported to a follow up appointment, awaiting return. At 3:16 p.m. the facility received a call from the resident and she would be admitted , needing another spinal surgery. The Progress Notes dated 9/8/23 at 7:04 a.m. documented the resident remained in the hospital. The facility lacked documentation they notified the long term care (LTC) Ombudsman of the transfer.

Based on interview, record review, and policy review, the facility failed to ensure call lights responded to in a timely manner for 3 out of 3 residents reviewed (Resident #12, #18, #19). The facility reported a census of 26 residents. Findings include: 1. Interview on 10/16/23 at 1:24 p.m., with Resident #12 revealed the staff take a long time to answer the call lights and last month she had to sit on the commode for over an hour. Review of facility provided document titled Alarm Event Report dated 10/3/23- 10/17/23 revealed the following: On 10/3/23 the call light turned on at 2:36 a.m. and was on for 16 minutes. On 10/3/23 the call light turned on at 8:17 a.m. and was on for 20 minutes. On 10/3/23 the call light turned on at 4:17 p.m. and was on for 33 minutes. On 10/11/23 the call light turned on at 2:25 a.m. and was on for 25 minutes. On 10/11/23 the call light turned on at 12:32 p.m. and was on for 25 minutes. On 10/12/23 the call light turned on at 10:58 a.m. and was on for 27 minutes. On 10/13/23 the call light turned on at 11:49 p.m. and was on for 28 minutes. On 10/14/23 the call light turned on at 4:36 a.m. and was on for 50 minutes. On 10/15/23 the call light turned on at 5:345 p.m. and was on for 21 minutes. On 10/16/23 the call light turned on at 10:16 a.m. and was on for 28 minutes. On 10/16/23 the call light turned on at 10:16 a.m. and was on for 18 minutes. 2. Interview on 10/16/23 at 1:46 p.m., with Resident #18 revealed on 10/15/23 he turned his call light on about 3:15 p.m., and no one answered his light until 5:00 p.m Resident #18 revealed he waits a long time for his call light to be answered and feels as if he is forgotten when he has to wait a long time. Resident #18 revealed he feels there is not enough staff to help all the resident ' s in the facility. Review of facility provided document titled Alarm Event Report dated 10/3/23- 10/17/23 revealed the following: On 10/3/23 the call light turned on at 2:38 p.m. and was on for 19 minutes. On 10/3/23 the call light turned on at 7:45 p.m. and was on for 48 minutes. On 10/4/23 the call light turned on at 9:27 a.m. and was on for 17 minutes. On 10/4/23 the call light turned on at 6:06 p.m. and was on for 36 minutes. On 10/4/23 the call light turned on at 7:18 p.m. and was on for 52 minutes. On 10/5/23 the call light turned on at 4:10 p.m. and was on for 19 minutes. On 10/5/23 the call light turned on at 7:36 p.m. and was on for 18 minutes. On 10/5/23 the call light turned on at 10:13 p.m. and was on for 18 minutes. On 10/6/23 the call light turned on at 10:54 a.m. and was on for 21 minutes. On 10/6/23 the call light turned on at 1:05 p.m. and was on for 28 minutes. On 10/6/23 the call light turned on at 2:18 p.m. and was on for 16 minutes. On 10/6/23 the call light turned on at 7:09 p.m. and was on for 27 minutes. On 10/6/23 the call light turned on at 7:36 p.m. and was on for 26 minutes. On 10/6/23 the call light turned on at 9:13 p.m. and was on for 25 minutes. On 10/7/23 the call light turned on at 7:22 a.m. and was on for 28 minutes. On 10/7/23 the call light turned on at 2:34 p.m. and was on for 16 minutes. On 10/7/23 the call light turned on at 6:18 p.m. and was on for 38 minutes. On 10/7/23 the call light turned on at 7:11 p.m. and was on for 47 minutes. On 10/7/23 the call light turned on at 8:48 p.m. and was on for 30 minutes. On 10/7/23 the call light turned on at 9:43 p.m. and was on for 24 minutes. On 10/8/23 the call light turned on at 10:50 a.m. and was on for 19 minutes. On 10/8/23 the call light turned on at 2:23 p.m. and was on for 19 minutes. On 10/8/23 the call light turned on at 4:19 p.m. and was on for 27 minutes. On 10/8/23 the call light turned on at 6:20 p.m. and was on for 29 minutes. On 10/8/23 the call light turned on at 8:55 p.m. and was on for 20 minutes. On 10/9/23 the call light turned on at 9:03 a.m. and was on for 18 minutes. On 10/9/23 the call light turned on at 6:40 p.m. and was on for 39 minutes. On 10/9/23 the call light turned on at 7:46 p.m. and was on for 28 minutes. On 10/9/23 the call light turned on at 8:47 p.m. and was on for 38 minutes. On 10/10/23 the call light turned on at 5:28 a.m. and was on for 22 minutes. On 10/10/23 the call light turned on at 6:35 p.m. and was on for 34 minutes. On 10/10/23 the call light turned on at 7:25 p.m. and was on for 31 minutes. On 10/11/23 the call light turned on at 12:50 p.m. and was on for 17 minutes. On 10/11/23 the call light turned on at 3:50 p.m. and was on for 32 minutes. On 10/11/23 the call light turned on at 6:07 p.m. and was on for 29 minutes. On 10/11/23 the call light turned on at 10:00 p.m. and was on for 20 minutes. On 10/11/23 the call light turned on at 3:50 p.m. and was on for 32 minutes. On 10/12/23 the call light turned on at 6:32 p.m. and was on for 1 hour and 5 minutes. On 10/12/23 the call light turned on at 7:46 p.m. and was on for 33 minutes. On 10/13/23 the call light turned on at 7:12 a.m. and was on for 23 minutes. On 10/13/23 the call light turned on at 8:42 a.m. and was on for 26 minutes. On 10/13/23 the call light turned on at 2:08 p.m. and was on for 36 minutes. On 10/13/23 the call light turned on at 4:02 p.m. and was on for 17 minutes. On 10/13/23 the call light turned on at 7:12 p.m. and was on for 16 minutes. On 10/13/23 the call light turned on at 9:02 a.m. and was on for 20 minutes. On 10/14/23 the call light turned on at 8:10 a.m. and was on for 16 minutes. On 10/14/23 the call light turned on at 8:10 a.m. and was on for 16 minutes. On 10/14/23 the call light turned on at 8:38 a.m. and was on for 20 minutes. On 10/14/23 the call light turned on at 1:57 p.m. and was on for 18 minutes. On 10/14/23 the call light turned on at 3:50 p.m. and was on for 31 minutes. On 10/14/23 the call light turned on at 7:17 p.m. and was on for 19 minutes. On 10/14/23 the call light turned on at 8:10 p.m. and was on for 47 minutes. On 10/14/23 the call light turned on at 9:27 p.m. and was on for 19 minutes. On 10/15/23 the call light turned on at 11:23 a.m. and was on for 25 minutes. On 10/15/23 the call light turned on at 2:14 p.m. and was on for 36 minutes On 10/15/23 the call light turned on at 3:34 p.m. and was on for 1 hour and 23 minutes. On 10/15/23 the call light turned on at 5:58 p.m. and was on for 17 minutes. On 10/15/23 the call light turned on at 6:53 p.m. and was on for 59 minutes. On 10/16/23 the call light turned on at 3:48 a.m. and was on for 28 minutes. On 10/16/23 the call light turned on at 7:27 a.m. and was on for 35 minutes. On 10/16/23 the call light turned on at 9:27 a.m. and was on for 47 minutes. On 10/16/23 the call light turned on at 2:04 p.m. and was on for 21 minutes. On 10/16/23 the call light turned on at 2:36 p.m. and was on for 23 minutes. 3. Interview on 10/16/23 at 1:42 p.m., with Resident #19 revealed she waits quite often for her call to be answered. She further revealed it happens quite often she waits over 15 minutes for staff but tries not to call the staff very often. Review of facility provided document titled Alarm Event Report dated 10/3/23- 10/17/23 revealed the following: On 10/6/23 the call light turned on at 6:14 p.m. and was on for 39 minutes. The facility does not have a policy on call light response times. Interview of 10/17/23 at 3:00 p.m., with the Director of Nursing (DON) revealed call lights should be answered in under 15 minutes. Interview on 10/17/23 at 3:04 p.m., with the Administrator revealed all call lights should be answered in under 15 minutes.

Based on clinical record review, staff interview and facility policy the facility failed to revise and update the care plan to include oral intake for 2 of 2 residents reviewed for oral intake (Resident # 1 and # 24) and failed to list high risk medications and side effects for 3 out of 5 residents reviewed for high risk medications (Resident #2, #12, #18). The facility reported a census of 26 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnosis of dysphagia and nutritional deficiency. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of clinical record shows an order dated for 6/23/23 for pleasure feedings for pureed foods - moist, nectar thickened liquids, okay for patient to have small amounts of moist pureed (up to 2 teaspoon per session) and up to 2 ounces nectar thickened liquids 2 times per day. Review of clinical record shows an order dated for 8/18/23 to offer 1 meal per day, discuss and fill out a menu and encourage her to get into the recliner to eat, may have pureed food and nectar thick liquids, up right in the recliner or w/c in the room or dining room, staff to do 1 on 1, rinse/spit with water prior to and after eating, continue to monitor lung sounds. Report concerns to therapy and physician. Review of the Progress Notes for Resident #1 showed documentation of oral intake for the following dates: 8/24/23 Resident is on honey thick liquids. Speech Therapy (ST) did a trial of thin liquids yesterday. No new orders at this time. 9/20/23 Resident attempts to eat sitting up in bed at lunch time and completes 5-10 bites before stopping and requesting a popsicle. 10/4/23 Resident ate bites of ravioli at noon with ST. 10/7/23 Resident fed in room by certified nursing assistant (CNA) lunch meal. Ate 50%. The review of the Care Plan for Resident #1 dated 6/12/23 lacked information regarding oral intakes. 2. The MDS assessment dated ,d+[DATE]//23 for Resident #24 documented diagnosis of dysphagia and cerebral infarction. The MDS showed a BIMS not completed due to Resident #14 is rarely understood. Review of clinical records revealed the facility received an order on 9/25/23 that the physician ordered pureed food 3 ounces twice daily as needed. Review of the Progress Notes for Resident #24 showed documentation of oral intake for the following dates: 10/13/23 resident had an increase in oral intake of pureed food as well as continues feedings. The Care Plan dated 8/22/23 for Resident #24 lacked information regarding oral intake. Interview on 10/18/23 at 4:44 PM with the Director of Nursing (DON), and Assistant Director of Nursing (ADON) they were instructed per upper management to write Diet as Ordered on the care plan. When asked how the staff knows about the diet changes, ADON revealed the diet is on the Point of Care charting for the CNA ' s. 44474 3. The MDS assessment dated [DATE] for Resident #2 documented diagnoses of diabetes mellitus and history of falling. The MDS showed a BIMS score of 14 indicating no cognitive impairment. Review of the October 2023 Medication Administration Record (MAR) revealed the following orders: Basaglar KwikPen Solution (Insulin), Hydrocodone-Acetaminophen Oral Tablet (opioid pain medication). Review of the MDS dated [DATE] revealed insulin injections were given 7 out of the last 7 days in the look back period and opioid medication was taken 4 out of the last 7 days in the look back period. Review of the Admission Orders signed 10/10/23 revealed the following orders: Basaglar KwikPen Solution with an order date of 10/5/23, Hydrocodone-Acetaminophen Oral Tablet twice daily with an order date of 8/1/23. Review of the Care Plan with a revision date of 9/17/23 lacked information regarding the side effects of insulin and opioid pain medication. 4. The MDS assessment dated [DATE] for Resident #12 documented diagnoses of depression and anxiety disorder. The MDS showed a BIMS score of 14 indicating no cognitive impairment. Review of the October 2023 Medication Administration Record (MAR) revealed the following orders: Diazepam (anxiety medication). Review of the MDS dated [DATE] revealed antianxiety medication was taken 7 out of the last 7 days in the look back period. Review of the admission orders signed 10/6/23 revealed the following orders: Diazepam with an order date of 8/24/23. Review of the Care Plan with a revision date of 10/4/23 lacked information regarding the side effects of anxiety medication. 5. The MDS assessment dated [DATE] for Resident #18 documented diagnoses of diabetes mellitus and depression. The MDS showed a BIMS score of 15 indicating no cognitive impairment. Review of the October 2023 Medication Administration Record (MAR) revealed the following orders: Lexapro tablet (antidepressant medication), Novolog Insulin (insulin), Lantus insulin (insulin). Review of the MDS dated [DATE] revealed insulin injections were given 7 out of the last 7 days in the look back period and opioid medication was taken 7 out of the last 7 days in the look back period. Review of the admission orders signed 10/23/23 revealed the following orders: Lexapro tablet with an order date of 9/7/23, Novolog Insulin with an order date of 6/16/23, Lantus insulin with an order date of 9/5/23. Review of the Care Plan with a revision date of 10/3/23 lacked information regarding the side effects of antidepressant medication and hypoglycemia side effects. The facility Care Plan Development policy dated 8/15 states an individualized, comprehensive care plan using the results of the RAI/MDS assessment, resident/family/legal representative and interdisciplinary input will be developed for each resident in the facility within 21 days of admission or 7 days after the completion date of a comprehensive MDS assessment, and describe the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental and psychosocial well-being. The care plan will include measurable objectives, interventions, goals, and timetables. The care plan will be reviewed and revised on an as needed bases and at least every 92 days. Interview on 10/18/23 at 9:25 a.m., with the Director of Nursing (DON) revealed the side effects should have been on the care plan.

Based on clinical record review, staff interviews, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 1 resident reviewed for elopement (Resident #121). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility failed to provide adequate nursing supervision to prevent injuries for 1 of 1 resident reviewed (Resident # 8). The facility reported a total census of 16 residents. Findings include: 1. The The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 121 documented diagnoses of [CONDITION(S)],COVID-19 and [CONDITION(S)]. The MDS did not include a Brief Interview for Mental Status (BIMS) score. Review of the Baseline Care Plan dated of 12/30/21 revealed the following: The resident is confused. Interventions include: resident is confused to person only, redirection as needed. Resident safety concerns include: exit seeking behavior. Interventions include: minimize risk of elopement and frequent monitoring. Review of the elopement risk assessment dated [DATE] at 2:09 p.m., revealed a score of 11 which indicated Resident #121 was at high risk for wandering. The assessment included a note that stated risk for elopement related to dementia and wandering. Review of Progress Notes revealed the following: a. On 12/30/21 at 5:49 p.m., alert to self only, very confused, family stated sundowning around 5:00 p.m., resident requesting to go home. He knows his home is around the corner from the facility, chair alarm on, attempting to ambulate without assistance. He is requesting to go home. b. On 12/20/21 at 6:16 p.m., resident needed one on one multiple times since admission. He verbalized his house is around the corner from the facility and he needs to go there. c. On 12/21/21 at 11:48 p.m., resident was noted to be wandering halls and anxious. Resident asked about his wife and daughter and where and what they were doing. Resident was trying to get up at 10:30 p.m., and stated he needed to go to California tonight and he could not sleep. d. On 1/3/22 at 11:17 a.m., resident has been needing one on one supervision from staff so far this shift. e. On 1/4/22 at 11:41 p.m., resident needed consistent one on one staff assistance as he continually attempted to get up and walk around without assistance. Resident wanted to go home, find his truck and go to bed. Resident not easily redirected. f. On 1/7/22 at 1:35 a.m., Resident needed one on one earlier in the evening this shift. g. On 1/10/22 at 1:47 a.m., Resident continued in isolation for COVID, restless in his room, he wanted to get out of his room. Staff had to stay with him for sometime. h. On 1/10/22 at 4:52 a.m., Resident in the hallway wondering, staff found him holding the exit door on the isolation side, and he was brought back to his room. i. On 1/10/22 at 9:55 p.m., See Risk Management for exit of facility. Review of the Incident Report dated 1/10/22 at 5:06 p.m., revealed Resident went out the north door of COVID hall and went around to the kitchen door banging on the door to get back in. Resident had on a flannel shirt and slipper socks. He had taken his brief off and left it in his room. Resident immediately assessed for injury and frostbite. Resident has dementia and usually ambulates with assistance. No injuries noted post incident. Resident had a recent room change to the COVID hallway. Physician, family and the Director of Nursing (DON) were advised of the incident. Interview on 6/28/22 at 4:33 p.m., with Staff H, Dietary Manager revealed she was serving supper and heard a loud banging on the kitchen door, it was so loud it scared her. Staff H stopped serving and went to the door to see what the noise was. When she opened the door, Resident #121 was standing outside. Staff H asked him what he was doing outside and Resident #121 said he was trying to get back in. Staff H revealed he was only wearing a flannel shirt and socks. He did not have any pants on. Staff H brought him in the facility right away and sat him in a chair and called for nursing staff to come right away. Interview on 6/29/22 at 8:35 a.m, with Staff A, Certified Nursing Assistant (CNA) revealed she remembered the incident. Resident #121 had COVID and was in quarantine when it happened. Staff A revealed Resident #121 was confused prior to getting COVID but it got worse when he had COVID. Staff A revealed Resident #121 did not wear any type of wander guard bracelet but he did have a chair alarm to alert staff when he was up. Staff A explained Resident #121 was extremely anxious and was up and down throughout the shift and when staff would try to help him he would get combative. Staff A revealed he went out the north door of the COVID unit and came around the back of the building to the kitchen door. Staff A further revealed Resident #121's house is right across the street. Staff A revealed there were no door alarms going off when he went out the door. Interview on 6/29/22 at 8:50 a.m., with Staff I, Registered Nurse (RN) revealed it was cold that day and Resident #121 was the only resident in the COVID hallway. Resident #121 had a chair alarm and it was supposed to signify he was up and moving around. Staff I revealed Resident #121 had gotten out the north door in the COVID unit and walked around to the kitchen door. Staff I was passing medication when the kitchen called for assistance with Resident #121. She further revealed she did Resident #121's assessment and took his vital signs. He was shivering when she got to him. Resident #121 was only wearing a flannel shirt that went down to his thigh area and a pair of socks. Staff I realized he did not have a brief on when she assisted him back to his room to use the restroom. Staff I had a CNA come down and assist the resident in getting redressed. Staff I stated the north door alarm was not buzzing and the chair alarm for the resident was not sounding when she entered into the COVID unit. Review of facility policy titled Elopement dated June 18, 2019 revealed the purpose of the policy is to maintain resident safety by identifying residents who are at risk for elopement behavior. The policy further revealed and evaluation will be completed upon admission, quarterly, and with significant change by a licensed nurse within Point Click Care titled, Wandering and Risk for Elopement. Any resident displaying significant wandering behavior will be evaluated for elopement risk and care planned appropriately. Care plans will address wandering as a specific problem. Approaches will be formulated, pattern identified, and the causes determined should be addressed. Interview on 6/29/22 at 4:15 p.m., with Regional Nurse Consultant revealed the facility did report the elopement to the Department of Inspections and Appeals (DIA). The facility did not have any documentation of the door alarm checks prior to the elopement. 2. The MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 4 for Resident #8 which indicated severe cognitive impairment. The resident needed the extensive assistance of 1 with transfers and total assistance of 1 with toileting. The resident's diagnoses included multiple rib fractures, anxiety, chronic heart failure [(CHF) causes shortness of breath and excess fluid], left femur fracture, pelvic fracture, age related cognitive decline, depression, fracture of a scapula (shoulder blade). The Progress Notes and Incident Reports from the resident's admission on 3/10/22 to 6/20/22 revealed the resident had 16 falls. The Neurological Flow Sheet was not completed for 11 of the resident's falls that were unwitnessed. The Care Plan had interventions placed related to falls at the resident's admission to the facility. The resident's Care Plan was not revised after 12 of the resident's falls. The Health Status Note on 5/5/22 revealed the resident had an unwitnessed fall. The Health Status Note revealed the following on 5/7/22: a. At 2:02 AM the resident complained of pain to a CNA. The nurse assessed the resident and noted the resident's hips were a bit swollen. b. At 7:00 AM, a CNA offered to assist the resident in getting up for the day, the resident refused. c. At 8:15 AM, a CNA offered to assist the resident in getting up for the day, the resident refused. d. At 10:00 AM, the resident was in bed sleeping. e. At 11:45 AM, the resident's left leg was swollen and did not look right, the resident complained of pain. The resident was transferred from the facility to the emergency department with her daughter's consent. f. At 2:14 PM, the resident was being transferred to another hospital for diagnoses of a broken hip. The Discharge Information dated 6/6/22 signed by a physician revealed the resident had a diagnosis of a left femur fracture (broken hip). The Fall Risk Assessment on 3/10/22 revealed the resident was at a moderate risk for falls. The Falls Risk Assessments on 5/14/22 and 6/6/22 revealed the resident was at a high risk for falls. The Fall Risk and Management policy revised date 04/13 revealed fall management included: provision of immediate care for injuries, evaluation of clinical condition to determine need for medical intervention, review of fall risk indicators and evaluation and/or modification of interventions. In an interview on 7/6/22 at 3:48 PM, the DON and Regional Nurse Consultant denied any additional documentation existed for the falls the resident had and nodded their heads in agreement that more interventions could have been in place to prevent the resident from falling. In the same interview, the DON and Regional Nurse Consultant both reported staff would be educated on the facility's fall policy and procedures due to assessing the need for education after reviewing the resident's chart during the survey. The facility corrected the Immediate Jeopardy on 1/11/22 by providing education to staff on elopements and called the door company who came to the facility on [DATE] and repaired the alarm system. The facility has been completing door alarm checks routinely since incident and door alarms were operational during survey. At the time of exit the scope and severity was lowered to a G.

Based on observations, interviews, and record review, the facility failed to provide appropriate infection control to prevent the spread of the novel coronavirus 2019 (COVID-19) which resulted in an immediate jeopardy to the residents health and safety. On 7/10/20, the Administrator worked while experiencing cough and allergy-like symptoms. On Monday, 7/13/20 went to the Doctor, who ordered a COVID-19 lab test. On 7/21/20, the lab result returned positive for COVID-19. The Administrator remained off work until 7/22/20. On 7/22/20, the Administrator worked from approximately noon until 3:00 PM for meetings with the Corporate Nurse and Director of Nursing (DON). Staff report the Administrator was coughing and showing symptoms while in the building. The Administrator did not return to work until 7/27/20. On 7/30/20, the Business Office Manager directed the surveyor to take their temperature (temp) and answer the screening questions, while standing inside the building. On 8/3/20, observed the therapist screen themselves before exiting the facility. Per the DON and other staff, the staff was to screen themselves when coming to work or leaving work. Observed multiple staff wearing their face masks under their nose and one nurse removed the mask from the face while at nurses' station with other staff at the station. The facility did not have designated personnel to work the COVID-19 wing with three patients in the wing, two residents that returned from the hospital, and one new admission. The facility reported a census of 28 residents. Findings include: Observations: a. On 7/30/20 at 1:21 PM, the Business Office Manager came to the door wearing a mask with the nose exposed and no face shield, instructed the surveyor to take their own temperature then complete the screening form. After asking how to use the thermometer, the Business Office Manager took the surveyor's temp by touching the thermometer to the surveyor's head and then placing a thermometer on the table without cleaning. b. An undated sign in the entranceway instructed that before entering a person must 1. Spray body, clothes, and personal items with disinfectant spray. 2. Take temp a. Place scanner near forehead but don't touch the skin. b. Then press scan. c. If you have a fever of 100.0 or above, you may not enter the facility. 3. Fill out visitor or staff log accordingly 4. Use hand sanitizer 5. Then you may enter the building - do not push the red button, we want the alarm to sound so that we are aware of your arrival. **Visitors, including deliveries, are not allowed to go beyond the family room entrance. Please call the facility to alert staff of your arrival and wait for a staff member to come.** c. An additional undated sign in the entranceway said to please remember to put an answer in every box when coming to work. The sign included a handwritten section of first and last names. d. A handwritten sign dated 4/14/20 related to thermometer use said to turn on the thermometer, hold close to your forehead, scan, then record your temp before and after your shift. e. On 7/30/20 at 1:56 PM, observed Staff A, Licensed Practical Nurse, sitting alone behind the nurses' station without a face shield and the face mask pulled down below their chin. The north hall has a stop sign on the door with a COVID-19 update and an isolation kit hanging from the west door, both doors closed. f. On 7/30/20 at 2:00 PM, observed Staff J, Dietary Assist, wearing a face shield and mask below the nose. g. On 7/30/20 at 2:04 PM, a non-facility employee entered the facility and completed the screening form. The Business Office Manager unlocked the door and allowed the person to enter the building. h. On 8/3/20 at 11:12 AM, Staff A observed sitting at the nurses' station with mask below chin and face shield off. i. On 8/3/20 at 12:41 PM, observed three staff members at the nurses' station with their face shields and masks off while eating. One staff member, Staff E, Registered Nurse (RN), was sitting on one side of the nurses' station. The other two staff, Staff B, CNA, and Staff C, were standing on the other side facing Staff B. The two were approximately two feet apart. After the staff observed the surveyor, Staff B applied a face mask with a face shield and went out to the dining room to check on the residents that were eating. The other two staff applied a face mask and shield before going into the dining area. No hand hygiene observed by the staff before assisting the residents. Staff E then sanitized their hands. j. On 8/3/20 at 12:48 PM, Staff A walked through the dining room with a face shield and mask on exposing their nose. After arriving at the nurses' station, Staff A removed the face shield and moved the face mask to their chin. Staff I, Dietary Assist, began to walk out of the kitchen with no face mask or shield until another dietary staff redirected them to put on their mask. k. On 8/3/20 at 1:53 PM, the Administrator wore the face mask upside down and face shield, the face mask slipped down below their nose. The Administrator adjusted the mask to cover their nose two times without completing hand hygiene. l. On 8/3/20 at 2:04 PM, Staff E and Staff A sat at the nurse's station with face shields off, and masks pulled down below their nose. Staff H, Dietary Assist, and Staff I sat at the dining room table, wrapping silverware with face shields and face masks exposing their nose. m. On 8/3/20 at 2:07 PM, Staff E moved face mask over their face covering their nose, no hand hygiene observed. n. On 8/4/20 at 8:17 AM, Staff D, RN, exited the designated COVID-19 wing, removed face mask, left face shield in place, and walked into the nurses' station then into the supply room to get a new face mask. Staff D applied a new face mask covering the nose and mouth. o. On 8/4/20 at 8:20 AM, the Dietary Assist brought out the fluids for the residents from the kitchen uncovered. Staff L, CNA, took the cart and passed out the drinks. p. On 8/4/20 at 8:21 AM, Staff L saw with face shield on and face mask covering the mouth, leaving the nose exposed. q. On 8/4/20 at 8:22 AM, Staff D observed picking things off the floor went to the medication cart pulled mask down to their chin. No hand hygiene completed. r. On 8/4/20 at 8:25 AM, Staff L returned the cart with fluids back to the kitchen uncovered. s. On 8/4/20 at 8:28 AM, Staff D walked into the hallway, pulled mask back onto the face. Without hand hygiene, Staff D walked down the hall with the assessment supplies in a clear plastic tote. Staff D walked into room ten and placed the clear plastic tote with assessment supplies on the counter with no barrier. Staff D used a [MEDICATION NAME] thermometer, took the resident's temperature, and then put it into the tote. Took out the fabric wrist blood pressure cuff and took the resident's blood pressure. Without cleaning blood pressure cuff, placed into the tote. Staff D then rubbed face through face mask without hand hygiene and gave residents their medication. Staff D took the medication cup and placed it into the clear plastic tote with the assessment supplies. t. On 8/4/20 at 8:34 AM, Staff D exited room ten and went to the medication cart. Staff D placed the clear plastic tote on the medication cart without a barrier. Checked the computer and then left the medication cart with a clear plastic tote of assessment supplies. Staff D entered room [ROOM NUMBER], placed clear plastic tote with assessment supplies on the counter without barrier. Staff D took the fabric wrist blood pressure cuff on the resident and took the resident's blood pressure. After taking the resident's blood pressure, Staff D placed the cuff without cleaning into the clear plastic tote. Staff D removed the [MEDICATION NAME] thermometer to take the resident's temp and returned the thermometer into the tote. u. On 8/4/20 at 8:36 AM, Staff L sat with Resident #1 assisting with their meal. Staff L's face mask was down below the nose, only covering their mouth. Interviews: a. On 7/30/20 at 1:30 PM during the entrance conference, the Administrator reported the facility only had one staff member that tested positive for COVID-19, and they were currently off work. The facility had another staff waiting for test results and they weren't allowed to work until the results returned. b. On 7/30/20 at 1:56 PM, Staff A reported there are two residents in the COVID wing, one new admission and one that returned from the hospital. c. On 7/30/20 at 2:40 PM, the Director of Nursing (DON) reported baseline testing completed on all staff and residents with negative results. The door is locked at all times to the facility. People that come into the facility screen themselves, and at night someone is supposed to sit at the entrance to make sure they are doing it. d. On 7/30/20 at 3:07 PM, a Resident Representative reported the Administrator sent a letter to the families that the facility had a positive COVID-19 test. Staff told the Resident Representative that the person was the Administrator. The Administrator was staying mostly in the office. The Administrator was wearing a face mask with a shield and told staff they were following the Center's for Disease Control (CDC) guidelines. The Resident Representative said they just received another email saying there was another case of COVID-19. This case was a Certified Nurses' Aide (CNA), and they were concerned with how bad this could be for the residents. The families used to be able to do a drive-up visit with the residents, but one incident of COVID-19 for the staff canceled that. e. On 7/30/20 at 4:00 PM, the Administrator reported one Department Head tested positive for COVID-19. The person that was positive with COVID-19 was the Administrator. The test was completed on 7/13/20, and the results came back a week later. The Administrator reported not working for 14 days. f. On 8/3/20 at 9:15 AM, the Administrator denied remember coming to the facility on [DATE]. The Administrator said they would look and get back to the surveyor. The Administrator said she had symptoms a couple of days before but has allergies [REDACTED]. On the morning of 7/13/20, the Administrator reported calling their Physician, who suggested getting tested for COVID-19. The Administrator said it was the worst on Sunday before she called the Physician. g. On 8/3/20 at 9:49 AM, the Administrator said the symptom onset date was 7/10/20 and tested on [DATE]. The results came back on 7/21/20. The Administrator reported they took a couple of extra days off work just to be safe. The Administrator said that if she had symptoms, she never would've come into work. The symptoms started late on 7/10/20 but unsure of the exact time. The Administrator said she could return to work on the 22nd but took extra time off. The Physician was extra cautious. The Administrator stated she came in on 7/22/20 for corporate meetings with the Nurse Consultant. Worked on 7/10/20 but just in the office area had much staff off, then worked from home until 7/27/20. The Corporate Office decides when the staff can return to work. Based on this, the Administrator could return on 7/21/20, not 7/20/20. h. During a follow-up interview on 8/3/20 at 10:29 AM, the Administrator reported the staff that attended the meeting on 7/22/20 was the Nurse Consultant and the DON, unsure if anyone else was in the meeting. The shortness of breath gone for quite a while, the only remaining symptoms were allergy symptoms. The Administrator reported knowing the difference between the COVID-19 signs and allergy symptoms, as they took allergy medications all the time. The Physician was just safe to allow them to rest. The Administrator said she only came in on 7/22/20 and no other time. On 7/22/20, she had no fever, but when everything started, she had a fever, but it didn't last that long. The fever was only in the first couple of days; she has everything recorded at home. The only reason the fever was known was because of taking temperatures and couldn't come in if the temperature was over 100 degrees Fahrenheit (F). The baseline testing for all staff and residents started around 6/11/20. i. On 8/3/20 at 11:12 AM, Staff C, CNA, reported seeing staff come into the facility showing symptoms. The person was coughing and hacking all over everyone. The person did not have a lot of personal protective equipment (PPE) and stayed up front most of the time. There were lots and lots of staff up there. j. On 8/3/20 at 11:30 AM, Staff F, CNA, stated to come to work screening was a do it yourself type thing with a sheet of paper. k. On 8/3/20 at 11:37 AM, the Social Worker said per the guidelines they could return to work on 8/7/20. Staff from the Corporate office said that even though the test was negative, she needed to remain out of work for the full ten days. The Social Worker stated the Administrator came into work with a cough. The Social Worker said the Administrator reported it was a cough, but it was just allergies [REDACTED]. The Social Worker said they were concerned that everyone should get tested as they were exposed to the Administrator. The Administrator was wearing a face shield and mask while in the building from approximately noon until 3:00 PM on 7/22/20. The Administrator did not leave the office or conference room that day. l. On 8/3/20 at 1:01 PM, Staff B reported no designated staff for the COVID-19 wing but stated that it would be nice. m. On 8/3/20 at 1:53 PM, the Administrator reported not being able to find the screening sheets from 7/10/20 through 7/12/20 but has messages out to staff, as three department heads were off work. To prevent losing the screening sheets, they were going to scan the papers into the computer and email them to the Corporate Nurse. n. On 8/3/20 at 3:11 PM, the Corporate Nurse reported not knowing the COVID wing needed to have dedicated staff and was surprised the boss missed that. o. On 8/3/20 4:10 PM, the Corporate Nurse stated the COVID-19 statement said when the staff was available. The Administrator reported that their symptoms improved on 7/22/20. p. On 8/4/20 at 8:45 AM, the Administrator reported still looking for the screening sheets dated 7/10/20 - 7/12/20 as the entire team was working that day. q. On 8/4/20 at 10:34 AM, Staff D reported being the nurse for the north (COVID-19 wing), east, and west halls. Staff D said an aide was sitting in the COVID-19 hall. Staff D stated there was no designated equipment for the COVID-19 wing. After using the supplies, Staff D said they placed them on a cart, cleaned the equipment with Sani-cloth plus wipes. r. On 8/4/20 at 10:49 AM, the Corporate Nurse said they expected each resident on the COVID-19 wing to have their own designated vital sign equipment. s. On 8/4/20 at 12:04 PM, the DON reported no staff planned to work the COVID-19 wing if a positive case occurred. The facility only had one staff member that agreed to work the floor, but they were currently in Wisconsin. The DON stated other staff said they would not work the COVID-19 wing due to other co-morbidities. t. On 8/4/20 at 1:40 PM, the Dietary Supervisor reported Staff H was new to the facility and still learning. u. On 8/4/20 at 4:34 PM, the Corporate Nurse said if there was anything not given to the surveyor, the facility was unable to find it. Record Review: a. The facility's undated supplied symptom tracker showed the Administrator's last date of contact with the facility was 7/10/20. The Administrator's date of illness onset was 7/10/20 of cough, headache, and shortness of breath. The ten-day post-onset date noted to be 7/20/20. Other health conditions documented as unknown. The Administrator tested on [DATE], with positive results on 7/21/20. b. The undated blank Staff Screening Log showed the staff needs to take their temp and answer the questions before their shift. If they have a temp of 100.0 F or greater, cough with shortness of breath, they couldn't work and must-see their Doctor. The staff must wear a mask and face shield when they are within six feet of a resident; this was not optional. The questions asked were the following. 1. Staff Name: All staff are required to wear a mask 2. Date 3. Take temp. For temp 100 degrees or greater, see the nurse. 4. Taken a cruise anywhere in the world in the last 14 days? Yes or no, if yes, you must isolate for 14 days from the last day of the cruise. 5. Live with someone who has symptoms of COVID-19 or tested positive for COVID-19? Yes or No. 6. Provided care for a patient with symptoms of COVID-19 or tested positive for COVID-19 without using PPE? Yes or No. 7. Had close contact (within six feet for more than two minutes) with a visibly sick person with respiratory symptoms (examples sneezing or coughing) or saying they are sick with a fever or respiratory symptoms? Yes or No. 8. Have you (or within the past seven days) cough with shortness of breath, pneumonia, or flu recently? Yes or No. 9. List any of the following symptoms you are currently having: Sore throat, headache, fever, chills, muscle pain, diarrhea, repeated shaking with chills, the new loss of taste or smell. If you have two or more symptoms, report to your supervisor immediately. 10. End of shift temp. For temp 100 degrees or greater, see the nurse. 11. Have you developed any symptoms listed in the previous screening questions today? Yes or No. If you answer yes, report to a nurse immediately. c.The COVID Visitor Screening Log dated 7/7/20 asked for the date, visitor's name, resident's name and the following 1. Have you been in contact with someone who had symptoms of COVID-19 or tested positive for COVID-19? Yes or no. 2. Do you currently have a new onset of cough, shortness of breath, sore throat, headache, fever, chills, muscle pain, diarrhea, repeated shaking with chills, a new loss of taste or smell? Yes or no. 3. Temp 4. In time 5. Out time d. On 7/22/20, the Administrator sent an email to the residents' representatives explaining a positive case of COVID-19 in the facility. The individual was receiving medical treatment and will remain in isolation per the CDC and Centers for Medicare and Medicaid Services (CMS) guidelines. e. On 7/22/20, the Administrator sent an email to the residents' representatives explaining that due to the increase of COVID-19 in the county, the vehicle visits would stop. f. On 7/28/20, the Administrator sent an email to the resident's representatives explaining there were now two positive cases of COVID-19. The individual was receiving medical treatment and will remain in isolation per the CDC and CMS guidelines. The email described the health and safety of their loved ones was their top priority. The facility was doing everything it could to stop the spread of COVID-19 within the facility and protect their loved ones. The facility would continue to screen all employees before the beginning of their shift; any employee with symptoms will not be allowed to work. g. On 7/22/20, the Staff Screening Log showed the Administrator screened into the facility with a temperature of 97.1 F. The question regarding current symptoms or within the last seven days had a cough with shortness of breath, pneumonia, or flu recently showed documentation of no. The end of shift temp was 99.3, with no newly developed symptoms listed in the previous screening questions as no. The Handwashing policy dated 3/15 explained that handwashing was mandated between resident or patient contact to prevent the spread of infection. Hands must be washed after the following, including but not limited to 1. Contact with blood or bodily fluids 2. Contact with contaminated items or surfaces 3. Contact with the resident or patient 4. Initiating a clean procedure 5. Removal of gloves The facility was notified of the immediate jeopardy on August 3, 2020 at 3:00 pm when the IJ template was provided to them. On August 3, 2020 the facility initiated proper door monitoring and staff education on screening, returning to work after having COVID-19 symptoms and proper wear and use of face masks. The Nurse Consultant educated the Administrator on the process for COVID-19 and returning to work with improved symptoms and without symptoms. On August 4, 2020 observations were made of staff still not wearing face masks correctly. The Director of Nurses identified those staff and provided additional coaching. The Immediate Jeopardy was abated on August 4, 2020.

Based on observations, record review, staff interviews and facility policy the facility failed to adequately supervise one resident with a history of elopement and poor safety awareness, ( Resident #1), which resulted in an immediate jeopardy to the resident's health and safety. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] noted Resident #1 had [DIAGNOSES REDACTED]. Resident #1 had some difficulty making daily decisions in new situations. The MDS indicated the resident always understood others, but they sometimes had difficulty understanding him. Resident #1 was independent with transfers and locomotion on and off the unit. Resident #1's Care Plan included potential for elopement related to dementia with behavioral disturbances and agitation, initiated on 7/3/18. The Care Plan indicated door alarms should be activated at all times and staff should follow the missing person's policy if Resident #1 left the grounds without notifying staff. The 7/5/18 revision noted Resident #1 signed a behavioral contract agreeing to notify staff when exiting the facility and signing out when leaving the grounds. The 8/14/18 revision indicated Resident #1 may sit outside unsupervised. The Care Plan included interventions dated 8/17/18; Resident #1's cigarettes and lighter will be kept in the medication cart when not in use and he will notify staff when going to the designated smoking area to smoke. A document titled, Residents allowed to sit outside unsupervised with frequent checks by staff, included Resident #1's name. A document titled #1673 Elopement dated 7/3/18 at 7:30 p.m. documented how a former employee reported seeing Resident #1 by Casey's (0.4 miles from facility per Google Maps). A Nurse went immediately and located him near the Casey's. Resident #1 stated he left to purchase cigarettes. The Nurse documented the cigarettes were confiscated and they placed a wander guard (added security device to activate the door alarms) on the resident. The Wandering and At Risk for Elopement document dated 4/3/19 rated Resident #1 as moderate risk for wandering due to loss of self-control, a room change, medication change and antidepressant use. A Behavior Noted dated 5/11/19 at 2:24 a.m. noted Resident #1 used the code to open doors in the facility. Resident #1 opened the front door for an unknown person and was asked to stop; especially for a stranger at that time of night. The Nurse noted Resident #1 lunged at her with a balled fist but retreated when the Nurse advised him the Police would be called. An Incident/Accident Report revealed Resident #1 eloped and was observed on the road by the parking lot on 6/7/19 at 4:30 a.m A document titled #2124 Elopement dated 6/7/18 at 4:50 a.m. documented an employee reported seeing Resident #1 on the road in front of the facility when she arrived for work that morning. The Nurse documented she provided education, assessed the resident and instructed Maintenance to change the door code. A Behavior Note dated 6/7/19 at 10:19 a.m. noted the Cook reported she saw Resident #1 on the road in front of the Nursing Home parking lot at approximately 4:30 a.m The Nurse noted she educated Resident #1 not to leave the facility grounds without signing out with staff, including onto the road. A Risk Management Statement/Interview Documentation dated 6/7/19 at 5:20 a.m. noted the Cook's statement. She wrote she saw Resident #1 coming down the road from the West into the parking lot, maybe looking into people's cars. The Cook noted she reported it to the MDS Coordinator and the Administrator. A Risk Management Statement/Interview Documentation dated 6/7/19 at 9:30 a.m. noted Staff B, CNA's telephone statement according to the MDS Coordinator. Staff B indicated she knew Resident #1 went outside to smoke; which he frequently did during the overnight shift. Staff B indicated she did not know he left the property; but he returned on his own. A Risk Management Statement/Interview Documentation dated 6/7/19 at 10:00 a.m. noted Staff H, CNA's telephone statement according to the MDS Coordinator. Staff H indicated she knew Resident #1 exited the building through the West exit to smoke. Staff H indicated she did not know he left the grounds; but he returned on his own. An e-mail correspondence between the MDS Coordinator and Staff D, RN at 12:25 p.m. revealed although the Staff D knew Resident #1 went outside in the early morning, she did not know that he went on the road. A Behavior Note dated 6/28/19 at 3:47 p.m. noted the DON and MDS Coordinator approached Resident #1 and asked him for his smokes and lighter; which he denied having. Staff confiscated smokes, lighter and alcohol while the resident bathed. Resident #1 approached them and demanded his smokes and lighter back. The Nurse said she would give him one cigarette but keep the lighter. Resident #1 became very upset; swearing and flipping them off while saying he would not follow the rules. An interview on 8/13/19 at 2:00 p.m. with the Cook revealed she saw Resident #1 in the road in his wheelchair when she arrived for work between 5:20 and 5:30 a.m. on 6/7/19. She said he approached the parking lot about the same time that she did. The Cook stated Resident #1 knows the code to get out and knows how to push the button to get back in without setting off the alarm. She said he's not much of a rule follower. The Cook said the resident can go out unsupervised. She said she went into the building without him; but assumed he would be following. She informed the Charge Nurse and then notified the MDS Coordinator that afternoon.The Cook recalled a previous incident about a year before when a former employee observed Resident #1 self-propelling his wheelchair unsupervised up a hill near the highway. The Cook said the former employee notified the facility. An interview on 8/14/19 at 9:30 a.m. with Staff D, Registered Nurse revealed she had only worked in the facility 5 or 10 times with 6/6/19 being one of the first times she worked there as the overnight Charge Nurse. Staff D said the facility questioned her. She last saw Resident #1 about 4:00 a.m. on her shift when he told her and a CNA he was going outside to smoke. Staff D said he went out unsupervised. When asked when Resident #1 returned, Staff D guessed he came back sometime after the Cook saw him outside at 5:20 a.m., based on what the facility told her when they called that afternoon. Staff D said she left the facility between 6:30 and 7:00 a.m. and did not know about it until they called. Staff D said neither of the CNAs said anything to her about it before she left. Staff D denied ever being told how Resident #1 had been seen near Casey's without the facility's knowledge on a previous occasion. An interview on 8/14/19 at 10:25 a.m. with Staff C, CNA revealed she has seen Resident #1 go outside to smoke unsupervised. The CNA said he goes out about 6 times during her 12 hour shift when he has cigarettes. Staff C said he returns his cigarettes and lighter to the nurse as of the last couple of months, although he has not always been so cooperative. Staff C said she did not know if Resident #1 was supposed to tell someone when he went out because they have his name on the list of people that can go outside unsupervised. Staff C said most people let them know when they go out. Staff C stated she has noticed Resident #1 goes out without telling anyone. She said he should sign out before leaving the grounds. When asked, Staff C said the facility never told her someone saw Resident #1 down by Casey's one time, nor did they say she should keep an eye on him. Staff C said she thought it would be a good thing to know. Staff C denied anyone told her how someone recently saw Resident #1 coming into the parking lot at 5:30 a.m An interview on 8/14/19 at 10:45 a.m. with Staff F, CNA revealed she has seen Resident #1 go outside unsupervised, which he is permitted to do. According to Staff F, the resident never tells her when he goes out. She stated the facility has never told her residents are supposed to sign out before they leave the premises. Staff F stated they had never informed her that Resident #1 had left the premises before without their knowledge, nor have they told her to pay attention to where he is at. During interview on 8/14/19 at 11:00 a.m. Staff A, CNA stated although she does not know how often Resident #1 goes out to smoke, she has seen him go out. She said he does not let her know very often when he goes out. According to Staff A, Resident #1 can go out unsupervised but should be checked on every 15 minutes. Staff A said she knew he left the grounds about a year ago and went to Casey's without letting anyone know. She said the Director of Nursing (DON) told her after that incident to keep a closer eye on him. Staff A said she never heard of the recent incident but thought she should be informed in light of his history. Staff A thought Resident #1 should be supervised whenever he goes outside. During an interview on 8/14/19 at 12:45 p.m. Staff G, RN, said she has seen Resident #1 go outside to smoke. He goes out about 5 or 6 times during her shift. Staff G said Resident #1 goes outside to smoke unsupervised. Although she did not know what their policy states, she said she peeks out there about every 15 minutes. She said the resident does not tell her when he goes out to smoke. Staff G stated he should not leave the premises unsupervised. An interview on 8/14/19 at 1:20 p.m. with Staff B revealed she works the 10:00 p.m. to 6:00 a.m. shift. Staff B said she knew Resident #1 went outside often. When asked about the recent incident with Resident #1, Staff B said she did not work with Resident #1 that night, she worked on the opposite end of the building. She said she heard about the incident later but did not know any of the details. She said she did not know if he went out that particular night. When asked, Staff B said the facility did not talk to her about it. Staff B stated she cannot say that he returned to the building that night because she did not know he left and that they could not account for him during the night. Staff B said she has seen Resident #1 go outside to smoke before, he could go outside unsupervised as long as he stayed on the property. Staff B said Resident #1 does not always tell her when he goes out. Staff B said nurses have maybe told her to check on him from time to time. When asked how frequently Resident #1 should be checked on Staff B stated although nobody said how frequently, part of caring for someone means checking on them periodically when they go outside. She said Resident #1 is supposed to return his cigarettes and lighter to the nurse that way they know when he goes out because he has to ask them for his cigarettes before going out. An interview on 8/14/18 at 3:15 p.m. with Staff H revealed she works the 10:00 p.m. to 6:00 a.m. shift. Staff H said she had no idea that Resident #1 left the faciity on the overnight shift recently. She said the facility did not talk to her about it. She denied submitting a statement to the facility regarding Resident #1's whereabouts on 6/7/19. Staff H said she heard about Resident #1 going to Casey's without staff's knowledge the year before, but nothing about the incident in question. Staff H said Resident #1 goes out unsupervised about 4 times during a shift when he stays up all night; which they permit him to do. She said she has never been told to check on him periodically when he goes out. When asked, Staff H said she did not know the Cook saw him outside at 5:20 a.m. on 6/7/19. Staff H said he usually asked for cigarettes before going out. Staff H said she did not recall the night in question it seemed uneventful without having any knowledge about Resident #1 not being accounted for. Staff H said she never usually checked on him when he went out to smoke. She said the facility never told her to nor did they emphasize the importance of tracking him due to his previous elopement. According to Staff H, unless he had to ask for his cigarettes, he never usually let them know when he left or when he returned. Staff H said Resident #1 did not always turn his cigarettes in either. She said Resident #1 liked to sit outside for awhile after having a cigarette. He also liked to go outside for fresh air even when he did not have cigarettes. Staff H said it would be real easy to lose track of him. An interview on 8/15/19 at 9:30 a.m. with the MDS Coordinator/RN revealed the Cook informed her at about 10:00 a.m. that she saw Resident #1 on the road right outside the building when she came into work that morning. According to the RN, the Cook said she never told the Charge Nurse; therefore they educated her to tell the nurse immediately when she saw something like that. The RN said she spoke to the overnight Charge Nurse. The Charge Nurse said she knew Resident #1 went out to smoke about 4:00 a.m.but did not know he left the property. The RN said they spoke to Resident #1 and told him he could not leave the property. She told him he needed to turn his cigarettes and lighter into the Charge Nurse. Although that has been a rule right along, the RN said he has not always done it. She said an outside source brought cigarettes into the facility for him without letting them know. The RN said they only give him one cigarette at a time now so he has to ask for one before he goes out.She said Resident #1 is supposed to let them know anytime he goes out. The RN said she wonders if the overnight staff always knows when he does. The RN said staff are supposed to do checks about every 15 minutes when he goes out even on overnight shift. She stated because of the incident on 6/7/19, they requested for Maintenance to change the door code as a new intervention because the resident apparently knew the code. The RN said she asked the Maintenance Man a couple weeks later if he changed it. According to the RN, he said no he had not figured it out yet. The RN said the Maintenance Man quit shortly afterwards without changing the code. She said the new Maintenance Man has it on his list of things to do, but has not figured it out yet either. According to the RN, the code remains unchanged. The RN said I don't know how affective it would be anyway because he will just figure it out again. When asked about other interventions that have been implemented since 6/7/19, the RN said Resident #1 agreed to notify staff before going outside and agreed to sign out if he intended on leaving the property. The RN said those interventions have been in place before this incident but they re-educated him as other new interventions. When asked whether overnight staff knew of Resident #1's whereabouts after 4:00 a.m., the RN said if they did not know, they should have. That's the expectation. An interview on 8/15/19 at 10:00 a.m. with the Director of Nuring (DON) revealed the MDS Coordinator told her on 6/7/19, in the afternoon, the Cook reported seeing Resident #1 self-propelling his wheelchair in the street and into the parking lot when she arrived at work at 5:20 a.m Although Resident #1 could go out unsupervised staff should check on him about every 15 minutes. The DON said Resident #1 is supposed to let someone know before going out and has to sign out if he leaves the grounds. According to the DON, they should have checked on him if they did not. When asked, the DON said she did not know what time Resident #1 went out or what time he returned. The DON said the Cook did not tell anyone about seeing him in the street until she told the MDS Coordinator later in the day. According to the DON, she should have told the Charge Nurse. The DON said they educated the Cook to inform the Charge Nurse immediately if/when something like that happens.The DON said Resident #1 goes out frequently and has to ask for his cigarettes; which notifies the Charge Nurse of his intentions. The DON said Resident #1 did not always return the cigarettes so she instructed staff to only give him one at a time. The DON said she knew Resident #1 received cigarettes from an outside source without their knowledge. According to the DON, they contacted the suspected family member and informed them to give cigarettes to the nurse. The DON said Resident #1 does not always have cigarettes, but still goes outside for fresh air. She said staff has been educated to check on residents frequently when they are outside. During interview on 8/20/19 at 11:00 a.m. Staff I, CNA stated Resident #1 did not like to listen to them and can become very combative. Staff I said she has seen him enter the code to leave the building so the alarm does not activate. Staff I said the resident does not let them know when he goes out although he is supposed to. Staff I said they do not supervise him once he goes outside. She said people trust him, although she does not think they should. According to Staff I, she has never been told to check on him periodically; but believes they should. She believed they listed him as one of the residents that could go out unsupervised. Staff I said he should probably be put on the supervised list now that he has left the grounds. Staff I said Resident #1 gets bored and goes outside for any reason not just to smoke. When asked, Staff I said nobody ever told her that he went to Casey's without informing staff. She said that would be good information to have so she knew how closely he should be monitored. Staff I thought they would be responsible for negative outcomes related to the risks he takes because they do not supervise him. She said he goes outside 4 to 5 times during her shift that she knows of but nobody really knows how often. An interview on 8/20/19 at 10:35 a.m. with the Maintenance Supervisor revealed he has worked at the facility for about 2 weeks. The Supervisor said they asked him to change the door alarm code last Wednesday or Thursday; which he did immediately. The Maintenance Supervisor said they told him the previous Maintenance Supervisor did not know how to change the code, but he did not find it difficult at all. The (MONTH) 2013 revised Elopement Prevention and Management policy included: the facility attempts to prevent resident elopement, while promoting and supporting resident mobility. The goal is to enable the resident to attain and maintain his highest practicable physical, mental and psychosocial well-being while reducing the risk of elopement. Components of the elopement program include, but are not limited to: *Protected list of names and photographs of Residents identified as being at risk for elopement. *Regular rounds. *Structured group activities. *Environmental modifications to promote safe mobility. Procedure: 1. Identify Residents who are at risk for elopement. All new admissions that are at risk for elopement will have interventions put into place immediately until further assessment is complete. Interventions may include but are not limited to: - Environmental modifications to prevent undetected exit (wander alerts, door alarms). - Increased frequency of Resident location rounds. Any Resident with a history of wandering/elopement in a prior setting. 2. Determine elopement risk factors, which include but are not limited to: History of wandering and/or elopement. New Admission with adjustment difficulties or a desire to return to previous living situation. Dementia or dementia related disease. Restless, irritable. Anxiety. 3. Document risk factors. 4. Develop and document individualized interventions to manage risk factors. 5. Discuss interventions and goals with Resident and/or responsible party. 6. Communicate risk factors and interventions to the caregiving team. 7. Monitor and document Resident response to elopement risk reduction interventions. 8. Evaluate effectiveness of interventions, modify goals and interventions as indicated and communicate the changes to the caregiving team, Resident and/or responsible party. The facility abated the immediate jeopardy on (MONTH) 20, 2019 by changing the door key code, staff education, elopement drills and risk for elopment audits completed with resident care plans updated as needed.

Based on observation, record review, staff interview and policy review the facility failed to always ensure residents remained free of development and provide treatment of [REDACTED]. (Resident #1, #2 & #3) The facility identified a census of 47 residents. Findings include: 1. According to the MDS dated [DATE] Resident #2 had [DIAGNOSES REDACTED]. [MEDICAL CONDITION] and failure to thrive. The MDS identified the resident had a BIMs score of 00 which indicated severe cognitive impairment. According to the MDS the resident required extensive assistance with bed mobility, transfers, dressing and toilet use. The MDS identified the resident at risk for developing pressure ulcers. The care plan with a revision date of 8/8/18 and target date of 10/29/18 directed a. CNAs (certified nursing assistant) to monitor for any skin breakdown with cares 2 times a day and as needed. b. Alert nurse of any abnormalities and nurse to alert physician. c. Treat as needed. d. Weekly skin assessment completed by nurse and document in nurse's notes. Alert physician of any anomalies and treat as needed/ordered. e. Staff to ensure resident is positioned side to side during the night. f. Ensure the resident is repositioned frequently throughout the day and night time hours. g. Monitor for skin breakdown 2 times a week and as needed with whirlpool/showers. Alert nurse of any abnormalities. h. Resident to lay own 1 hour in am and PM. Resident will refuse to lay down at times. staff to reeducate on importance of laying resident own in am/pm to prevent skin breakdown. Added to the MAR (medication administration record) to ensure good effort is made and monitor compliance daily. Review of the Braden Scale dated 8/2/18 revealed the resident had a score of 13 which indicated moderate risk for the development of pressure areas. Review of the physician's orders [REDACTED]. The area cleansed and barrier applied. An area also observed on the right inner buttock pink, reddened, excoriation and without drainage. The area measured 3.5 cm by 1.3 cm. Area cleansed and skin barrier applied. The new order included Exuderm dressing bandage every 3 days and as needed. Review of the physician's orders [REDACTED].>Review of the physician's orders [REDACTED]. a. right buttock apply [MEDICATION NAME] and foam dressing 3 times a week and as needed for saturation. b. Left buttock cover with foam dressing to be changed 3 times a week and as needed for saturation. c. Continue preventative measures, air mattress, cushions to chair, lie down to rest in AM and PM. d. Nutritional supplement to be given 2 times a day or nutritional consult recommended. Review of the physician's orders [REDACTED]. Review of the Physician's Process Notes dated 9/17/18 revealed the following orders: a. Discontinue wound care to the right buttock. b. Change left side dressing to venelix and gauze 2 times a day and as needed for saturation for 7 days, then report. c. Implement [MEDICATION NAME] to areas not under gauze. Review of the Physician's Progress Notes dated 10/2/18 revealed the following orders: a. Discontinue gauze and tape. b. Continue with venelex covered with [MEDICATION NAME] gentle. c. New cushion to wheelchair; maybe try waffle. d. New air mattress or have current one checked to ensure working properly. Review of the Physician's fax dated 10/14/18 revealed the resident in substantial pain due to the wound. When up for meals and sitting on her left buttock. She is wincing and writhing and won't eat half the time due to pain. Order received for [MEDICATION NAME] ([MEDICATION NAME]) 50 mg (milligram) every 6 hour as needed for pain. Review of the Wound Care Nurse notes revealed the following assessments: a. 8/27/18 Left buttock, wound appears to be a healed pressure ulcer pink and intact. Right gluteal region 1.5 cm by 2 cm by 0.1 cm, 75% yellow slough and 25 % pink epithealialized tissue present. The edges attached and surrounding tissue intact. b. 9/17/18 Right ischial wound intact and pink, Left ischial area declined 3.5 cm by 3.5 cm, yellow with brown center and moist to touch. The surrounding tissue intact. c. 10/2/18 Left ischium wound measures 2.9 cm by 3 cm by 0.5 cm open moist and yellow. Edges attached and surrounding skin intact. When exam initiated resident saturated with urine and her dressings were saturated as well. d. 10/16/18 Left ischium. Wound measures 3.5 cm by 3.7 cm by 2.5 cm. The wound open, wet and all necrotic tissue. The surrounding skin remains intact. Feel the wound tunnels down further to 2.5 cm and a possibility of a probing to the bone but due to the pain the resident requests the exam stop. The document identified the pressure ulcer had greatly deteriorated since last seen and the wound care nurse had not been contacted sooner. Unfortunately we are at a place that needs further intervention if progressive treatment warranted. Surgical intervention probably what will have to be sought next. The resident could be treated in the facility as best as can using topical remedies, could be seen through the emergency room and admitted to the hospital for surgical consult and intervention which would then probably require IV antibiotics,, surgical procedures and possible wound VAC or could possibly even look into something like hospice care if there wishes just to keep her comfortable and pain-free at the present time pain one of the biggest issues with the wounds in regards to the resident's overall status. After long discussion with family she feels they should start with the basics of getting some lab work completed. Review of the Progress Notes dated 7/24/18 at 9:12 revealed the CNA reported and open area. The nurse observed the left buttock, between the upper thigh and buttock a 2 cm by 0.3 cm excoriation with bloody drainage. The nurse cleansed the area and applied barrier. The nurse also observed the right inner buttock a pink reddened excoriation without drainage. The area measured 3.5 cm by 1.3 cm. The area cleansed and skin barrier applied. Review of the Non-Pressure Weekly Skin Record revealed the resident had an area to the left lower buttock first observed 7/27/18. The following assessments recorded of the area: a. 8/16/18, the area had scant, serous exudate and measured 3.3 cm by 3.5 cm by 0 cm. The wound had no odor, had granulation tissue and normal surrounding skin. b. 8/23/18, the area measured 3.5 cm by 3.5 cm by 0 cm. The wound had no odor, had [MEDICATION NAME] tissue and normal surrounding skin. c. 8/30/18 the area measured 3 cm by 3 cm by 0 cm. The wound had no odor, had [MEDICATION NAME] tissue and normal surrounding skin. d. 9/10/18 the area measures 2.5 cm by 3 cm width. The wound with odor, and wound bed with [MEDICATION NAME] tissue, surrounding tissue normal. Improving. e. 9/19/18 the area measured 2.5 cm by 3 cm by 0 cm. The wound had no odor, had [MEDICATION NAME] tissue and normal surrounding skin. f. 9/17/18 the wound measured 3 cm by 4 cm by 0 cm. The wound had no odor, had granulation tissue and excoriated surrounding skin. g. 9/24/18 the area measured 3 cm by 2.5 cm by 0 cm. Review of the Pressure Injury Weekly assessment dated [DATE] revealed the area identified a pressure area. The area had the following measurements: and measured a, 9/19/18, 3 cm by 4 cm by 0 cm and unstageable. The wound bed had black tissue in the center and yellow surrounding. b. 10/15/18, 2.8 cm by 3.8 cm by 2.5 cm and unstageable. The wound had a large amount of purulent drainage and slight foul odor present on the dressing. The wound bed had 100% slough tissue. The surrounding tissue purple in color and edges rolled. Review of the TAR (treatment administration record) (MONTH) 1, (YEAR) through 9/30 18 revealed the following: a. Left side buttock apply venelex ointment, cover with gauze 2 times a day and as needed for saturation for 7 days then report. The treatment not documented administered on 9/23/18 at hour of sleep. b. Effective 9/18/18: Left side buttock apply venelex ointment, cover with gauze 2 times a day and as needed saturation for 7 days. Treatment not documented administered. Review of the TAR dated 10/1/18 through 10/31/18 revealed the following treatments: a. Effective 10/4/18: Cleanse wound. Apply venelex ointment to left buttock wound, cover with [MEDICATION NAME] gentel 2 times a day and as needed for soilage. The treatment not documented completed on 10/4/18 AM or 10/8/18 on the AM or PM treatments. b. Left side buttock apply venelex ointment, cover with gauze 2 times a day and as needed saturation for 7 days. No treatments documented from 10/1/18 through 10/4/18. Observation on 10/17/18 at 10:30 AM revealed Staff A, LPN (licensed practical nurse) provided would care to the resident's Left buttock with area 3 cm by 4 cm open area. Depth not measured and identified by Staff A packing placed by wound nurse and to remain. Staff A also identified the wound infected. Wound cleansed with [MEDICAL CONDITION]% Venelex ointment to wound base and new dressing applied. During an interview with Staff A, LPN on 10/17/18 at 3:15 PM she stated the resident's wound inside had been bright red and beefy. A few days later it had been black and a few weeks later had been pussy looking. The wound looks like it's closing a bit now. She stated she noticed it getting worse and she kept educating staff to reposition her. She further stated all CNAs are getting it now and she has not seen the resident on her back since this week and she had been positioned on her sides. During an interview with the Wound Nurse on 10/18/18 at 1:50 PM she stated she 1st saw Resident #2 the end of August. At that time the wound was 1.5 cm by 2 cm by 0.1 cm, was yellow but had some [MEDICATION NAME] tissue. Staff tried [MEDICATION NAME] and foam dressing. The switched to venelex and on the 18 th of (MONTH) it had gotten bigger. She stated she tried to be at the facility every other week. The area almost doubled in size and she had not been contacted. She ordered a foley catheter due to incontinence and worsened ulcer. She went back in 2 weeks and the area looked better. She continued venelex and the wound had no depth and no tunneling. She suggested a new mattress or have the supplier check it and have a new cushion. She stated she was told there was a new one. Staff were to contact her if the wound worsened. Now it is open, necrotic and has tunneling. She did measure 2.5 cm depth and probably could have gotten more and suspects it's to the bone, but had to stop due to pain. She went over treatment options with family and had not heard back any decisions at this time. She further stated she definitely expected the facility to notify her when there had been a change. She stated she also noted [MEDICATION NAME] was ordered for pain in the wound which also indicted a change. 2. According to the MDS dated [DATE] Resident #3 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs score of 15 which indicated intact cognition. According to the MDS the resident required extensive assistance with bed mobility, transfers, ambulation, dressing and toilet use. The MDS identified the resident at risk of developing pressure ulcers. The care plan identified potential alteration in kin integrity related to decreased mobility, diabetes, MS, and occasional urinary incontinence. initiated 1/14/16 and revised on 6/14/18 directed staff to: a. Monitor for skin breakdown with baths 2 times weekly and as needed. b. Monitor for skin breakdown while providing cares 2 times a days and as needed and notify the nurse of any anomalies and alert the physician. c. Provide treatment to heel/ankle per physician orders [REDACTED]. Review of the Braden Scale dated 8/29/18 revealed the resident had a score of 15 which indicated a low risk for developing pressure ulcers. Review of the MD (Medical Doctor)/Nursing Communications dated 7/26/18 revealed the resident noted to have excoriated area measuring 0.3 cm by 0.3 cm to the right inner mid buttock. The resident stated she did not know it had been there but had excoriated areas on her buttock in the past. The area measured and [MEDICATION NAME] applied. Review of the Discharge Instructions dated 8//12/18 revealed the resident fitted with a boot and to follow up with orthopedics. Orders include elevate the left lower leg and ice/cold pack applied for 20 minutes at a time every hour to 2 hours. Review of the MD/Nursing Communications dated 9/3/18 revealed staff found a new skin area to the coccyx. The area measured 0.9 cm by 0.2 cm. No drainage observed. No increased redness/inflammation surrounding the area. Skin pink/red in color. The resident continued with loose stools, skin barrier applied. New order included clean, dry and apply [MEDICATION NAME] till healed, change position every 2 hours and keep off the area as much as possible. Review of the FAX to the Physician dated 9/6/18 revealed the resident had a blister measuring 2.5 by 4.5 cm to her inner heal. The blister dark red and intact. Staff discontinued the heel boot related to the ankle sprain and she is currently transferring with a hoyer lift due to increased weakness. New order included consult to Physical therapy and protect with allevyn dressing until then. Review of the Consultation/Clinic Referral dated 9/11/18 revealed the following: a, Left heel and lateral malleolus-deep injury. Change dressing weekly if remains intact. b, Left calcaneus-stage 3 pressure injury: dressing change Monday, Wednesday and Friday; gentle cleanse with sterile saline or afclens. Cover with silicone foam dressing. c. Sacrum stage 3 pressure injury: dressing change Monday, Wednesday and Friday; gentle cleanse with sterile saline or safclens. Cover with silicone foam dressing and change more often if soiled or displaced. d. Nutritional consult-consider supplementation e. Alternating air pressure mattress, f. T-gel pressure relieving device at all times when sitting. g. Repositioning schedule. Every 30 minutes awake, every 2 hours asleep. Follow-up every 2 weeks unless condition worsens. Review of the Fax dated 9/13/18 revealed the order for [MEDICATION NAME] 1 packet every day for skin healing. Review of the Physician Fax dated 9/14/18 revealed the order to change coccyx and right buttock treatment with wound cleanser, pat dry, apply skin prep and cover with hydrogel wound dressing. Change every 3 days and as needed if soiled or falls off. Discontinue when healed. Review of the Doctor's Order sheet dated 9/25/18 revealed the following orders: a. Left lateral malleolus now open and tender: continue with same dressing recommendations as 9/10 except add silicone gel disc over lateral malleolus on top of allevyn gentle and hold in place with soft. b. Dressing on sacrum needs to follow dressing orders from 9/10. Dressing was also soiled underneath with feces today. c. Please obtain t-gel or inflatable Roho cushion for her chair. Review of the Consultation/Clinic Referral dated 10/2/18 revealed the resident had liquid stools today and into the sacral wound. The wound did not have a dressing on. Please follow current dressing plan and replace if soiled or displaced. Observation on 10/11/18 at 11:30 AM physical therapy wheeled resident to the dining room table. Observation revealed pressure relieving cushion in wheel chair. Observation on 10/11/18 at 1 PM resident wheeled self back to room feet resting on wheel chair pedal. During an interview with family on 10/17/18 at 3:40 PM she stated she had been to all of the resident's appointments at the wound clinic. She further stated the resident did not have placement of a dressing over her wound on one of the appointments. She had diarrhea and it did appear fecal material had coated the wound. The wound clinic had been very upset about it and she talked to the facility about the incident. 3. According to the MDS (minimum data set) dated 8/9/18 Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview of mental status) score of 5 which indicated severe cognitive impairment. According to the MDS the resident required extensive assistance with bed mobility, transfers, dressing and toilet use. The care plan dated 8/10/18 revealed the resident had a history of [REDACTED]. The care plan directed staff to: a. Monitor for any skin breakdown with cares 2 times a day and alert the nurse/physician if any occur and treat as needed/ordered. b. Monitor for skin breakdown with cares BID (twice daily). c. Alert nurse/physician if occur and treat as needed/ordered. Review of the Braden Scale dated 8/9/18 revealed the resident had a score of 13 which indicated moderate risk for developing pressure sores. Review of the physician's orders [REDACTED]. The wound bed pink with no drainage. Orders included cleanse with wound cleanser and apply [MEDICATION NAME], change every other day and as needed till healed. Review of the Medical Doctor Communications note dated 10/12/18 revealed the following: Left buttock open area measured 5 cm by 7 cm, hard, indented area, dark purple/maroon in color at base with blue/purple color on outer edges, does wince in pain when assessing and cleansing area. No drainage noted, does have foul odor present and also has hard area extending up thee left butt cheek. The order included wound consult. Review of the Consultation/Clinic Referral dated 10/17/18 revealed the order for [MEDICATION NAME] (antibiotic) 875 mg (milligrams) 2 times a day for 14 days and wound referral. (Note the order was received 5 days after communication to the medical doctor on 10/12/18). Review of the Non-Pressure Weekly Skin Record dated 9/28/18 revealed the resident had an area on the left buttock that measured 0.5 cm by 0.4 cm by 0 cm. Review of the Weekly Skin Assessment revealed the resident had the following open areas. a. 10/5/18 - left buttock pressure area stage 2 that measured 3 cm by 2 cm and a pressure area stage 2 on the sacrum that measured 2.5 by 0.5 cm. Review of the Pressure Injury Weekly Assessment revealed the following measurements of the left buttock: a. 10/12/18 - 5 cm by 7 cm by 0 cm Open area with indentation, purple/maroon area to base, blue/red outer edges. Review of the Pressure Injury Weekly Assessment revealed the following measurements of the coccyx: a. 10/12/18 0.5 cm by 0.1 cm by 0 pink/red wound bed appearance. Observation on 10/17/18 at 3:55 PM revealed the resident had a dressing with large amount of drainage and the dressing started to become loose. The DON (Director of Nursing) removed the old dressing and a pressure area 5 cm by 3 cm with yellow slough noted to the left lower buttock. The surrounding tissue firm to touch. The DON cleansed the wound with cleanser and applied a new dressing. Review of the Provider Wound assessment dated [DATE] revealed the resident ischium had a large open area that measured 3.5 cm by 5 cm by 1 cm that had black to brown in the center, yellow around the edges, wet with a moderate amount of serosanguineous drainage present. The surrounding tissue red and [DIAGNOSES REDACTED]tous and very indurated and hard with retraction present. There is a small foul odor present. The resident also had a small open fink and moist pressure ulcer to her sacral region that is midline and measured 0 3 cm by 0.3 cm and the surrounding skin pink but intact. The resident verbalized some discomfort to the lower larger area. The resident required further examination by the personal care physician, Contacted the resident's physician and made hi aware of the findings and concerns. Treatment options reviewed with the family and can range from anywhere to treating at the facility by keeping the resident comfortable and managing the symptoms to surgical intervention that could be completed in the hospital setting and may be even the consideration of consulting hospice. During an interview with the wound nurse on 10/18/18 at 1:50 PM she stated she had been asked to look at the resident's wound and it had been the first time she had seen it. She called the resident's Doctor and she did feel the wound had a lot of necrotic tissue and the surrounding skin indurated. She stated she may need surgical intervention. She stated she should have been seen by a provider sooner. She further stated the facility has a lot high complex care residents and use a temp staff. Review of the Consultation/Clinic Referral dated 10/9/18 revealed all areas improving and dressings in place. Review of the Pressure Injury Weekly Assessment revealed the following measurements for the right buttock: a. 8/20/18 1 cm by 0.5 cm., red. b. 8/27/18 7 cm by 4 cm., pink and fragile. c. 8/29/18 7.2 cm by 4.8 cm., pink/red. d. 9/11/18 2 cm by 2.5 cm., open and red. e. 9/18/18 0.6 cm by 0.2 cm., Stage 2, pink. f. 9/24/28 0.1 cm by 0.2 cm., Stage 2 with 100% pink granulation. g. 10/3/18 0.1 cm by 0.1 cm Stage 2 100% pink. The non-pressure weekly skin record dated 9/14/18 identified the right buttock 1.2 cm by 1.3 cm. Review of the Pressure Injury Weekly Assessment revealed the following measurements for the left inner heel: a. 9/6/18 2.5 cm by 4.5 cm., Stage 2 blister b. 9/11/18 2.5 by 4.5 cm., Stage 2 blister c. 9/18/18 2.5 cm by 4.5 cm., unstageable, outer pink, 1.3 by 2.8 cm slough center d. 9/24/18 3.5 cm by 3.2 cm unstageable, 90% necrotic, 10% pink granulation. e. 10/3/18 2.5 cm by 3 cm unstageable, 75% white/yellow slough, 25% pink granulation f. 10/9/18 1.6 cm by 2.9 cm unstageable, 100 % pink granulated tissue. Review of the Pressure Injury Weekly Assessment revealed the following measurements for the sacrum: a. 9/11/18 2 cm by 0.5 cm open with a scab layer of white blood cells. Stage 3 b. 9/18/18 1.2 cm by 1 cm by 0.1 cm stage 2. 50% pink and 50 % slough. c. 9/24/18 1 cm by 1 cm Stage 2. 50 % white slough 50 % pink granulation. d. 9/24/18 1 cm by 1 cm by 0.1 cm., Stage 2. 50% white slough, 50% pink granulation. c. 10/3/18 1 cm by 0.5 cm by 0.1 cm., unstageable. 90% slough, 10% granulation. d. 10/9/18 0.7 by 0.2 cm by 0 cm., unstagable. 100% slough. Review of the Pressure Injury Weekly Assessment revealed the following measurements for the left outer ankle: a. 9/14/18 1.7 cm by 0.8 cm., Stage 1, dark pink b. 9/18/18 1 cm by 0.6 cm., Stage 1, dark red. c. 9/24/18 1.5 cm by 1.5 cm., unstageable, cover with scab-like tissue. d. 10/3/18 1.2 cm by 1.5 cm., unstageable, 75% pink granulation, 25% slough. e. 10/9/18 1.2 cm by 0.6 cm., unstageable, pink granulation tissue. Review of the Pressure Injury Weekly Assessment revealed the following measurements for the left outer heel. a. 9/14/18 1.4 cm by 3.5 cm Stage 1, dark pink. b. 9/18/18 0.5 cm by 0.8 cm Stage 1, dark red. c. 9/24/18 0.8 cm by 0.8 cm unstageable. dark red. d. 10/3/18 0.6 cm by 0.8 cm Stage 1, red/purple. e. 10/9/18 0.3 cm by 1 cm Stage 1, (No wound bed assessment) During an interview with Staff A, LPN on 10/17/18 at 3:15 PM she stated nurses responsible for assessing skin under a boot every week. The CNAs good at reporting any changes or open areas of resident's skin. During an interview with Staff D, CNA she stated she had to take the resident's boot off to dress her and looked at her skin every day. She noticed open areas and let the nurse know. Before the areas opened, they were red. The red faded but still remained there. She further stated there have been times she went in the resident's room and she did not have dressings on. Review of the Policy and Procedure titled Skin Care and Wound Management dated 6/2015 directed staff to do the following: a. Complete the Braden Scale on admission, weekly times 4 and then quarterly to identify the resident pressure ulcer risk indicators. b. Complete the Admission Skin Sweep and the Admission Clinical Information and initial care plan on admission. Initiate the weekly skin sweep thereafter, Identify areas of skin impairment and any pre-existing signs. c. Determine the reason a resident at risk for pressure ulcer development. d. Develop a care plan with input from the interdisciplinary team and the resident and family party. Document individualized goals and interventions to manage risk factors. e. Communicate risk factors and interventions to the care giving team, resident and family party.

Based on record review, observation, resident interview and policy review the facility failed to always ensure residents remain free of injury during assisted transferring for 1 of 5 residents reviewed. (Resident #3) The facility identified a census of 48 current residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE] Resident #3 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs score of 15 which indicated intact cognition. According to the MDS the resident required extensive assistance with bed mobility, transfers, ambulation, dressing and toilet use. The resident's Care Plan initiated on 10/7/14, and revised on 11/17/15 identified the resident had a potential for falls related to a history of falls; altered balance, hypertension, [MEDICAL CONDITION], spinal stenosis, depression, and history of TIA/[MEDICAL CONDITION]. A Focus area dated 8/1/17 revealed staff were instructed on proper use and importance of gaitbelt. The care plan also directed staff resident may be transfer independently in her room from recliner. Interventions included but not limited to the following: Aides instructed on proper use and importance of a gaitbelt. 8/1/17. Monitor resident for safety techniques and provide cues/prompts and increased assistance as needed. Initated 10/7/14 and updated 3/23/18. Ensure resident has gripper socks or slippers on when going to BR or ambulating in room during the night and early AM. Initated 8/13/16, and updated 8/17/16. Ensure call light is pinned to the bed at bedtime. Add grip strips beside the bed. Initiated 8/7/17. Resident is to be one (1) assist with transfers and ambulation. Resident re-educated to use the call light and wait for assistance. Initiated 6/2/16. Staff to assist resident with HS cares as noted to be slightly unsteady. Initiated 4/26/16. According to the Resident Transfer Determination Form dated 2/26/18 at 8:15 AM Resident #3 required minimum assistance with gait belt and may use walker for transfers. The resident bears weight less than 4 seconds. Has upper body strength. Sits up with assistance. Unsteady. Follows directions. Review of the Progress Notes dated 4/19/18 at 6:36 PM revealed the CNA assisted the resident with transferring for supper. CNA turned to grab the wheelchair when she though the resident stable enough to stand. The resident fell on her left side under the bed, resulting in a gash to her left upper eye. Moderate amount of bloody exudate noted from the area. Vital signs and neuros in place. The ambulance called and the resident transferred to the emergency room via ambulance. Review of the Incident Report dated 4/19/18 at 6:26 PM revealed the CNA (certified nursing assistant) assisted the resident to stand and walk to the dining room. The resident fell on her left side and her head hit the edge of the bed. The emergency room visit Notes dated 4/19/18 documented the resident had a fall (from standing height) she was walking back from the bathroom getting ready to sit in the chair and tripped and fell forward. They believe that she hit the left side of her head on the bed rail or the floor, she had quite a bit of bleeding. She ended up somewhat underneath the bed after the fall. They got her up and sat her in a chair. She did not remember anything about the fall. She complained of some back pain so EMS services were requested. The resident had ecchymosis of the left orbital ridge, and active bleeding of the left superior orbit, swelling over the left eye and tenderness of the superior orbital ridge left eye and zygomatic arch of the left cheek. Review of the Radiology Details dated 4/19/18 revealed the resident had acute [MEDICAL CONDITION] spine an additional acute type 2 fracture through the base of the odontoid which is minimally distracted. The Major Injury Determination Form (MIDF) completed by the Registered Nurse on 4/20/18 at 7:30 AM documented: On 4/19/18 at 6:30 PM the resident fell in her room causing a cervical fracture. The CNA turned from standing resident to grab the wheelchair to follow the resident ambulating. The resident requires limited to extensive assistance with transfers, limited assistance with dressing, toileting, and ambulation. Independent with eating with set up assistance. The physician signed the MIDF on 5/15/18 at 2:00 PM and indicated: After reviewing the circumstances of the incident causing the injury, the previous functional ability of the resident and the resident's prognosis, I believe the injury sustained is a major injury. Review of the Progress Notes dated 4/21/18 revealed the resident arrived back from the hospital via med star. Resident placed in recliner. Could not bear any weight on left leg. Resident states that she has pain in her left hip area when Range Of Motion (ROM) performed. Call placed to family and physician. Family would like to wait for further treatment. Call placed to ER Physician ok to wait until Monday. Feels like this is related to what happened on Thursday (4-19-18). Resident denies pain when sitting in her recliner. Only with movement does she feel pain. Will continue to monitor. Progress Notes dated 4/22/18 at 3:40 PM documented the resident confused, with left hip pain and left foot turns in. Pain with movement. Unable to bear weight to left hip. Neuros reveals left pupil unresponsive and right pupil sluggish. Bilateral hand grips reveal left hand slightly weaker. Denies dizziness and headache. Resident sent to hospital by ambulance for evaluation. Progress Notes dated 4/22/18 at at 7:05 PM documented the resident admitted to acute care, with a pelvic fracture. Progress Note dated 4/25/18 at 11:55 AM documented resident returned to facility from hospital. Resident only bears weight to right leg. When interviewed on 6/13/18 at 3:30 PM the resident stated Staff use the gait belt all the time now; prior to the fall they did not use it consistently. Review of the Incident Report dated 8/1/17 at 11:02 PM revealed the resident walked from the bathroom to her bed and lost strength in her legs. The resident lowered to the floor around the arms by the CNA. The gaitbelt not in place. The resident's legs in front of her and arms at her sides. Vital signs normal, denied headache or dizziness and no new injuries noted. Review of the Policy and Procedure titled Gait Belt dated 1/13 directed staff to do the following to minimize the risk of injury to the resident and caregiver while performing transfers and ambulating: a. Review any special precautions or approaches to take when using a gait belt with a resident. Obtain assistance as needed. b. Fasten the gait belt securely around the resident's waist wit the buckle at the side. The belt soul not come in contact with the resident's skin. c. Position one hand under the belt. d. Position the other hand under the belt. The belt should be snug. e. Transfer the resident using proper body mechanics. f. Remove belt. g. Assist resident to a comfortable position with call light in reach. h. Instruct resident to notify nursing staff for assistance with transferring and ambulation.

Based on record review, observation and staff interviews, the facility failed to assess and provide timely interventions for residents with a change in skin areas and bowel conditions. Resident #6 had open areas present on the buttocks/coccyx and blisters on the bottom of feet/heel that the facility had not identified. The facility identified Resident #6 had no bowel movements for 6 days and the facility did not complete a gastrointestinal assessment. The facility identified a census of 53 residents. Findings include: 1. Resident #6 had a MDS (Minimum Data Set) assessment with a reference date of 11/3/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 13. A score of 13 identified the resident with no cognitive impairments. The MDS indicated the resident required extensive assistance with bed mobility, transfers and toilet use and limited assistance with walking and dressing. The MDS identified the resident always continent of bowel and bladder. The MDS indicated the resident required 2 or more staff for toileting. The MDS indicated the resident had no pressure sores. The Care Plan dated 9/12/16 identified interventions that included and directed staff that the resident required limited assistance of 1 staff person for use of the toilet. The Care Plan identified an initiated date of 9/12/17 for the resident with the potential for alteration of skin integrity due to incontinence, age related skin changes and decreased mobility. The intervention directed staff to perform weekly skin assessment by the nurse, document in the Nurse's Notes and notify the physician of any anomalies. Review of the BM (bowel movement) Report dated January, 2017 identified the resident had no BM documented on the following days: January 6 through January 11, 2017 (6 days). Review of the Interagency Handoff Report dated 1/6/17 identified the following order: Milk of Magnesia 400 mg/5 mg 1 time a day as needed for constipation. Review of the MAR (medication administration record) dated 1/1/17 through 1/31/17 identified no Milk of Magnesia administered to the resident. Review of the Progress Notes dated 1/6/17 through 1/11/17 identified no documentation of a gastrointestinal assessment. Review of the weekly Skin Sweep documents dated 8/10/16 through 11/18/16 identified no documented skin sweep after 11/18/16. Review of the record identified no open skin issues identified. Review of the Progress Notes dated 1/11/17 at 10:46 AM indicated the resident left the facility per ambulance. Review of the hospital document titled Wound Sheet, dated 1/11/17 at 2:15 PM, indicated the following wounds and measurements: The right bottom foot, pre- existing, had a red area with a raised blister that measured 6 cm (centimeters) by 6 cm with blister in the center that measured 2 cm by 1.5 cm by 0.5 cm depth. The left lateral lower heel, pre-existing, measured 2 cm by 3 cm area. Left and right buttocks with multiple colored area to bilateral (both) buttocks and coccyx, pre-existing; multiple areas of purple and the left buttocks has blisters too. Left Lateral Upper foot, pre-existing, a blister measuring 1 cm by 4 cm. On 8/10/17 at 2:00 PM, Staff E, LPN (licensed practical nurse) was interviewed and stated unaware the resident had wound areas. 2. Resident #10 had a MDS with a reference date of 7/6/17. Resident #10 had [DIAGNOSES REDACTED]. The MDS identified the resident had long and short term memory problems and severely impaired cognitive skills for daily decision making. According to the MDS the resident required extensive staff assistance with bed mobility, transfers, dressing and toilet use. The MDS identified the resident as frequently incontinent of bowel and bladder. The Care Plan, updated on 4/21/17, directed staff to check and change the resident frequently to keep clean and dry during the day and night time hours. The Care Plan directed staff to toilet the resident as needed per request and provide medications as ordered per the physician. Review of the BM Report dated 7/26/17 through 8/24/17 identified no BM documented on the following days: On 8/6, 8/7 and 8/8/17 (3 days). On 8/10, 8/11, 8/12, 8/13, 8/14 and 8/15/17 (6 days). Review of the Order Summary Report dated 8/21/17 revealed the following orders: Milk of Magnesia 1200 mg/15 ml, give 30 ml by mouth as needed for constipation once a day only. [MEDICATION NAME] suppository insert 10 mg rectally as needed for constipation daily as needed. Review of the MAR indicated [REDACTED]. Review of the Progress Notes dated 8/6/17 through 8/8/17 and 8/10/17 through 8/15/17 revealed no documentation of assessment of the resident's gastrointestinal status. During an interview with Staff E LPN (licensed practical nurse) on 8/10/17 at 2:00 PM, she stated the night nurse looks and lets the day nurse know the residents that had gone 3 days without having a BM. The day nurse then follows protocol.

Based on record review, physician and staff interviews and review of the policy and procedures, the facility failed to perform ongoing thorough assessment and timely intervention, including notification to the physician, when a resident had a change of condition (Resident #4). The sample consisted of 15 residents and the facility reported a census of 57 residents. Findings included: Resident #4 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 2/26/17. The MDS identified the resident had short term memory loss, moderately impaired cognition, made poor decisions and required cues and supervision. The MDS indicated the resident required extensive assistance from 2 staff members for bed mobility, transfer, toilet use and personal hygiene. The MDS identified the resident as frequently incontinent of bowel. According to a [DIAGNOSES REDACTED].#4's [DIAGNOSES REDACTED]. Review of a physician note dated 3/7/17, indicated the resident was recently hosptalized on [DATE] with hematuria (blood in the urine), had an acute kidney injury, may have had an infection and required the use of a Foley catheter (urinary catheter). A Care Plan with a revision date of 3/2/17 included a focus for alteration in elimination and frequent incontinence of bowel and bladder. The Care Plan indicated the resident had a history of [REDACTED]. The Care Plan included an intervention for staff to monitor the resident for signs and symptoms of a UTI such as urinary frequency, urgency, bloody urine, odorous urine, painful urination, flank discomfort and directed staff to notify a physician of any of the above signs and symptoms. A facility document form titled, Clinical Change in Condition Management dated 6/2015, included an overview for the facility to strive to identify and manage residents who experienced a change in condition and included the following procedures: Assess a resident when a change in condition is identified, which may include but not limited to: vital signs (temperature, pulse, respirations and blood pressure), lung sounds, pulse oximetry (a sensor that monitors oxygenation of the blood), mental and neurological status, bowel sounds, pain, skin color and temperature. Review the resident's condition with a registered nurse, contact a physician and provide information about the resident's condition. Review of Resident #4's nursing Progress Notes identified the following: On 4/26/17 at 2:30 P.M. - Staff changed the resident's Foley catheter with difficulty, had return of pale yellow urine with some blood noted and notified the resident's physician. On 4/26/17 at 6:31 P.M. - The Resident continued to have pain at the catheter insertion site, noted blood in the urine and documented the need to continue to monitor for any increased blood. Record review revealed staff failed to document any further assessment of the resident such as vital signs, lung sounds, bowel sounds, observation of or palpation (touch) of the resident's abdominal area or an attempt to communicate with the resident in regards to his/her pain severity. Not until 4/27/17 at 3:08 A.M. (approximately 8 1/2 hours later), staff described the resident as moaning and crying some. Unable to understand what he/she needed and the Foley catheter drainage bag had no urine in it. Staff flushed and advanced the catheter with a return of a small amount of pink urine. The resident had 2 large bowel movements and a suppository for bladder spasms due to the Foley catheter being change earlier in the day. The note lacked any further assessment of the resident such as vital signs, lung sounds, bowel sounds, palpation or exam of the resident's abdomen, or an attempt to communicate with the resident in regards to his/her pain. Not until 4/27/17 at 8:03 A.M. - (5 hours after the last assessment in regards to the resident moaning and crying), the resident still had near to nothing urinary output, staff flushed the catheter with few blood clots. Monitor the resident to see if he/she gets any better at the time staff assisted the resident out of bed. On 4/27/17 at 8:30 A.M. - Staff assisted the resident out of bed. The resident had a large dark brown emesis and she/he became unresponsive for a few seconds. Staff documented the resident's vital signs as temperature- 103.1 degrees Fahrenheit, pulse-136 beats per minute, respirations- 38 and blood pressure 112/72. Staff recorded a pulse oximetry of 88% on room air. Staff documented the resident's lung sounds as diminished and administered oxygen. The following range determines normal vital signs: Temperature: 97.7 - 99.5, Pulse: 60-100 beats per minute and Respirations: 16-18 per minute. A Pulse Oximetry reading of 95-100 % is considered normal. On 4/2717 at 8:35 A.M. - Staff contacted a nurse in an emergency room and documented the need for the resident to be transferred to the emergency room via ambulance. On 5/2/17 at 1:45 - The resident returned to the facility after hospitalized for [REDACTED]. Review of emergency room Visit Notes dated 4/27/17, included the following Physician documentation: Laboratory results revealed [MEDICAL CONDITION] (life threatening condition that arises when the body's own response to infection causes injury to its own tissue and organs) documented the resident in critical status and admitted to eICU (intensive care unit). The physician documented a primary impression as [MEDICAL CONDITION] with septic shock. A hospital Discharge Summary dated 5/2/17, identified the resident's physician documented the resident's [DIAGNOSES REDACTED]. During an interview on 5/10/17 at 8:30 A.M., Staff C, Licensed Practical Nurse/LPN stated if a resident moaned and cried in pain, she needed to obtain vital signs and do a thorough assessment of the resident. During a telephone interview on 5/10/17 at 9:10 A.M., the resident's physician confirmed an assessment of the resident's vital signs in the middle of the night on 4/27/17, may have been beneficial in assessment of a change in condition in the resident, especially because of the resident's inability to speak. During an interview on 5/10/17 at 9:30 A.M., the facility Administrator/Registered Nurse confirmed she expected nursing staff to perform further assessment of a resident moaning and crying in pain. During an interview on 5/10/17 at 9:40 A.M., Staff D, LPN stated if a resident moaned and cried in pain she needed to complete a head to toe assessment and obtain vital signs.

Based on record review, observation, review of policy/procedures, staff and physician interviews, the facility failed to identify and assess multiple wounds located on Resident #7's buttocks, legs, toes and left heel and failed to obtain timely treatment and services to prevent complications such as infection and septic shock. On [DATE], Resident #7 was transferred to a smaller hospital and the emergency room physician identified untreated multiple wounds and ordered a blood culture test which now showed Group A Streptococcus (bacterial infection). On [DATE], the physician identified [DIAGNOSES REDACTED] up to the groin of the right leg and transferred the resident to a larger hospital for treatment of [REDACTED]. The physician at the larger hospital identified the resident in septic shock (A life-threatening condition that arises when the body's response to an infection injures its own tissues and organs and can lead to organ injury and dangerously low blood pressure) secondary to [MEDICAL CONDITION] (skin inflammation) of the wounds. On [DATE] the resident transferred back to the smaller hospital for hospice care and expired on [DATE]. The facility failed to timely identify, assess and provide perineal care in a manner to prevent infection of open areas located on Resident #1's buttocks. Observation identified Resident #1 had multiple open areas located on the buttocks and coccyx area. A staff member performed incontinency care and wiped feces over the open areas. Due to lack of identification and contamination of wounds, the Director of Nursing was notified and she measured and assessed the wounds. The sample consisted of 4 residents and the facility identified a census of 52 residents. Findings include: 1. Resident #7 had a MDS (Minimum Data Set) assessment with a reference date of [DATE]. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (Brief Interview of Mental Status) score of 15. A score of 15 indicated no problems with long or short term memory. According to the MDS, the resident required extensive assistance of 2 or more staff members for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS identified the resident as frequently incontinent of bowel and bladder. Review of the Care Plan dated [DATE], identified the resident had sores present on the left heel and left shin on [DATE]. The Care Plan directed staff to apply dressing to the excoriated areas and change as needed. Review of the New Skin Area (identified an incident report) dated [DATE] indicated the nurse was called to the resident's room to look at the right foot/ankle area. Staff stated there are multiple blisters, open areas and weeping. The open areas to the right inner ankle measured 4.5 by 2 cm (centimeters) and the top of the right foot measured 3 by 3.5 cm. Blisters between the 1st and 2nd toe measured 1 by 0.5 cm, between the 2nd and 3rd toe, 1.5 by 1.3 cm and 4th toe 1.5 by 1.5 cm. On [DATE] staff added the resident had new areas of skin breakdown, a long history of skin problems, worsening circulation in legs, areas likely related to circulation. The resident had increased [MEDICAL CONDITION] and sees the wound care nurse regularly. The physician and wound care nurse recommendations to be followed included heel boots on at all times, air mattress on bed and pressure relieving cushion in wheel chair. Review of the Medical Doctor/Nursing Communications dated [DATE] revealed the resident had 2 open areas; 4.5 cm by 2 cm to the right inner ankle and 3 by 2.5 cm to the top of the right foot. The resident also had 3 blisters to the right foot: 1 by 0.5 cm between the 1st and 2nd toe, 1.5 by 1.3 cm between the 2nd and 3rd toes and 1.5 by 1.5 cm between the 3rd and 4th toe. Open areas cleansed and [MEDICATION NAME] applied. The resident denied pain to areas and the skin to the right lower extremity as red and taunt. Open areas are weeping. New orders included to have the resident seen by the wound nurse see or have an appointment in the physician's office. Review of the Medical Doctor/Nursing Communications dated [DATE] indicated the dressing change completed to the right leg and the resident noted to have 3 to 4 plus [MEDICAL CONDITION] to the right leg. The leg noted to have slough tissue peeling off of the leg and the leg weeping clear fluid. The right leg had ABD (large absorbent dressing) applied and wrapped with Kling wrap. The new order included to increase [MEDICATION NAME] (diuretic) 2.5 mg from Monday, Wednesday, Friday to daily for 7 days and BMP (blood test-basic metabolic panel) in 7 days. Review of the Consultation/Clinic Referral sheets revealed the following: On [DATE]: Leg wound 1.3 cm by 2.5 cm by 0 cm. The orders included change the left leg wound on Mondays and as needed: Clean with saline and gauze. Cover with xeroform and ABD. Change left heel wound on Mondays and as needed: Clean with saline and gauze. Apply skin prep to periwound and cover with [MEDICATION NAME] AG and [MEDICATION NAME]. On [DATE]: Change dressing on left heel as needed on Thursdays if unable to be seen by PT on Thursdays. Apply lotion liberally to the bottom of the feet 2 times a day. On [DATE]: Discontinue left shin wound care (wound healed). Continue current orders on left heel. On [DATE]: Left heel discontinue dressing orders (area healed) May resume shoe wear during the day. Continue heel protector at night. Right knee cover with xeroform and ABD dressing. Change every 3 days and as needed. Left ear cover with xeroform cut to size and paper tape. Change every 3 days and as needed. Remove glasses as much as possible. On [DATE]: All large wounds healed. Small scratches remain. Cover knee with xeroform and hold on with stockinet. No elastic. Review of the Skin Grid for All Other Skin Impairments revealed the following areas identified with treatment: Right skin/knee dated [DATE] revealed an area 3 cm by 6.5 cm pink granulation tissue with slight bloody drainage. On [DATE] the area 22 cm by 17 cm red scratches scabbed area. Review of the Skin Grid for All Other Skin Impairments revealed the following areas that had resolved: Bottom/Coccyx dated [DATE] revealed area 10 cm by 13 cm with maceration/red. On [DATE] the area identified healed and intact. On [DATE] 0.5 cm by 0.5 cm red area. On [DATE] 2 cm by 0.25 cm scab to left side and pink on right side intact. On [DATE] through [DATE] the area identified intact. Abdomen-3 cm by 2 cm red/brown scabbed abrasion. On [DATE] the area resolved. Left heel- [DATE], 2.5 by 3.2 cm serosanguinous with red wound bed. On [DATE] the area healed per wound care nurse. Left shin dated [DATE], 5 cm by 3 cm serosanguinous red wound bed. On [DATE], the area resolved/healed per the wound care nurse. Right inner knee/thigh measured 18 by 5 cm abrasion scabbed with red wound bed color. On [DATE] the area resolved. Review of the Weekly Skin Sweep form dated [DATE], revealed no new skin impairment identified. Review of the MAR (medication administration record) dated [DATE] through [DATE] revealed the following: a. Left ear pressure area cover with Xeroform cut to size and paper tape. Change every 3 days and as needed. b. Right knee cover with [MEDICATION NAME] and abdominal pad change every 3 days and as needed to right knee every 3 days and as needed. c. Critic ointment to bilateral buttocks 2 times a day for skin irritation. Review of the TAR (treatment administration record) dated [DATE] through [DATE] revealed the following treatments: a. Cleanse wound front of right shin with saline, cleanse, and apply nonstick dressing daily until healed every day for skin. b. Ensure alternating air mattress functioning every shift. c. Clearsite to affected areas as needed for skin. d. Duoderm/flexicol to affected areas as needed for skin. e. Hydrofilm/opsite to affected areas as needed for skin. f. Steri-strips to affected areas as needed for skin. The TAR failed to document areas identified with treatment of [REDACTED]. Review of the Progress Notes dated [DATE] at 9:43 AM revealed the resident noted to have large red, warm, swollen area to the right inner upper thigh. The area tender to touch and slightly shiny. The nurse notified the physician. On [DATE] at 11:44 AM, a telephone call from the physician's clinic nurse, directed the nurse to have the resident evaluated in the emergency room since it may be a clot. At 12:30 PM, the resident was transported to the hospital emergency room . Review of the emergency room Visit Notes dated [DATE] at 1:00 PM revealed the resident presented for increasing bilateral lower extremity [MEDICAL CONDITION] with new areas of redness and firmness in the right thigh. The resident had a history of [REDACTED]. The resident reported pain in his/her feet and can't really state when it started. The resident had previously followed with wound care but hasn't been seen in several weeks. The resident had numerous small open areas on the buttocks. He/she had a large area of [DIAGNOSES REDACTED] and induration of the right thigh medial and posterior. He/she had more stasis [MEDICAL CONDITION] of lower legs/feet with weeping and sloughing of the skin. The tip of the left toe black. The Emergency Department documentation dated [DATE] at 3:30 PM revealed the resident placed on the bed pan checking wounds to the bottom and legs. Wounds moist and bleeding on the bottom. Multiple wounds all over the bottom. Wounds to the lower legs as well. Multiple wounds and sores to the legs. The lower legs warm and wet to touch. Resident painful to touch in the buttocks area. Resident had numerous open areas on the bilateral buttocks bleeding at times. Roughly around 10 areas. Review of the Hospital Progress Note dated [DATE] revealed the following ulcers: a. Ulcer of heel: Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin. b. Ulcer of toe: Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin. c. Ulcer of toe: Non-pressure chronic ulcer of other part of left foot limited to breakdown of skin. d. Pressure ulcer, buttock: Unspecified pressure ulcer stage. Review of the hospital wound measurements dated [DATE] revealed the following: a. Right lateral knee 0.3 by 0.3 cm b. Right knee midline 0.3 by 0.2 cm - 5 spots c. Right knee medial 0.3 by 0.4 cm - 4 spots d. Right knee patellar notch 0.7 by 0.2 cm e. Right knee proximal tibia 5.5 by 1.5 by 0.1 cm f. Right knee lateral distal 1.4 by 0.9 cm and 0.3 by 0.3 cm g. Right lateral foot 7.8 by 7 cm h. Right proximal 2nd toe 1.8 by 2.2 cm i. Right medial great toe 1.8 by 1.4 k. Plantar foot 11 by 8.4 cm l. Plantar metheads digits ,[DATE] 2.4 by 4.8 cm m. Between ,[DATE] toe 3 by 2 cm n. Right calf 11.1 by 12 cm o. Left lateral mid-thigh 0.8 by 0.6, 3.5, by 0.2 and 0.4 by 0.4 cm. p. Left lateral knee 1.1 by 1.1 cm q. Left mid knee 0.5 by 0.4 cm, 0.5 by 0.5 cm, and 0.4 by 1.2 cm. r. Left knee medial/distal 1.4 by 1.7 cm s. Medial knee 0.3 by 0.2 - 9 spots t. Distal lateral 1.7 by 1.9 cm u. Proximal tibia midline 1.9 by 2.9 cm v. Left dorsal foot 11.7 by 5.9 cm w. Left dorsal 2nd toe 2.5 by 2 cm x. Left great toe distal 4.2 by 3.8 cm y. Left plantar 2nd toe 0.5 by 1.6 cm z. Left lateral mid leg 4.4 by 0.4 cm and 0.6 by 0.4 cm aa. Left heel medial 1.3 by 2 cm blister bb. Left heel lateral 1.8 by 3.2 cm black cc. Ride side proximal medial 3.5 by 3 cm dd. Right side midline 3.5 by 0.5 cm ee. Left medial 2.5 by 3.5, 0.7 by 0.5 cm and 0.3 by 0.3 cm ff. Proximal right thigh 4 by 4.5 cm gg. Proximal left thigh 7.5 by 5 cm hh. Proximal left thigh-below 0.5 by 1.5 cm ii. Medial proximal right thigh 1 by 1.4 cm The physician History and Physical report documented the resident had Group A [DIAGNOSES REDACTED] infection. admitted yesterday with right leg [DIAGNOSES REDACTED] appears to be [MEDICAL CONDITION]. Blood cultures positive and resident complains of pain in buttocks. Extremities right leg with [DIAGNOSES REDACTED] up to the groin, ulcerations of the left great toe and open area on the heel. The History and Physical reported identified laboratory tests as the following: white blood count of 49,000 (normal 4,,[DATE].5 and red blood count 2.71 (normal 4XXX,[DATE].0). The resident's hemoglobin registered at 8.9 (normal 13XXX,[DATE]). The resident's vital signs indicated temperatures 97XXX,[DATE].9 (normal 98.6), pulse range of ,[DATE] (normal is ,[DATE]), respiration ,[DATE] (normal ,[DATE]), blood pressure ,[DATE] to ,[DATE]). The resident's pulse oximetry measured oxygen level from 84 to 97 percent. The resident received oxygen per nasal cannula. The physician ordered peripheral venous blood culture. Other abnormal tests identified and included Bun/Creatinine (kidney function) test of 61.3 (normal ,[DATE]), sodium level of 133 (normal ,[DATE]) and potassium level 3.0 (normal 3XXX,[DATE].1). The resident was transferred to a larger hospital. The History and Physical report dated [DATE], from the transferring hospital physician pulmonologist, identified the resident was transferred to the hospital for [MEDICAL CONDITION]. The physician identified the resident with septic shock and questioned this secondary to [MEDICAL CONDITION]. The resident had crackles upon exam and increased oxygen requirements. The physician ordered medication to maintain blood pressure and [MEDICATION NAME] and [MEDICATION NAME] (antibiotics). The physician ordered the resident be admitted into intensive care unit. The resident received pressers (medication to raise blood pressure). The discharge [DIAGNOSES REDACTED]. The physician Discharge Summary dated [DATE] indicated the resident transferred to the smaller hospital for Hospice care. The Discharge Summary dated [DATE], identified the resident developed complete [MEDICAL CONDITION] and expired on [DATE]. During an interview with Staff D, CNA on [DATE] at 11:15 AM she stated she cleaned the resident during morning cares. She stated she saw both of the resident's ankles and heels areas wrapped. She placed the protective boots on the resident. Staff D stated she saw a dressing on the resident's bottom. She identified the area on the coccyx area. During an interview with Staff E, CNA on [DATE] at 2:05 PM, she stated had worked with the resident the same day he/she went to the hospital. Staff E stated she saw both feet wrapped and knew they had not been wrapped 1 week prior to that day. She put soft blue boots on both feet. She further stated she saw red all the way up the resident's leg. She showed the nurse the red areas and the resident said he/she had been feeling hot. During an interview with Staff G, CNA on [DATE] at 1:30 PM, she stated approximately 4 days prior to the resident's hospitalization , a nurse had come to the room and put a bandage on an open area on the resident's bottom. The area identified close to the crease and the open area identified an approximate size of a nickel. During an interview with Staff H, CNA on [DATE] at 2:30 PM she stated she remembered seeing an area the approximate size of a nickel on the resident's bottom but unable to remember who. The nurse told her there had really been nothing they could do about it. At a later date she talked to the MDS coordinator about it and she told her she did something about the open area. During an interview with Staff D, CNA on [DATE] at 1:20 PM, she stated she cleaned the resident during morning cares. She stated she saw both of the resident's ankles and heels wrapped. She placed the protective boots on the resident. She also stated she saw a dressing on the resident's bottom. She identified the area on the coccyx area. During an interview with Staff J, LPN (Licensed Practical Nurse) on [DATE] at 4:30 PM she stated she did the resident's skin checks on [DATE]. When she did skin checks she looks at previous identified areas and ask the CNAs. The resident always scratched areas on his/her legs. The resident sometimes had a dressing on if the skin had been pink so not to break open. She did not think at that time the resident had a dressing in place. If the resident did, it would be documented on the TAR (treatment administration record). During an interview with Staff C, RN on [DATE] at 1:00 PM, she stated the resident had a history of [REDACTED]. The areas reopen and heal. She stated she put another dressing on the resident's bottom that had been an excoriated area but could not identify the size of the excoriated area. She did not remember if she documented it or not but did state the dressing had been [MEDICATION NAME] that had a foam to absorb drainage. She further stated she normally would document. She did not remember when she placed the dressing and thought possibly done on the weekend or could have been before. She identified the area on the left ischial tuberosity (lower buttock) area. Staff C stated she did not know about an area on the resident's heel. During an interview with the emergency room Nurses on [DATE] at 10:30 AM, they stated the resident had both feet wrapped. The Physician removed the 4 by 4 dressing wrapped in kling from the resident's left foot. The left heel had a wound and the left great toe observed to be blackened. They also stated the physician had removed the dressing from the resident's bottom. The dressings had been like [MEDICATION NAME] dressing with Band-Aid area and cushion in the middle. They further stated the wound nurse measured the resident's wounds after he/she was admitted . On [DATE] at 3:10 PM the resident's physician was interviewed and stated had documentation from the facility that identified wounds on the right ankle and foot only. He stated the resident had a history of [REDACTED]. The resident had [MEDICAL CONDITION] and no open area needed to cause [MEDICAL CONDITION]. He also stated the resident had severe [MEDICAL CONDITION] and diabetes mellitus and sat with his/her legs down no matter how the facility tried to elevate. He stated the cause of death had been acute [MEDICAL CONDITION]. On [DATE] at 12:55 PM the hospital emergency room physician was interviewed and stated the resident came to the emergency room and had [MEDICATION NAME] wrapped and around both his/her feet and ankles. The resident also presented with a dressing on the right side of the gluteal fold in the rectal area. The resident had heel boots on both feet. She also stated the resident had been incontinent and saturated in urine. The resident had a Stage I to stage II pressure area on the sacrum and had more than 10 open areas on the buttocks that appeared macerated from laying in urine (not pressure but from incontinency). The physician stated the wounds on the heel had more of an appearance of pressure ulcers. The physician stated there would not be a chance of developing the wounds from the facility to the hospital. The resident also had acute [MEDICAL CONDITION] and could not urinate enough in that amount of time to be saturated with urine. The physician stated she had spoken to the attending physician and the attending had not been aware of all of the resident's wounds. Review of the policy and procedures titled Skin Care and Wound Management dated ,[DATE], directed staff to do the following: a. Identification of resident/patients at risk for developing pressure ulcers. b. Implementation of prevention strategies to minimize the potential for developing pressure ulcers and skin integrity issues. c. Weekly monitoring of resident/patient skin status. d. Daily monitoring of existing wounds. e. Application of treatment protocols based on clinical best-practice standards for promotion of wound healing. f. Interdisciplinary review of identified skin impairments. g. Monitoring for consistent implementation of interventions and effectiveness of interventions. Review and modification of treatment plans, as applicable. Analysis of facility pressure ulcer data for quality improvement opportunities. 2. Resident #1 had a MDS assessment with a reference date of [DATE]. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview for mental status) score of 8. A score represented the resident had moderate impairment of cognitive skills impairment. According to the MDS, the resident required extensive assistance of 2 staff members with bed mobility, transfers, personal hygiene and toilet use. The MDS identified the resident had 1 Stage III pressure ulcer present upon admission. The pressure ulcer measured 2.5 centimeters (length) by 3.2 centimeters (width). The MDS indicated the resident had a pressure relieve device on the bed and chair. The MDS identified no turning or repositioning program. The care plan dated [DATE] directed staff to monitor the resident for skin breakdown 2 times a day with cares and twice weekly with baths. The care plan directed staff to provide pericare (cleansing of the perineal area) 2 times daily and as needed after any episode of incontinence and to provide an air mattress on the bed. Review of the Braden Scale dated [DATE] revealed the resident had a total score of 17. A score of 17 identified the resident at low risk for the development of developing pressure ulcers. Review of the Physician Nursing Home Note dated [DATE], identified the resident had a pressure ulcer on the left calcaneus (heel), approximately 3 cm (centimeter) in diameter and had a thick eschar and thus unstageable (cannot see the wound bed due to eschar covering) i.e.: eschar is a collection of dead tissue cells. . Review of the Skin Grid for All Other Skin Impairments dated [DATE] identified a pressure ulcer on the left heel. The form indicated on [DATE] the left heel area measured 2.5 cm by 2.5 cm area with serous drainage and granulation slough tissue. The wound had no odor present. The Care Plan identified the skin breakdown to the left heel, could be from friction/shear and on [DATE], initiated the resident to wear heel protectors to the right foot/ ankle at night. The intervention initiated on [DATE] directed staff to perform a dressing change to the left heel per the wound nurse/physician orders [REDACTED]. Review of the Weekly Skin Sweep dated [DATE] revealed no new skin impairment identified. The TAR (Treatment/Medication Administration Record [REDACTED]. Observation on [DATE] at 5:10 PM revealed Staff K, CNA (certified nursing assistant) Staff L, CNA and Staff M, CNA provided incontinent care for the resident. The resident had been incontinent of a moderate amount of loose stool. Staff removed the incontinent brief and turned the resident on his/her left side. Observation identified 4 superficial open areas noted. One open area on the coccyx and 3 areas on the buttocks (buttocks not pressure). Staff M provided incontinent care and wiped the perineal-rectal area with a cleansing wipe and moved it directly over the open areas. Staff M did not use a clean wipe on the open areas. Staff applied a clean incontinent brief and transferred the resident to the wheelchair. Staff M did not identify the open areas to the nursing staff. On [DATE] at 9:25 AM, a nurse was asked to visualize the resident's open areas. Staffs B, RN (Registered Nurse) and the DON (Director of Nursing) were present. The resident transferred from the wheel chair to the bed. The resident turned to the left side and 4 open areas were observed and identified. The DON measured the areas as follows: a. Top of crease (coccyx) 1 cm by 1 cm with 0.5 cm by 0.3 cm area of granulation b. Right buttock lateral to coccyx: 1 cm by 1 cm c. Right buttock distal to coccyx: 1 cm by 0.5 cm d. Right buttock lower area: 0.5 cm by 0.5 cm During an interview with the DON on [DATE] at 9:25 AM, she stated staff will let the physician know and will ask if he wants a barrier cream or a dressing applied. Note: At the time of the complaint investigation, the complaint was coded at a J, immediate and serious jeopardy. By [DATE], the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the G level. The Director of Nursing examined all residents to determine if other residents had open skin issues not identified. The Director of Nursing provided training to certified nursing assistants about proper perineal care. All nurses were provided education on physical assessment of wounds and charting, prevention strategies, reporting to physician and obtaining orders for treatment according to treatment protocols and or physician orders, implementation of new interventions, daily monitoring of existing wounds, review and modification of treatment plans, updating and following care plans. As of the [DATE] exit date, the facility needed to: · Continue to monitor nursing staff to assure compliance with the education provided to the nursing personnel regarding skin problems and perineal care. · Continue to monitor staff to ensure the policy/procedure titled Skin Care and Wound Management is followed by staff.

Based on record review, observation, and interview the facility failed to prevent the development of a right foot heel blister for one resident admitted with a right foot diabetic ulcer (Resident #3). Three residents with skin wounds were reviewed. The facility reported a census of 50 residents. Findings included: A hospital History & Physical dated 1/23/14, documented Resident #3 had been admitted with an elevated blood sugar of 444 (normal range 70 to 100) and a lateral right foot ulcer secondary to pressure and diabetes and measured 1.5 cm (centimeter) by 1.2 cm by 0.1 cm. Other [DIAGNOSES REDACTED]. A hospital Discharge Summary, dated 2/4/14 documented the resident with one to two plus pedal [MEDICAL CONDITION] of extremities, paraparesis of legs, had a venous stasis right [MEDICAL CONDITION] that slowly improved while hospitalized , and had a pressure ulcer of the coccyx due to immobility and prolonged time in wheelchair that slowly improved with repositioning. The Minimum Data Set (MDS) assessment tool, dated 2/11/14 documented Resident #3 admitted to the facility on [DATE]. The resident had intact cognitive skills and no behavior issues. The assessment identified the resident required two staff assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The MDS revealed the resident had not walked and use a wheelchair for mobility. The resident had range of motion impairments in both upper and lower extremities. The MDS documented the resident unable to balance except for transfers between the bed, chair or wheelchair. The MDS documented the resident's [DIAGNOSES REDACTED]. The MDS documented the resident short of breath with exertion and when lying flat. The MDS dated [DATE] documented Resident #3 at risk for development of pressure ulcers, had a [MEDICAL CONDITION], pressure reducing device for chair and bed, and dressings to feet. A Physical Therapy Plan of Care documented the resident began PT services 2/4/14. The note documented the resident demonstrated PROM (passive range of motion) of bilateral lower extremity knee extension limited to 45 degrees and impacted the resident's ability to position self appropriately in bed. The PT goal was for the resident to increase PROM of bilateral knee extension to 35 degrees to help improve bed positioning. The Pressure Ulcer CAT (Care Area Triggers) Worksheet documented the resident's [DIAGNOSES REDACTED]. The CAT documented the resident needed assistance to reposition frequently during the day, a pressure reduction cushion in the resident's electric wheelchair, wheelchair tilted back to assist with weight changes, resident able to make minor weight changes, and needed assistance for major weight changes. The resident's Initial Care Plan, dated 2/4/14, directed staff to turn the resident every two hours and when needed. The care plan revealed Resident #3 required one to two staff assistance for ADL's. The ADL (Activities of Daily Living) CAT worksheet, dated 2/11/14, documented the resident required extensive to total assistance with bed mobility, transferred via a sling lift, and independent with an electric wheelchair. The resident's Braden Scale For Predicting Pressure Sore Risk documented a score of 17 on 2/4/14, 2/12/14 and 2/25/14. A score of 16 or less indicated the resident was considered at risk for development of pressure ulcer(s). The Braden Scale assessment identified the resident without impairment for sensory perception, skin rarely moist, and excellent nutrition needs. The Braden Scale determined the following risk factors for Resident #3: the resident's mobility very limited (made occasionally slight changes in body or extremity position and unable to make frequent or significant changes independently); chairfast (ability to walk severely limited or nonexistent, unable to bear weight, and required assistance into chair or wheelchair); and friction and sheer a problem (required moderate to maximum assistance to move, complete lifting without sliding against body sheets impossible, frequently slid down in bed or chair, required frequent positioning with maximum assistance, and [DIAGNOSES REDACTED], contractures, or agitation led to almost constant friction.) A Weekly Skin Assessment For Braden Scale High Risk 16 and Below And Other Skin Problems sheet, dated 2/4/14, documented the following skin impairments: a. The resident admitted with a left great toe abrasion that measured 1.0 centimeters (cm). length x 0.5 cm. width, and yellow/red in color. The February 2014 MAR indicated [REDACTED]. b. The resident admitted with two blister like areas on the top of the left foot, red and yellow in color, and measured 0.5 cm., length x 0.2 cm. width and 0.2 cm. length x 0.2 cm. width. c. The resident admitted with a left inner ankle open area that measured 0.3 cm. x 0.4 cm. with clear drainage. The February 2014 MAR indicated [REDACTED]. The March 2014 MAR indicated [REDACTED]. d. The resident admitted with a cut/open area between the right great toe and second toe that measured 3.0 cm by 0.4 cm with redness, no drainage, and covered with gauze. The sheet documented the area left open to air on 2/6/14. A Consultant Dietician Interdisciplinary Progress Note, dated 2/13/14, documented the resident's 1/23/14 [MEDICATION NAME] 3.8, resident above ideal body weight, ate 75% to 100% of meals, open skin area present, and [MEDICATION NAME] and Multiple Vitamin ordered to enhance skin healing. The resident's March 2014 MAR (Medication Administration Record) documented the resident received [MEDICATION NAME] Powder one packet daily and a Multiple Vitamin with Mineral once daily. A Nurse's Notes entry dated 2/6/14 at 12:40 a.m., documented the resident repositioned every two hours. An entry dated 2/10/14 at 2:15 a.m., documented the repositioned every two hours, cooperative, and pleasant. An entry dated 2/16/14 at 2:30 a.m. documented the resident repositioned every two hours. The notes lacked documentation whether or not pressure relief for the heels provided. A Weekly Wound Assessment sheet dated 2/5/14, documented the resident admitted with a right foot diabetic ulcer. On 2/6/14, staff documented the area a callus that measured 1.6 cm. length x 1.3 cm. width, no depth, no odor, no drainage, no pain, pink/red color and intact, and surrounding skin without redness. The sheet documented the area had peeling skin on 2/13/14 and left open to air on 2/27/14. A February 2014 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A PT Therapist Progress note, dated 2/17/14, documented the resident demonstrated AAROM (Active Assist Range of Motion) of bilateral lower extremity knee flexion to 50 degrees and knee extension limited to 20 degrees impacting the resident's ability to position self in bed and complete bed mobility safely with maximum assistance. The note documented the resident able to initiate rolling, but not able to complete the roll. A Weekly Wound Assessment sheet, dated 2/17/14, documented the resident with a new right outer heel intact blister that measured 4.0 cm. length x 2.5 cm. width and the depth as .5 cm; the blister covered with Coba foam and Hydrofilm. A facsimile physician order, dated 2/18/14, directed staff to apply [MEDICATION NAME] to the blister four times daily to dry the blister out. The February 2014 MAR indicated [REDACTED]. The Weekly Skin Assessments documented the right heel as follows: a. On 2/20/14 the blister measured 4.0 cm. length x 3.0 cm. width, brown color, no drainage, odor, or pain. A Nurse's Notes entry dated 2/17/14 at 8:30 p.m. documented staff observed the resident with a right outer heel blister and Coba foam and heel protectors applied. The resident's permanent Care Plan, dated 2/17/14, documented the resident with the following Problem/Need areas: a. Potential for cognitive deficits related to occasion confusion and mild short term memory deficits at times. A hand written intervention, dated 2/17/14, directed staff to apply heel protectors to heel and coba foam to cover blister to right heel. b. Self care deficits related to Paraplegic Immobility Syndrome and required a sling lift and extensive assistance with bed mobility. c. Skin integrity impaired with open areas to scrotum, penis, diabetic right foot ulcer, open area to left inner ankle, and abrasion to top of left great toe. Interventions included an air mattress overlay to bed, assist to reposition at least every two hours, tilt back electric wheelchair and the resident adjusted sitting position, and a pressure relieve cushion to the wheelchair seat. During observation 3/11/14 at 12:42 p.m., Staff N, LPN (Licensed Practical Nurse,) applied [MEDICATION NAME]/Iodine Prep Solution to the drying and intact blister on the resident's right outer foot and reapplied the resident's sock and blue heel boot after the solution dried. During the treatment the resident stated he/she able to move/lift the right foot, but lacked strength to hold the foot up very long. Observation revealed an air over lay mattress on the resident's bed. During observation 3/11/14 at 2:50 p.m., Staff P, RN (Registered Nurse), assisted the resident with active/passive upper and lower extremity range of motion exercises while the resident sat in the scooter. The resident able to perform upper extremity exercises independently. Staff P instructed the resident to kick feet out and the resident able to kick feet slightly on own. Staff P performed bilateral leg lifts and ankle pumps with minimal resident assistance. During interview 3/11/14 at 4:10 p.m., the resident stated he/she would go to bed for an hour or so twice a day, but not two hours. The resident stated staff don't come back after an hour. During interview 3/12/14 at 1:05 p.m., Staff Q, CNA, stated the resident wore shoes on feet during the day when first admitted and the shoes no longer fit due to [MEDICAL CONDITION]. During interview 3/12/14 at 1:10 p.m., the resident stated he/she wore shoes during the day when first admitted to the facility. During interview 3/13/14 at 7:40 a.m., the DON stated when the resident admitted to the facility staff elevated the resident's heels on pillows to prevent pressure sores. The DON stated she had not found documentation the heels floated. During interview 3/13/14 at 7:50 a.m., the DON stated the resident's Braden sores all 17; and 16 or less indicated the resident at higher risk for pressure sores. The DON stated an air over lay mattress placed on the bed when admitted and staff documented on the February 2014 MAR indicated [REDACTED]. The preventive measures included skin kept clean, moisture barrier applied, linens kept clean, out of bed for meals, air mattress on bed, Vitamin D3, and heels floated. During interview 3/13/14 at 8:23 a.m., Staff K, LPN, stated she worked the night shift the first weekend after the resident admitted to the facility. Staff K stated staff did not do a lot for the resident at night, resident slept with head of bed elevated, shifted own weight some, staff did not turn the resident from side to side during the night, and the resident moved self from side to side. Staff K stated the staff placed one pillow under the resident's calves to dangle the resident's heels. Staff K unaware if the heels stayed floated because the resident moved some in bed. During interview 3/13/14 at 10:30 a.m., Staff J, LPN, stated she usually worked the evening shift and worked day shift on weekends. Staff J stated she documented the resident had decreased sensation in feet because the resident denied pain during wound care to feet, and the resident stated he/she could kind of feel their feet. Staff J stated the resident wore diabetic socks when first admitted , unable to lay with legs straight and the legs turned out, and preferred no pillows under legs when in bed. Staff J stated the CNA's instructed to turn the resident off his/her back during the night, the resident became angry, hollered at the CNA's, and refused to turn. During interview 3/13/14 at 10:55 a.m., Staff L, RN/MDS nurse, stated she worked the floor on the night shift every fourth weekend and more often lately. Staff L stated staff tried to reposition the resident every two hours when awake and the resident refused. Staff L stated staff would try to elevate the resident's heels at night, the resident adamant about likes and dislikes, and the resident had a right to refuse. During interview 3/13/14 at 11:15 a.m., Staff H, LPN, stated she documented the resident lacked sensation in feet because the resident denied pain in the heel including when the treatment completed. Staff H unable to remember what the resident wore on feet during the day prior to heel boots. During interview 3/13/14 at 12:30 p.m., Staff M, PTA (Physical Therapy Assistant), stated the resident able to kick feet and march with feet when in PT. Staff M stated the resident unable to complete exercises as well when sat in scooter. Staff M stated the resident wore shoes with worn soles prior to the blue heel boots. A PT-Therapist Progress and Discharge Summary documented the resident received PT services from 2/4/14 to 3/4/14. A current level of functioning note dated 3/4/14 documented the resident discharged from PT services and range of motion goal unmet. The therapist documented the resident demonstrated passive range of motion of the left knee extension 45 degrees and the right knee extension 30 degrees and impacted ability to improve bed mobility.